How to use the I-cant-see-nothing-scope?

[The Angriest Bird]

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I mean the ophthalmoscope. I remember having our first practice session in the eye clinic. One girl jumped around, claiming that she has seen this and that, while everyone is deadly sure that she didn't seen no **** just like everyone else.

Then in the following patient encounters during 2nd year, everyone including myself just pretended to use it so that attending/resident knew 1) you've bought it 2) at least you think the fundus exam is important.

Two weeks later, I had lunch with a 3rd-year internal medicine resident. He confessed to me, without any hesitations, that he could not get important findings in 9 out of 10 fundus exams.

Last summer, I worked in a thoracic surgery clinic. The heart surgeon I shadowed used the ophthalmoscope on every patient, but he put the scope at least 5 inches away from the cornea. And we all know, at that distance you don't see anything.

Anyway, is this instrument just a bogus? I mean it's not that hard to see the arteries and the macula, but for all those fancy terms (cotton wool, silver wire, Roth spot) I doubt I'd ever see them.

 

[Law2Doc]

I mean the ophthalmoscope. I remember having our first practice session in the eye clinic. One girl jumped around, claiming that she has seen this and that, while everyone is deadly sure that she didn't seen no **** just like everyone else.

Then in the following patient encounters during 2nd year, everyone including myself just pretended to use it so that attending/resident knew 1) you've bought it 2) at least you think the fundus exam is important.

Two weeks later, I had lunch with a 3rd-year internal medicine resident. He confessed to me, without any hesitations, that he could not get important findings in 9 out of 10 fundus exams.

Last summer, I worked in a thoracic surgery clinic. The heart surgeon I shadowed used the ophthalmoscope on every patient, but he put the scope at least 5 inches away from the cornea. And we all know, at that distance you don't see anything.

Anyway, is this instrument just a bogus? I mean it's not that hard to see the arteries and the macula, but for all those fancy terms (cotton wool, silver wire, Roth spot) I doubt I'd ever see them.

The instrument is optimally used after you dilate a patient's pupils with eye drops. If you do that, you can usually see stuff. if you don't do that, it's much harder. Most med students only see significant findings once they are told they are there and go back and look a second time. But yes they do work, once you have a decent amount of experience and know what you are looking for/at. And they are a lot better than the magnifying glass and candle devices of yesteryear, which also did, in fact reveal a lot of the findings of today. Once you have an optho or neuro clerkship/elective you probably will learn to use it better. Second year, they mostly just want to teach you how to hold it and turn it on.

 

[Ashers]

I usually only see the vasculature. I practiced when I first got it by using it on my cat; she wasn't happy, but you can see a lot in a cat's eye when they're dilated.

 

[AmoryBlaine]

AB's 3 Goals for Education in Direct Ophthalmoscopy

1. See the optic nerve and examine its borders for blurriness (and therefore possible papilledema).

2. Make a general observation of the retina for big, bad findings (like CRAO or CRVO).

3. Recognize that you are getting a horribly inadequate view of the fundus and don't try to imply too much from this exam. For proof, ask your friendly neighborhood Opthalmologist if you can look through one of their teaching scopes while they do some exams. Bonus: try your hand at D.O. when the pt is still dilated. You will quickly see that if a patient needs their fundus examined they need Opthalmologic consultation.

 

[Blade28]

Practice, practice, practice.

I probably looked at a couple hundred patients' eyes during med school...still didn't feel totally comfortable until the middle of my MS-IV year.

 

[Orthodoc40]

Did the jumping up and down girl have a pan-optic? You can see a lot more with those at first.

 

[Droopy Snoopy]

Dim the lights and dilate the patient if you can. You should be able to get the red light reflex from across the room even, just follow it in and it'll lead you straight to the disc.

 

[The Angriest Bird]

We are not allowed to dilate the pupil, because I think that eye drop is a prescription drug.

 

[ACSurgeon]

We are not allowed to dilate the pupil, because I think that eye drop is a prescription drug.

Even without dilating you should be able to see the vessels, but probably couldn't evaluate the cup to disc ratio. In our eye clinic we had ophthalmologists to dilate the subject's eye. Either way, I agree that it is difficult. We had an ENT surgeon for a small group leader (outside the eye clinic), and he said that he still has a hard time using the ophthalmoscope... so don't feel bad.

 

[Blade28]

We had an ENT surgeon for a small group leader (outside the eye clinic), and he said that he still has a hard time using the ophthalmoscope... so don't feel bad.

It IS a tough skill, agreed.

...but to be fair, ENTs don't look in the eyes that often.

 

[smq123]

I mean the ophthalmoscope. I remember having our first practice session in the eye clinic. One girl jumped around, claiming that she has seen this and that, while everyone is deadly sure that she didn't seen no **** just like everyone else.

I got better at it, surprisingly, on peds. We did them for every well child visit, and some kids have big pupils. I mean, big enough that you can actually see vessels, even from 5 inches away.

The biggest trick is getting them to keep their eyes still for long enough, but, surprisingly, a fair number of kids over the age of 3 will cooperate.

Just keep practicing. Don't be squeamish, and confidently take as much time as you need.

 

[jocg27]

I mean the ophthalmoscope. I remember having our first practice session in the eye clinic. One girl jumped around, claiming that she has seen this and that, while everyone is deadly sure that she didn't seen no **** just like everyone else.
.

medical school would be so boring without these people.

 

[ZagDoc]

Haha love the thread title. I definitely feel like my "skill" with the ophthalmoscope is a lot like my "skill" in throwing wet spaghetti against a wall. Sometimes I get the result I want, most of the time its just a mess.

 

[Bushido416]

I tried a lot with the older tech opthalmoscopes.....so I got http://www.welchallyn.com/promotions/PanOptic/default.htm

It's kinda like the difference between trying to find your way to the out house in the middle of the night with and without a flash light. (Bad summer memories at great grandma's house). I realize it's an expensive toy for non opthamologists but it's really impressive in comparison to traditional ones.

 

[Tiger26]

I tried a lot with the older tech opthalmoscopes.....so I got http://www.welchallyn.com/promotions/PanOptic/default.htm

It's kinda like the difference between trying to find your way to the out house in the middle of the night with and without a flash light. (Bad summer memories at great grandma's house). I realize it's an expensive toy for non opthamologists but it's really impressive in comparison to traditional ones.

I think the pan-optho can also be used as an anti-tank weapon if the need should ever arise

 

[ChickFingaz]

I usually only see the vasculature. I practiced when I first got it by using it on my cat; she wasn't happy, but you can see a lot in a cat's eye when they're dilated.

That is dedication!👍

 

[Ashers]

That is dedication!👍

No, more entertainment and novelty of the whole thing. In toto I practiced about 10 min on non-patients (my dad, mom, sister, cat). My dad (ortho) was amazed by the Panoptic, since that's what I have, and he practiced with it too, amazed he could see anything.

 

[The Angriest Bird]

The problem with the Panoptic is, besides the price, its humongous size. When we rotate we really have to keep a lot of things with us, and they all have to fit in the lab coat pockets.

 

[Blade28]

Yeah I've never used the Pan-Optic...just trained myself on the regular good ol' ophthalmoscope.

 

[mjl1717]

Even without dilating you should be able to see the vessels, but probably couldn't evaluate the cup to disc ratio. In our eye clinic we had ophthalmologists to dilate the subject's eye. Either way, I agree that it is difficult. We had an ENT surgeon for a small group leader (outside the eye clinic), and he said that he still has a hard time using the ophthalmoscope... so don't feel bad.

I agree with Blade... But I wouldnt feel reassured or have a false sense of security since ENT is not a "master of the opthalmoscope".

 

[mjl1717]

medical school would be so boring without these people.

Yes, reminds me of 4 people;;

1)The guy who brags he did research wiith Debakey at Baylor..
2)The folks who say its easy to be profound, non judgemental, conscientious physician..
3) The guy who absolutely lived a VERY SHELTERED middle class life.
4)And the guy who always sees Kerley B lines..

Its Very entertaining and its life!!

 

[Blade28]

I agree with Blade... But I wouldnt feel reassured or have a false sense of security since ENT is not a "master of the opthalmoscope".

Agreed. ENT = head...except for the eyes.

😉

 

[Jwax]

On a follow up thought... how many people actually buy this doo-hicky? I have zero interest (and certainly don't have the grades) in going into optho. They told us it was "recommended" that we buy them, but I don't particularly want to part with several hundred dollars for something I'm going to use only during 3rd year. Can I get away with it?

 

[Ashers]

On a follow up thought... how many people actually buy this doo-hicky? I have zero interest (and certainly don't have the grades) in going into optho. They told us it was "recommended" that we buy them, but I don't particularly want to part with several hundred dollars for something I'm going to use only during 3rd year. Can I get away with it?

It was "required" to buy the PanOptic at my school. I bought it. I've used it once M2 year for an official school thing, and people borrowed it from me for the same dilated pupil exam. Then I practiced on my family and cat, as I said above (it also helped me feel like I hadn't wasted so much money).

Most clinics/hospitals (not the VA outside of the ED) for M3 year had scopes that I could use. The otoscope was more useful since my peds outpatient rotation didn't have otoscopes in each room, so I actually had to use that. I guess I did use my panoptic briefly on peds for 3 or 4 red reflexes.

You can probably get away without having one if you know people who do.

 

[ACSurgeon]

I agree with Blade... But I wouldnt feel reassured or have a false sense of security since ENT is not a "master of the opthalmoscope".

Well, I would. I would bet any ENT has more experience than a first/second year med student who only used the ophthalmoscope once or twice in their life!

 

[The Angriest Bird]

In our second year, not having an ophthalmoscope is "unprofessional," but not knowing how to turn on the switch is completely forgiven.

 

[PeepshowJohnny]

On a follow up thought... how many people actually buy this doo-hicky? I have zero interest (and certainly don't have the grades) in going into optho. They told us it was "recommended" that we buy them, but I don't particularly want to part with several hundred dollars for something I'm going to use only during 3rd year. Can I get away with it?

Most of the time, absolutely. My second year of medical school I got away with a combination of A) Borrowing a classmates (who was actually interested in Ophtho) for a monitored physical exam B) Using the hospital's portable one when inpatient and C) Using the one on the wall in clinics.

However, I was "strongly recommended" to buy one by my family practice attending who did a lot of house calls, although he didn't even use his all that much (I think only the otoscope). But whatever, bought a cheap odl junker. I'll have it in case I ever need it, which I probably won't.