Peng Yong Sim: Is there a future for direct ophthalmoscopy?

Since its invention in 1851, the direct ophthalmoscope has offered unprecedented diagnostic capabilities. Through it, the mysteries of the inner eye were unravelled and the links between eye manifestations and systemic diseases have been revealed.

As a diagnostic tool it has been almost as important as the stethoscope: from the first time retinal detachment was seen in 1853 to the first viewings of central retinal occlusion in 1855 and papilloedema in 1860.1

Unfortunately, over recent decades there has been a decline in ophthalmology teaching at medical school level, and reduced direct ophthalmoscopy proficiency in both medical students and non-ophthalmologist doctors.2

These factors, alongside technical difficulty and the considerable price tag of an ophthalmoscope, have led to a general lack of confidence in direct ophthalmoscopy across the medical profession.3,4 There is even evidence suggesting that direct ophthalmoscopy performed by ophthalmologists is inadequate for screening of common eye diseases like diabetic retinopathy.5

Most of my peers–myself included–have had minimal, if any, exposure to direct ophthalmoscopy throughout our training. Any pursuit for further practice has been dependent on self-motivation. And even then, most of it has been under the supervision of GPs and emergency medicine doctors, the majority of whom admit a lack of proficiency in direct ophthalmoscopy themselves.

There are different views on the role of direct ophthalmoscopy within the ophthalmology community6,7 but I believe that this basic skill is crucial, especially as our health service is under increasing financial pressure. For example, the ability to triage, signpost, and refer patients appropriately–for which direct ophthalmoscopy is essential–reduces demand on hospital eye services and promotes more efficient use of precious resources.

Technological development in the last decade has allowed, not only the availability of low cost ophthalmoscopes,8,9 but the emergence of several new alternatives–such as nonmydratic fundus photography10,11 and smartphone ophthalmoscopy12-14–which could help preserve the art of direct ophthalmoscopy. It is time my generation of digital doctors embraced such innovations and made the inner eye less mysterious once again.

Not commissioned, peer reviewed.

Peng Yong Sim is a FY2 in ophthalmology at West Hertfordshire Hospitals NHS Trust.

Competing interests: None declared

References:

  1. Sherman SE. The history of the ophthalmoscope. Doc Ophthalmol 1989;71:221-8.
  2. Mottow-Lipa L. Ophthalmology in the medical school curriculum: reestablishing our value and affecting change. Am J Ophthalmol 2009;116:1235-6.
  3. Wu EH, Fagan MJ, Reinert SE, et al. Self-confidence in and perceived utility of the physical examination: a comparison of medical students, residents, and faculty internists. J Gen Intern Med 2007;22:1725-30.
  4. Shuttleworth GN, March GW. How effective is undergraduate and postgraduate teaching in ophthalmology? Eye (Lond) 1997;11:744-50.
  5. Benbassat J, Polak BCP, Javitt JC. Objectives of teaching direct ophthalmoscopy to medical students. Acta Ophthalmol 2012;90:503-7.
  6. Yusuf IH, Salmon JF, Patel CK. Direct ophthalmoscopy should be taught to undergraduate medical students-yes. Eye (Lond) 2015; 29:987-9
  7. Purbrick RMJ, Chong NV. Direct ophthalmoscopy should be taught to undergraduate medical students—No.Eye (Lond) 2015;29:990-1.
  8. Lowe J, Cleland CR, Mgaya E. The Arclight ophthalmoscope: a reliable low-cost alternative to the standard direct ophthalmoscope. J Ophthalmol2015;2015:743263.
  9. Harle DE, Davies K, Shah R, et al. Technical Note: A comparison of a novel direct ophthalmoscope, the Optyse, to conventional direct ophthalmoscopes. Ophthalmic Physiol Opt2007;27:100-5.
  10. Bruce BB, Lamirel C, Wright DW, et al. Nonmydriatic ocular fundus photography in the emergency department. NEJM 2011;364:387–9.
  11. Pérez MA, Bruce BB, Newman NJ, et al. The use of retinal photography in non-ophthalmic settings and its potential for neurology. Neurologist 2012;18:350–355.
  12. Bastawrous A, Giardini ME, Bolster NM, et al. Clinical validation of a smartphone-based adapter for optic disc imaging in Kenya. JAMA Ophthalmol 2016;134:151-8.
  13. Russo A, Morescalchi F, Costagliola C, et al. A novel device to exploit the smartphone camera for fundus photograph. J Ophthalmol 2015;2015:823139.
  14. Hong SC. 3D printable retinal imaging adapter for smartphones could go global. Graefes Arch Clin Exp Ophthalmol2015;253:1831-3.

 

  • Dr David Nicholl

    Agreed…if this was embedded in exams, I think people would learn this important skill. The figures are shocking, you cannot competently assess a patient with new onset headaches unless you know how to do fundoscopy. The Arclight is very good. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4693104/