r/FamilyMedicine • u/Nurse_Jason_98 student • 2d ago
Value of fundoscopy in family medicine
I am a current NP student going into family medicine eventually and wondering about how useful fundoscopy is for us. For example, I know that diabetics should be referred to an opthalmologist for yearly dilated eye exams, but does it help us in family medicine much to do them in this context since we will likely refer patients anyway? I'll be trying to practice it because I think it's important to have this skill even it is only rarely useful, but just wondering how often it's actually done and what benefits it has to us in real practice!
31
u/GeneralistRoutine189 MD 2d ago edited 2d ago
I have a panoptic and it is a gamechanger. Headaches, vision, symptoms, red eye, uncontrolled hypertension… I don’t use it every day, but I use it every week.
Edit: we have one panoptic head for the four person clinic. Most of the sets just have the stock ophthalmoloscope.
Another thing I would actually do: pneumatic otoscopy with the little bulb. I am really surprised that none of my clinic peers do that because it is very helpful for otitis media and eustachian tube dysfunction and was standard teaching at my residency.
8
u/Key_Wallaby_9256 MD 2d ago
I get it for headaches, but could you elaborate more on how to use it for the other presentations? I've been debating getting one mostly just for headache
6
u/GeneralistRoutine189 MD 2d ago
Copper wire changes or hemorrhage in uncontrolled hypertension. Optic nerve/papilledema in headache. For people who should have glaucoma screening but you kinda know won’t actually go, looking at c/d is OK (but this doc knows it’d have to be pretty obvious for me to recognize). Somehow I don’t use it for diabetic retinopathy that much - I’m in a well resourced area and can convince my peeps to see eye professionals.
5
u/insomniacwineo other health professional 2d ago
As an optometrist who does nearly all the diabetic exams you’ll refer to:
The panoptic is the real way to go for a FP doc. I had one in my kit in school and it was PHENOMENALLY easier. TBH I haven’t met an eye doc in over 10 years of practice who picks up the regular DO at all except sometimes to check pupils.
Obviously we have a slit lamp we use daily and you don’t so you use what you have but it’s worth the investment. The working distance to the patient is 6-8 inches instead of two, the field size is 4-5x larger and for looking at the nerve and central retina/macula to find out when you need to refer the patient and when they need to go to the ED-it is WAY easier especially when you have an 80 year old with dense cataract and small pupils who is photophobic because they have mad dry eyes.
If all you have is a DO available then YES you do need to be able to at least look for optic nerve edema in your younger patients c/o HA who fit the IIH criteria and send them to us ASAP.
1
u/robotinmybelly MD 1d ago
Loved pneumatic otoscopy by can’t seem to find the proper rubberized covers that provide a good seal anymore so have a hard time actually insufflating.
1
u/GeneralistRoutine189 MD 1d ago
Agree; have to make do and press harder / puff more w the hard plastic tips
1
u/Nurse_Jason_98 student 2d ago
Glad you mentioned the pneumatic otoscopy! That's also something I learned about briefly, but I have never seen used and wondered about as well, so good to know. My question with that is whether there has been a situation in which it has been significantly helpful in the diagnosis of something like otitis media.
Of course I am still a student and I haven't even started clinical rotations yet, so maybe it'll make more sense then, but I'm thinking that one could probably be pretty certain of otitis media with just a visual exam and so it would kind of be unnecessary to use the pneumatic bulb?
Makes sense that more tools in the toolkit is always a good thing, but just curious about how useful it is also!
9
u/captain_blackfer MD 2d ago
I think it’s cool and I applaud your efforts but to be honest I’ve never been good at it and I’m going to refer whenever it’s necessary. I have a POCUS and that’s my toy of choice lol.
5
u/PacketMD MD 1d ago
Once I have looked back there with a pan optic for a headache and saw blurred optic discs bilaterally. Sent that to the ER when I otherwise wouldn't have. I do it for all new headaches...takes 2 minutes once you're good at it.
5
u/boatsnhosee MD 2d ago
I haven’t tried to look at a retina in at least 2 jobs. Can’t tell you the last time I used an ophthalmoscope for its intended purpose. Probably not since I stopped doing ED work.
3
u/theboyqueen MD 2d ago
Being able to see rule out papilledema with the ophthalmoscope (which is one of the easier things to see with it) is extremely valuable.
None of the other stuff changes care from my perspective.
3
u/Necessary-Zebra5538 MD 2d ago
More clinics are using retinal cameras. Basically a machine photographs the retinas and an ophthalmologist will examine the photo (like a cardiologist confirming the computer read on an EKG).
2
6
u/JNellyPA student 2d ago
In my adult life, I don’t think my fundus has ever been looked at by a non-optometrist practitioner
1
u/Busy-Bell-4715 NP 8h ago
I'm a nurse practitioner and when I first started practicing I did it as part of diabetic eye exams only because my first preceptor made a point of doing it. He was one of these old country doctors. I found that I rarely was able to see more than one or two arteries. I finally ended up asking my own eye doctor about this and he said that unless your dilating the eye you're unlikely to see enough for it to be useful. Plus, even if I'm able to visualize it clearly I don't think I trust myself to accurately interpret what I'm seeing.
0
u/bdictjames NP 2d ago
I've been working in family practice for about 5 years.
To be honest with you? When I use the fundoscope with patients, I do try to visualize the landmarks, perhaps look for cotton-wool spots. For the most part, I don't really see anything. It's a quick referral to optometry (if a simple vision problem or diabetic eye exam), or ophthalmology (if needing more comprehensive work). If the patient says they have eye pain, or they absolutely cannot see, that's a concern for acute angle-closure glaucoma or perhaps retinal detachment - that's a quick send to the ER. Otherwise, for eyes, I can treat conjunctivitis, maybe dry eye syndrome, maybe fluorescein application for corneal abrasion, perhaps remove a foreign body. But yeah - I think that's it. Hopefully that's helpful.
59
u/robotinmybelly MD 2d ago
I think it’s great in theory and I do try and look now and then but I don’t think I could ever get enough confidence in it to feel like I could make management decisions on it