OPHTHALMOSCOPY- A USEFUL BUT NEGLECTED SKILL BY THE NON-OPHTHALMOLOGIST DOCTORS.
Objectives: The purpose of this study was to assess the views of hospital doctors on ophthalmoscopy and their ability to examine the ocular fundi and diagnose abnormalities.
Study design: A questionnaire based cross-sectional study.
Setting: Khyber Teaching Hospital Peshawar, Pakistan, where study lasted from June 2007 to September 2007.
Patients and Methods: An indigenous questionnaire was designed and distributed among non-ophthalmologists doctors of different specialties of the hospital. The subjects were asked to rank the frequency of using ophthalmoscope and difficulties facing in using it. A list of common ophthalmoscopic findings was also given in questionnaire and doctors were asked about their recognition using ophthalmoscope.
Results: A total of 71 non-ophthalmologist doctors were included in the study. Twenty four (33.8%) belonged to medical and allied specialties, 39 (54.9%) to surgical and allied specialties, six (8.5%) to paediatrics and two (2.8%) to emergency department. Only 28 (39.4%) had ophthalmoscope at their work place, 9 (32%) of which were non functional. Only 14 (19.7%) use ophthalmoscope daily, 26 (36.7%) occasionally and 31 (43.7%) do not use it at all. Only 20 (50%) of the 40 doctors who perform ophthalmoscopy, dilate pupil and the rest do not. Regarding competency of using ophthalmoscope only 22 (31.2%) doctors were confident in ophthalmoscopy, 17 (24%) had difficulty in focusing fundus, 22 (31.2%) had difficulty in recognizing findings and 10 (14.7%) did not know its use. Almost all (96%) mentioned the need of a training course to improve their skill of ophthalmoscopy.
Eye examination skills are taught at medical schools, assessed at university examinations and practiced in all medical and surgical disciplines. Ophthalmic examination by non-specialist includes testing visual acuities and performing ophthalmoscopy.
Ophthalmoscopy (ocular fundoscopy) has traditionally been considered an integral part of physical examination of patients in many disciplines of medicine including internal medicine, family medicine, paediatrics, neurology and neurosurgery. Life-threatening conditions such as raised intracranial pressure, milliary tuberculosis, and cytomegalovirus infection may be revealed by ophthalmoscopy1. In patients with diabetes mellitus, regular ophthalmoscopic examination is mandatory to screen for diabetic retinopathy as visual loss due to diabetes can be prevented by retinal laser treatment if retinopathy is spotted early. In arterial hypertension, hypertensive changes in the retina closely mimic those in the brain and may predict cerebro vascular accidents. In children, early detection and prompt treatment of ocular disorders is important to avoid permanent visual impairment2. Direct ophthalmoscope is undoubtedly the most practical instrument available to a physician for ophthalmic examination3.
Received: 08 Oct 2007;
Accepted: 07 Jan 2010
With increasing wor1kload for doctors, routine fundoscopy may be abandoned. It is not known how often doctors, other than ophthalmologists, perform fundoscopies or how skilled they are in performing them. The purpose of this study was to assess the views of hospital doctors on ophthalmoscopy and their ability to examine the ocular fundi and diagnose abnormalities using ophthalmoscope.
MATERIAL AND METHODS
This questionnaire based cross-sectional study was performed in a university hospital, (Khyber Teaching Hospital, Peshawar, Pakistan) from June 2007 to September 2007.
An indigenous questionnaire was designed by the author (IH). The frequency and proportion rating scales used in this questionnaire were easy to administer and simple to score. The questionnaire was distributed among non-ophthalmologist doctors of the hospital in medical, surgical, paediatric and emergency department. Doctors of orthopaedic and skin department were excluded from study because they felt that they do not need ophthalmoscopy. House officers were also excluded. In this study the subjects were asked to rank the frequency of using ophthalmoscope and difficulties facing in using it. A list of common abnormal ophthalmoscopic findings including papilloedema, hemorrhages, soft exudates, hard exudates, macular edema and retinal detachment was given in the questionnaire and doctors were asked about their recognition using ophthalmoscope.
Data was compiled using software "SPSS Version 10" and results obtained.
A total of 71 non-ophthalmologist doctors were included in the study. Twenty four (33.8%) belonged to medical and allied specialties, 39 (54.9%) to surgical and allied specialties, six (8.5%) to paediatrics and two (2.8%) to emergency department.
Among the doctors 23 (32.4%) were consultants, 10 (14.1%) were medical officers (also working as General Practitioners in private practice) and 38 (53.5%) were trainee registrars. Only 28 (39.4%) had ophthalmoscope at their work place, 9 (32%) of which were non functional.
Frequency of use of ophthalmoscope by the subjects in practice is shown in Table-1.
Table-1: Frequency of using ophthalmoscope by the respondents
Use of Opthalmoscope###Frequency
Once a week###06(8.5%)
Only 20 (50%) of the 40 doctors who perform ophthalmoscopy, dilate pupil and the rest do not. Reasons for not dilating the pupil include non-availability of dilating drops in wards in 7 out of 40 respondents (17.5%) and risk of side effects especially precipitation of angle closure glaucoma in 13 (32.5%).
Competency of using ophthalmoscope is shown in Table-2.
Table-2: Competency of performing opthalmoscopy by the doctors
Don't know use of###10 (14.7%)
Difficulty in focusing fundus###17 (24%)
Difficulty in recognizing###22 (31.2%)
Confidence in###22 (31.7%)
Frequency of recognition of common abnormal findings by the doctors is shown in Table-3.
Table-3: Frequency of detecting abnormal fundus findings by the doctors
Retinal Hemorrhages###49 (69%)
Soft exudates###29 (40.8%)
Hard exudates###29 (40.8%)
Macular edema###08 (11.3%)
Retinal detachment###06 (11.3%)
Regarding Teaching and training of ophthalmoscopy, 43 (60.6%) doctors learned the skills at medical school, 18 (25.4%) at fellowship and only 5 (7%) attended special course on the subject. The remaining 5 (7%) did not respond to this question. Almost all (96%) mentioned the need of a training course to improve their skill of ophthalmoscopy.
In this study only 19.7% non-ophthalmologists doctors use Ophthalmoscopy in their daily practice, 36.7% use it occasionally and 43.7% don't use it at all. In a study by GS Ang and Dhillon B. on Junior House Officers, 18.5% perform ophthalmoscopy daily, 24.6% weekly, 33.8% monthly and 23.1% occasionally4. In a study by Roberts et al, reviewing of charts of 100 patients treated by physicians disclosed that only three had fundus examination reported5. Similar results were reported from survey done in Australia6.
In our study only 39.4% doctors had ophthalmoscope at their work place, one third of which were non-functional. This is a common hurdle in many set ups. In above mentioned study by Ang and. Dhillon4 in a Scottish University Hospital 66% Junior House Officer were certain that working ophthalmoscope was present in the Ward, 20% were certain that there was not and 13.8% were unsure of the presence of a working ophthalmoscope. One of the reasons not using it could be non-availability of the instrument.
Regarding competency in using ophthalmoscope, only 31.7% doctors in our study, considered themselves confident in this skill. These results are not too different from other similar international studies. In a study from United Kingdom on 41 general practitioners, sixty six percent of the respondents did not feel confident with their skills in performing a fundus examination5.
In a study from Israel in which hospital pediatricians' ability to diagnose abnormalities of ocular fundi was assessed, mean score for the fundus pictures quiz was 48%1. This excludes the difficulties of using ophthalmoscope on live patients. Similarly in above mentioned study by GS Ang majority of Junior House Officers (56.9%) did not carry ophthalmoscopy as routine because of multiple reasons, one of those is lack of confidence in using this skill4.
In a study from Canada ability of non-ophthalmologists to diagnose retinal haemorrhages was examined. A fairly large number (36%) of respondents did not attempt to examine followed by those who were unable to examine (19%) the fundus in 72 children with shaken baby syndrome. A significant number (13%) of respondents missed the retinal haemorrhages when fundus was examined7.
Fifty percent of doctors, who perform ophthalmoscopy in our study, do not dilate pupil, the reason being nonavailabilty of dilating drops or risk of its side effects. There is no doubt that diagnostic yield is increased by ophthalmoscopy through dilated pupil. In a study by Seigle et al8 32% of posterior pole anomalies were missed during ophthalmoscopy through undilated pupil. Another study mentions that sensitivity of fundoscopy through a dilated pupil for detecting diabetic retinopathy is twice as high as detection through an undilated pupil9. Common reason for not dilating pupil is concern about the risk of precipitating acute angle closure glaucoma. Recent population based studies indicate that this risk is extremely low. In a study from Rotterdam, on 6760 people acute angle closure glaucoma was precipitated in only two (0.09%) individuals of of more than 55 years of age, after use of mydriatic eye drop10.
The Baltimore eye survey of 4870 people found no cases of acute angle closure glaucoma precipitated by mydriatics11. On basis of this discussion we strongly recommend the dilatation of pupil before ophthalmoscopy. However patient should certainly be warned to seek medical attention if symptoms of acute angle closure glaucoma (red painful eye, blurry vision, nausea and vomiting) occur12.
As far as teaching and training aspect is concerned, a large proportion of doctors (60.6%) in our study learned this skill in medical school. Unfortunately specific formal instruction in ocular fundoscopy is rarely given to medical students13. As a result of limited ophthalmology education in medical schools and primary care residency programmes, medical students and primary care residents are inadequately trained to deal with even the most basic ophthalmic problems14,15. This decline is not limited to ophthalmic knowledge; Lippa et al16 recently described a "worrisome erosion" in medical students' eye examination skills. According to another study from Australia by Jackson et al5, little formal eye skills training has historically been available to Australian general practitioners at undergraduate or postgraduate levels. In that they had inadequate training for ophthalmoscopy.
This shows that lack of adequate training at under graduate and postgraduate level could be the main reason that doctors are not skilled in ophthalmoscopy and hence they don't practice it.
This study shows that ophthalmoscopy is being neglected by general doctors. Every skill that is not practiced is lost. The same is sadly, true for ophthalmoscopy. The issue of training and encouragement to perform ophthalmoscopy needs to be addressed before it becomes a forgotten art.
1. Morad Y, Barkana Y, Avni I, Kozer E. Fundus anomalies: what the pediatrician's eye can't see.Int J Qual Health Care 2004; 16:363-5.
2. Committee on Practice and Ambulatory Medicine, Section on Ophthalmology, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and strabismus and American Academy of Ophthalmology. Eye Examination in Infants, Children, and Young Adults by Pediatricians. Pediatrics 2003; 111: 902-7.
3. Sit M, Levin AV. Direct ophthalmoscopy in pediatric emergency care. Pediatr Emerg Care 2001; 17:199-204.
4. GS Ang, Dhillon B. Do junior house officers rountinely test visual acuity and perform ophthalmology?Scott Med J 2002; 47:60-3.
5. Roberts E, Morgan R, King D, Clerkin L. Funduscopy: a forgotten art? Postgrad Med J 1999; 75:282-4.
6. Jackson C, de Jong I, Glasson W. Royal Australian College of Ophthalmologists and Royal Australian College of General Practitioners National GP Eye Skills Workshops: colleges and divisions reskilling general practice. Clin Experiment Ophthalmol 2000; 28:347-9.
7. Morad Y, Kim YM, Main M, Huyer D, Capra L, Levin AV. Nonophthalmologist accuracy in diagnosing retinal hemorrhages in the shaken baby syndrome. J Pediatr 2003; 142:431-4.
8. Siegel BS, Thompson AK, Yolton DP, Reinke AR, Yolton RL. A comparison of diagnostic outcomes with and without pupillary dilatation. J Am Optom Assoc 1990; 61:25-34.
9. Klein R, Klein BE, Neider MW, Hubbard LD, Meuer SM, Brothers RJ. Diabetic retinopathy as detected using ophthalmoloscopy, a nonmydriatic camera and a standard fundus camera. Ophthalmology 1985; 92:485-91.
10. Wolfs RC, Grobbee DE, Hofman A. de Jong PT. Risk of acute angle-closure glaucoma after diagnostic mydriasis in nonselected subjects: the Rotterdam Study. Investigative Ophthalmology Viaul Sci 1997; 38: 2683-7.
11. Patel KH, Javitt JC, Tielsch JM, Street DA, Katz J, Quigley HA, et al. Incidence of acute angle-closure glaucoma after pharmacologic mydriasis. Am J Ophthalmology 1995; 120:709-17.
12. Liew G, Mitchell P, Wang JJ. Fundoscopy: to dilate or not to dilate? BMJ 2006; 332:3.
13. Cordeiro MF, Jolly BC, Dacre JE. The effect of formal instruction in ophthalmoscopy on medical student performance. Med Teach 1993; 15:321-5.
14. Stern GA, Association of University Professors of Ophthalmology Education Committee. Teaching Ophthalmology to Primary care physicians. Arch Ophthalmol 1995; 113:722-4.
15. Sussman EJ, Tsiaras WG, Soper KA. Diagnosis of diabetic eye disease. JAMA 1982; 247:3231-4.
16. Lippa LM, Boker J, Duke A, Amin A. A novel 3-year longitudinal pilot study of medical student's acquisition and retention of screening eye examination skills. Ophthalmology 2006; 113:133-9.
Correspondence: Dr Ibrar Hussain, Associate Professor of Ophthalmology, Khyber Teaching Hospital Peshawar
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|Author:||Hussain, Ibrar; Zafar, Danish; Sethi, Sadia; Arif, Muhammad|
|Publication:||Pakistan Armed Forces Medical Journal|
|Date:||Dec 31, 2010|
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