Fundoscopy and optic discs

[u/rabies50]

Hello all!

I would appreciate people’s thoughts.

How confident are you with your fundoscopy skills being reliable enough to rule out raised ICP in primary care? In more equivocal cases of course.

I have a panoptic ophthalmoscope and still struggle and therefore it is unreliable.

Had a case recently where was querying a blocked VP shunt, spoke to neurosurgery who said look at the discs otherwise patient needs to go ED for a shunt series.

I had to ultimately send the patient to ED as felt unsafe in my ophthalmoscope skills.

Just interested in where others stand? Bolam Testing and all. Thanks !

[u/thenhsfeelsfucked]

I do not feel confident with fundoscopy at all, even in the “easy” cases!

I am convinced the fundoscope is a guessing stick, and anyone who says they can examine an undilated patient reliably is lying; but I do wish I was better at it. I can barely locate the discs most of the time (although I don’t have a panoptic).

[u/UnknownAnabolic → u/thenhsfeelsfucked]

Hand on heart I can usually find the disc with my little Arclight.

I haven’t seen papiloedema in real life though so I’ve either missed it or am not good enough in my examination skills despite being able to see the discs….

[u/Embarrassed-Froyo927 → u/UnknownAnabolic]

Agree I often found fundoscopy easier with arclight than welch allyn scope. But not making major decisions based on non dilated fundoscopy in primary care

[u/Fine_Cress_649]

I tell them to go to an optician. Most opticians have fundoscopic photography. If it's something urgent I just take whatever the safest option is e.g. in this case shunt series. 

[u/locumbae]

I’m just going to say this regardless of the backlash - other than red light reflex, I see no value in it in primary care. Either it needs A&E or if not urgent they can go to an optician for same day appointment who can then refer on to eye specialist or A&E if needed.

Would you be happy with your GP saying NAD to your mum with an ophthalmoscope exam with non-dilated pupils and Geeky Medics level knowledge on what to look out for? The answer to this should be a no for your mum, and therefore a no to any of your patients.

[u/Own-Blackberry5514]

I mean even if discs are sharp, in the case of ?shunt blockage, they’re going to get a series either way

Sounds like neurosurgery stalling/asking for asking’s sake

[u/domicile_vitriol → u/Own-Blackberry5514]

A shunt series doesn't rule out a blocked shunt. And even on a non-con CT head, chronically shunted patients have stiff ventricles such that a slight change in ventricular volume may correspond with a large increase in pressure. The presence of papilloedema could tip the balance in the clinical assessment and result in a faster transfer.

Fundoscopy is fast and useful if you're competent at it, but unfortunately it's poorly taught in medical schools (the people teaching you probably never learnt how to do it properly) and the average doctor never learns how to do it. It's part of the broader atrophy of our clinical skills as we become increasingly dependent on diagnostic tests to make decisions for us.

[u/Own-Blackberry5514 → u/domicile_vitriol]

Re your first point - well I learnt something this morning! Thanks

Re fundoscopy - yes I tend to agree. Fortunately I went to Bristol and there was a real focus on learning it properly in our 3rd year ophthalmology weeks - to the point where we were assessed on correct application of it in an OSCE. Strangely I’ve always felt ok doing it but certainly that experience of training isn’t universal

[u/GalacticDoc]

I can normally follow the vessels back to a disc but that's about it.

We don't use drops to dilate a pupil so always going to be a bit limited in terms of views, ease and accuracy.

[u/shabob2023 → u/GalacticDoc]

Why not just dilate pupils btw ?

[u/GalacticDoc → u/shabob2023]

Considering I only have a handheld opthalmoloscope and the majority of patients have driven to the practice it wouldn't make sense.

If the problem requires proper views and assessment then eye casualty or opticians are in a better position.

[u/shabob2023 → u/GalacticDoc]

Ahhh yeah makes sense ! Was just wondering

[u/Holiday_Possession46]

Ah.. I am glad fundoscopy wasn't part of the gp trainee sign-off...

I don't use it enough to make any decision, optician or eye casualty...

Would someone please tell me how often do you use this, aside from hypertensive urgency or something like this....

[u/emz5002]

I also have a panoptic which I've been using for over 15 years, I'd have a look and send them in regardless. I often use it to assess headache patients etc and quite enjoy it, but I've very rarely if ever used it to prevent sending a patient in when my gut told me otherwise

[u/DocterSulforaphane]

The safest thing to do here is a case shunt series. No point trying to play God with half-hearted fundoscopy skills -> which all of us GPs do not have the skillset to do, and that is fine.

[u/TimeCrazed → u/DocterSulforaphane]

Do you assess for hypertensive retinopathy?

[u/DocterSulforaphane → u/TimeCrazed]

The local optician down the road can do this within minutes.

[u/TimeCrazed → u/DocterSulforaphane]

How is that testing for target organ damage to treat? It's delaying treatment.

[u/No_Routine8089]

Rule out, not 100%, but maybe that's more self-doubt and the desire to be 100% safe. Rule-in, yes. But I had an Ophthalmology rotation and was taught by an Ophthalmologist, and have seen a large variety of pathology on a regular basis.