Principles of Ophthalmoscopy

August Colenbrander

No other single invention has shaped the evolution of ophthalmology like the invention of the
ophthalmoscope has. Ophthalmoscopy was introduced by Hermann von Helmholtz in December of
1850.1,2 However, Jan Purkinje (known for the Purkinje images) had described the complete
technique and published it in Latin in 1823,3 but his audience apparently was not yet ready and his
publication went unnoticed. A quarter of a century later, however, the situation changed.

Like many other important inventions, the ophthalmoscope was not based on any radically new
concepts. Rather, it combined the appropriate application of various known principles with a
recognition of its potential impact and presentation to an appropriate audience. Under the
leadership of men like Bowman in London, Donders in Holland, and von Graefe and von Helmholtz in
Germany, ophthalmology was emerging as the first organ-based specialty in medicine. Bowman
(1816 to 1892) is known for Bowman’s membrane and for his work in anatomy and histology.
Donders (1818 to 1889) clarified the principles of refraction and accommodation (1864) and defined
visual acuity as a measurable quantity. His coworker Snellen developed the Snellen chart. In Berlin,
Albrecht von Graefe (1828 to 1870) was a leader in stimulating the clinical application of new
techniques and the careful documentation of new findings. He is remembered for Graefe’s knife
and Graefe’s Archives (1854) (one of the first ophthalmic journals), and he founded the German
Ophthalmological Society (Heidelberg, 1857). Several workers had tried to visualize the inside of the
eye but had fallen short of putting it all together. Kussmaul (known for “Kussmaul’s airhunger”)
described the imaging principles in a thesis in 18454 but failed to solve the illumination problem.
Cumming5 (1846) in England and Brücke6 (1847) in Germany had shown that a reflection from the
fundus could be obtained by bringing the light source in line with the observer, but they failed to
solve the imaging problem. Babbage,7 the English mathematician, reportedly constructed an
ophthalmoscope in 1847, but his ophthalmologist friend did not recognize the importance and did
not publish it until 1854, when von Helmholtz’ instrument was well known.

In the fall of 1850, von Helmholtz tried to demonstrate the inside of the eye to the students in his
physiology class. On December 6, he presented his findings to the Berlin Physical Society1; on
December 17, he wrote to his father8:

I have made a discovery during my lectures on the Physiology of the Sense-organs, which was so
obvious, requiring, moreover, no knowledge beyond the optics I learned at the Gymnasium, that it
seems almost ludicrous that I and others should have been so slow as not to see it…. Till now a
whole series of most important eye-diseases, known collectively as black cataract, have been terra
incognita…. My discovery makes the minute investigation of the internal structures of the eye a
possibility. I have announced this very precious egg of Columbus to the Physical Society at Berlin, as
my property, and am now having an improved and more convenient instrument constructed to
replace my pasteboard affair…

Helmholtz’ monograph on ophthalmoscopy was published in 1851 and soon was widely circulated.
The next year there were several important improvements contributed by other workers.
Rekoss,9 von Helmholtz’ instrument maker, added two movable disks with lenses for easier focusing.
Epkens, working with Donders in Holland,8 introduced a perforated mirror for increased illumination.
Ruete10 in Germany did the same and also developed the indirect method of ophthalmoscopy. With
these basic components in place, future generations provided technical improvements. In 1913,
Landolt11 listed 200 different types of ophthalmoscopes. The most important changes are related to
the change from candle light to gas light, to external electric light and, finally, to built-in electric light
sources. This chapter concentrates on currently available forms of ophthalmoscopy. For additional
information on the history of ophthalmoscopy the reader is referred to references 8 and 12.

Although the older generation found it difficult to adapt to the new instrument, the younger
generation did so eagerly. One of them was Eduard von Jaeger (1828 to 1884) from Vienna, best
known for his print samples that were based on the print catalogue of the Vienna State Printing
House. He was the son of a well-known ophthalmologist and an artistically gifted mother. In 1855, at
the age of 27, he published his first atlas; he continued to add to his collection of authoritative
fundus paintings until his death in 1884.13

BASIC PRINCIPLES OF DIRECT OPHTHALMOSCOPY

The basic principle of direct ophthalmoscopy is simple (Fig. 1). If the patient’s eye is emmetropic,
light rays emanating from a point on the fundus emerge as a parallel beam. If this beam enters the
pupil of an emmetropic observer, the rays are focused on the observer’s retina and form an image of
the patient’s retina on the observer’s retina. This is called direct ophthalmoscopy.

Fig. 1. Imaging in direct ophthalmoscopy. If patient and observer are both

emmetropic, rays emanating from a point in the patient’s fundus will emerge as a
parallel beam and will be focused on the observer’s retina.

However, there is a problem with this method: Sufficient light for visualization of the fundus
emerges only if the patient’s fundus is properly illuminated. Because of the optics of the eye (Fig. 2),
incident light reaches only the part of the fundus onto which the image of the light source falls.
Conversely, only light from the fundus area onto which the observer’s pupil is imaged reaches that
pupil. The fundus can be seen only where the observed and the illuminated areas overlap; in the
emmetropic eye this can happen only if the light source and the observer’s pupil are aligned
optically. Under normal conditions this does not happen, and the pupil normally appears black. How
a reflection can be seen under abnormal conditions is discussed later in this text.
 Fig. 2. The illumination problem in direct ophthalmoscopy. If the light source and
the observer are not aligned optically, the observer views a part of the fundus that
is not illuminated.

There are several ways in which optical alignment of the illuminating and observing beams can be
accomplished (Fig. 3). Von Helmholtz solved the problem with a semireflecting mirror made up of
several thin parallel pieces of glass (see Fig. 3A). Epkens and Ruete used a perforated concave
mirror, which places illuminating light rays all around the observation beam (see Fig. 3B). A
modification of this arrangement is used in the fundus camera. Most hand-held instruments now
have a small mirror or prism (see Fig. 3C), which uses the lower half of the patient’s pupil for
illumination and the upper half for observation.
 Fig. 3. Illumination methods in direct ophthalmoscopy. A. Illumination with
semireflecting mirror (Helmholtz). B. Illumination with perforated mirror (Epkens,
Ruete). C. Illumination with mirror or prism (modern).

FIELD OF VIEW IN DIRECT OPHTHALMOSCOPY

If the patient’s fundus is properly illuminated, the field of view is limited by the most oblique pencil
of light that can still pass from the patient’s pupil to the observer’s pupil (Fig. 4). In direct
ophthalmoscopy the retinal point that corresponds to this beam can be found by constructing an
auxiliary ray through the nodal point of the eye.11 The point farthest from the centerline of view that
can still be seen is determined by the angle α, that is, the angle between this oblique pencil and the
common optical axis of the eyes.
 Fig. 4. Field limits in direct ophthalmoscopy. The maximum field of view is
determined by the most oblique pencil of rays (shaded) that can still pass from one
pupil to the other.

Angle α, and therefore the field of view, is increased when the patient’s or the observer’s pupil is
dilated or when the eyes are brought more closely together.

The more peripheral pencils of light use ever-smaller parts of each pupil. This means that, even if the
patient’s fundus is uniformly illuminated, the luminosity of the fundus image gradually decreases
toward the periphery, so that there is no sharp limitation to the field of vision. In practice, therefore,
the effective field of vision is determined by the illuminating system not by the viewing system. Most
ophthalmoscopes project a beam of light of about one disc diameter.

EXTENDING THE FIELD—INDIRECT OPHTHALMOSCOPY

Even with appropriate illumination, direct ophthalmoscopy has a small field of view. Figure 5 shows
that of four points in the fundus, points one and four cannot be seen because pencils of light
emanating from these points diverge beyond the observer’s pupil. To bring these pencils to the
observer’s pupil, their direction must be changed (Fig. 6). This requires a fairly large lens somewhere
between the patient’s and the observer’s eye. This principle was introduced by Ruete10 in 1852 and
is called indirect ophthalmoscopy to differentiate it from the first method, in which the light traveled
in a straight, direct path from the patient’s eye to the observer.
 Fig. 5. Limited field of view in the direct method. Peripheral pencils of light do not
reach the observer’s pupil.

Fig. 6. Extended field of view in the indirect method. The ophthalmoscopy lens
redirects peripheral pencils of light toward the observer.

The use of the intermediate lens has several important implications that make indirect
ophthalmoscopy more complicated than direct ophthalmoscopy.

The primary purpose of the ophthalmoscopy lens is to bend pencils of light toward the observer’s
pupil. Figure 6 also demonstrates one of the most characteristic side effects of this arrangement:
Compared with the image in direct ophthalmoscopy, the orientation of the image on the observer’s
retina is inverted. For the novice, this often causes confusion in localization and orientation. Figure
6 further shows that in this arrangement the patient’s pupil is imaged in the pupillary plane of the
observer. In optical terms the pupils are in conjugate planes. This fact is useful later in this
discussion.

FIELD OF VIEW IN INDIRECT OPHTHALMOSCOPY

The field of view in indirect ophthalmoscopy is determined by the rays emerging from the patient’s
eye that can be caught in the ophthalmoscopy lens. With optimal placement of the lens and of the
observer’s eye, the distance from the patient’s eye to the lens is only slightly more than the focal
length of the lens. (The exact distance will be calculated later.) The field of view, therefore, is
determined by the ratio of lens diameter and focal length. This ratio can also be written as a
product:
Lens diameter/Focal length = Lens diameter × dioptric power

This provides an easy formula for comparing the field of view of various lenses.

Given lenses of equal power, a larger lens provides a wider field of view. If lenses have equal
diameters, a stronger lens provides a wider field of view; however, because stronger lenses often
have a smaller diameter, a stronger ophthalmoscopy lens does not always provide a larger field. A
20-diopter (D) lens of 30 mm provides about the same field of view as a 30-D lens of 20 mm or as a
13-D lens of 45 mm (because 20 × 30 = 30 × 20 = ±13 × 45).

IMAGING IN INDIRECT OPHTHALMOSCOPY

Figure 6 shows that light emerging from the patient’s fundus is directed toward the observer’s eyes.
It does not specify whether the observer sees a focused image or just an unstructured red
reflex. Figure 7 traces the rays within one of the pencils of light from the patient’s fundus to the
observer’s retina.

Fig. 7. Imaging in the indirect method. A pencil of rays (shaded) is traced from the
patient’s fundus to the observer’s retina. An intermediate, inverted image of the
patient’s fundus is formed in the focal plane of the ophthalmoscopy lens. The
observer must accommodate on this image.

If the patient is emmetropic, the pencils emerging from the eye are composed of parallel rays, but
this changes once the pencils pass through the ophthalmoscopy lens. In fact, because the rays within
each pencil enter the ophthalmoscopy lens with zero vergence, they are brought to a focus in the
focal plane of the ophthalmoscopy lens. Proceeding beyond that point, the rays within each pencil
are divergent.

Considering all pencils emerging from the patient’s eye together, an aerial image of the patient’s
fundus will be formed in the focal plane of the ophthalmoscopy lens. This image is inverted with
respect to the patient’s fundus, and it is this image that the observer is viewing. To focus the aerial
image on his or her own retina, the observer must accommodate for the aerial image plane and
hence cannot approach too closely.

It may be useful to recall the difference between tracing of pencils and tracing of rays. In any optical
system, tracing of pencils is necessary to determine the limits of the field of view; tracing of rays is
necessary to determine the position of the image plane.Optical diagrams may confuse the
uninitiated, because they generally trace only one ray per pencil (see Figs. 5 and 6) and may use
theoretic auxiliary rays beyond the physically existing pencils (see Fig. 4) to facilitate the
construction of object and image planes.
In direct ophthalmoscopy, peripheral pencils of light are increasingly cut off by the observer’s and
patient’s pupils (see Fig. 4). In indirect ophthalmoscopy (see Fig. 7) this does not happen; only the
observer’s pupil limits the diameter of the pencils that reach the observer’s retina. The apparent
luminosity of the fundus image, therefore, is constant throughout the field (provided, of course, that
the fundus is illuminated evenly). This is one reason fundus cameras are built around the imaging
principle of indirect ophthalmoscopy.

In summary, the purpose of the ophthalmoscopy lens in indirect ophthalmoscopy is to redirect

diverging pencils of light emerging from the patient’s pupil toward the observer’s eye. In doing so,
the lens also focuses parallel rays within each pencil into an inverted aerial image of the patient’s
fundus. The existence of an inverted aerial image is one of the most prominent and unavoidable
characteristics of indirect ophthalmoscopy.

Another characteristic of indirect ophthalmoscopy is that it requires a considerable distance

between the patient and the observer. This is in contrast to direct ophthalmoscopy, in which close
approximation is advantageous. When tuberculosis and other respiratory infections were common,
the arm’s length distance between observer and patient was considered an additional advantage of
the indirect method. In Europe, indirect ophthalmoscopy has been the preferred method; direct
ophthalmoscopy is used mainly for additional detail. In the English-speaking countries the opposite
has occurred; indirect ophthalmoscopy did not become popular until the introduction of the
binocular indirect ophthalmoscope by Schepens.14

The indirect method offers a wider field of view than does direct ophthalmoscopy, but this
advantage is at the expense of decreased magnification. How do the two methods compare?

MAGNIFICATION IN DIRECT OPHTHALMOSCOPY

If the patient and the observer are both emmetropic, the optical diagram for direct ophthalmoscopy
(see Fig. 4) is completely symmetric. It is easy to see that the size of the retinal image in the
observer’s eye will equal the size of the fundus detail seen. In this sense the magnification is 1/1,
that is, the image of the patient’s disc will measure one disc diameter on the observer’s retina.

Another more conventional way of defining magnification is to compare the observer’s view of a
given object with the view that would be obtained when looking at the same object from a standard
distance. The usual standard for comparison is 25 cm. How much larger does the patient’s disc
appear than does the disc of a dissected eye viewed at 25 cm?

For this calculation the optics of the reduced eye (discussed elsewhere in these volumes) may be
compared with a linen tester or other hand-held magnifier of 60 D (Fig. 8). Such a lens allows a
viewing distance of 0.0167 m, 15 times shorter than the reference distance of 0.250 m. Thus, the
viewing angle is 15 times larger, and the magnification is said to be 15 times.
 Fig. 8. Magnification in the direct method. Viewing the fundus through the optics of
the patient’s eye (60 D in the reduced eye) can be compared with viewing a
specimen under a 60-D magnifier.

If the patient and the observer are not both emmetropic, the calculations are more complex. Axial
length of both eyes, refractive power of both eyes, and the position of the compensating lenses in
the ophthalmoscope must all be considered; the eyes of myopic patients have extra plus power and
the ophthalmoscope must carry a negative lens. This combination, in part, acts as a Galilean
telescope for the observer, and fundus details are seen larger. In aphakia the reverse happens:
fundus details are seen smaller, as through a reversed Galilean telescope.

In direct ophthalmoscopy the image on the observer’s retina is about as large as the fundus detail
viewed and is 15 times larger than it would be if the same fundus detail were viewed from 25 cm.

An additional 2× magnification can be achieved by placing a small Galilean telescope on the

ophthalmoscope, but fundus microscopy with the slit lamp and a contact lens is a better way to
achieve this level of magnification.

MAGNIFICATION IN INDIRECT OPHTHALMOSCOPY

Magnification in indirect ophthalmoscopy can best be understood if broken down into two
components: magnification from fundus detail to aerial image and magnification from aerial image
to the observer’s retinal image. Magnification in the first step depends on the power of the
ophthalmoscopy lens; magnification in the second step depends on the observation distance.

If the patient is emmetropic, the aerial image is formed in the focal plane of the lens (compare Fig.
7). Figure 9 shows that
 Fig. 9. Magnification of the aerial image in the indirect method. Aerial image size is
found through construction of an imaginary, auxiliary ray (dotted line). Fundus
detail f × sin α. Aerial image is f × sin α.

Aerial image/Fundus detail = flens × sin α/feye × sin α = flens/feye

converting from focal length to diopters and assuming 60 D as the power of the eye

Aerial image/Fundus detail = flens × sin α/feye × sin α = flens/feye = Deye/Dlens = 60/lens power

Thus the aerial image formed by a 20-D lens will be 60/20, or three times larger than the
corresponding fundus detail; with a 30-D lens it will be 60/30, or two times larger.

When the aerial image is viewed from 25 cm, no further magnification is involved, because 25 cm is
the reference distance for magnification. A 25-cm viewing distance from the aerial image requires 4
D of accommodation on the part of the observer; a more common viewing distance is 40 cm,
requiring 2.5 D of accommodation. Changing from 25 cm to 40 cm reduces the observer’s retinal
image size by 25/40 or 5/8.

Combining both steps we obtain the following: With a 20-D lens and a distance of 25 cm from aerial
image to observer, the patient’s disc is seen 3 timeslarger than the disc of a dissected eye at 25 cm.
With direct ophthalmoscopy this would have been 15 times larger. Indirect ophthalmoscopy in this
case provides five times less magnification than does direct ophthalmoscopy. For a 40-cm viewing
distance the magnification becomes 5/8 × 3, which is approximately 2, or 8 times less than direct
ophthalmoscopy.

Similar calculations can be made for other lenses. Figure 10 summarizes data for lenses of 30 D, 20
D, and 13 D. As the magnification becomes less, the area of the patient’s fundus that can be imaged
on a given area of the observer’s retina increases quadratically; for instance, 8 times less linear
magnification potentially results in a 64-times larger area seen. Whether this potential is realized
depends on the factors mentioned in the discussion of the field of view in both methods: width of
the illuminating beam in direct ophthalmoscopy and diameter of the ophthalmoscopy lens in
indirect ophthalmoscopy.