Street Smarts

Eulogy for the Direct Ophthalmoscope

Though this little instrument was once all the rage, it's time to bury it for good.

By Dan Beck, OD, Leland, N.C.

The direct ophthalmoscope, long revered as an important part of the ophthalmic diagnostic kit, usually is the first purchase optometry students make. From day one, students place it at the top of the list for competence when taking clinical skills courses.

In advertising, optometric offices have featured images of doctors using the direct ophthalmoscope on patients far more than any other instrument. Just walk by any LensCrafters: The proof is on the wall right next to the OD.

Going the Way of the Dinosaurs

The truth is, for all its popularity, the direct ophthalmoscope is an eyecare dinosaur that has virtually no use in today's optometric practice.

Retinal views through a direct ophthalmoscope provide painfully limited, monocular images of the optic nerve and little else. A clinician's face has to come within 1 inch of the patient's face to achieve best results. The majority of the population is very uncomfortable having their personal space invaded to the extreme degree that's necessary for direct ophthalmoscopy.

Dispelled Myths

The old argument that you need direct ophthalmoscopy in undilated patients has long been debunked. You can get great views of the posterior pole in patients who aren't dilated with most slit lamp condensing lenses. Direct ophthalmoscopes also fall pathetically short in patients with tiny pupils and cataracts. They're considered little more than fancy flashlights in real eye care.

It Has its Place

I'm not suggesting that professors should stop teaching optometry school students how to use the direct ophthalmoscope. That would be unrealistic. I'm simply saying the importance clinicians may place on it and the time spent learning how to use it should be limited.

Students certainly shouldn't be required to buy a direct ophthalmoscope. That money would be better spent on a biomicroscopy lens. Some of the newer condensing lenses provide views that come close to those of the binocular indirect ophthalmoscope.

The only legitimate places for direct ophthalmoscopes are in practices that don't have slit lamps, such as general practitioners' offices or small clinics. In optometric practices, however, the instrument should be extinct. nOD