Find the disc. Follow the vessels. Locate the macula.

Direct ophthalmoscopy, step by step

1. 01 / Set up

   Dim the room. Dilate if you can. Your right eye to the patient's right eye, your left to their left, so noses do not meet. Ask the patient to fix on a distant point and keep fixing even when your head gets in the way.

2. 02 / The red reflex

   From an arm's length, dial in a plus lens and look through the ophthalmoscope at the pupil: a red glow. A black shadow in it is an opacity in the media, a cataract or a vitreous haemorrhage; a white reflex in a child is an emergency.

3. 03 / Approach

   Come in at about fifteen degrees temporal to the line of sight, close to the eye, dialling the lens towards zero until the retina is sharp. Coming in from the temporal side lands you near the disc.

4. 04 / Find the disc

   If you land on vessels, follow them: their branching points, like arrows, point back to the disc. Describe the disc before anything else: margin, colour, cup, and the vessels emerging from it.

5. 05 / Follow the vessels

   Trace each of the four arcades out from the disc as far as you can see. Note calibre, crossings, tortuosity, sheathing, and anything beside them: haemorrhage, exudate, cotton wool spots.

6. 06 / Locate the macula

   Ask the patient to look straight into the light. The macula is two disc diameters temporal to the disc: darker, vessel-free, a pinpoint reflex at the fovea in a young eye.

7. 07 / The periphery

   Ask the patient to look up, down, left and right, and follow. The direct ophthalmoscope sees little of the periphery; the indirect and the widefield camera see it all.