Introduction
The eye examination and fundoscopy OSCE tests your ability to assess vision systematically and interpret retinal findings. Diabetic retinopathy is the most common cause of blindness in working-age adults in the UK and the most tested fundoscopy scenario.
💎 Clinical Pearl
Dim the room, ask the patient to focus on a distant point, and approach from 15 degrees lateral to the visual axis to see the optic disc first. Warn the patient the light will be bright.
1. Visual Acuity — Snellen Chart
- Position 6 metres from the chart (or 3 m mirror)
- Test each eye separately; use a pinhole if acuity is reduced (corrects refractive error, not optic nerve disease)
- Record as 6/x where x is the smallest line read correctly
| Snellen | Meaning |
|---|---|
| 6/6 | Normal |
| 6/12 | Reads at 6 m what a normal person reads at 12 m |
| 6/60 | Minimum standard for visual fields driving assessment |
| Below 6/60 | Test: counting fingers (CF), hand movements (HM), light perception (LP) |
2. Visual Fields — Confrontation Testing
- Sit 1 m from the patient at eye level; cover your right eye, patient covers left
- Bring a red hat pin or finger from the periphery in each quadrant
- Map patient's field against yours as the control
- Test for central scotoma: ask if the pin changes colour centrally
| Field defect | Location |
|---|---|
| Monocular visual loss | Retina or optic nerve (ipsilateral) |
| Bitemporal hemianopia | Optic chiasm (pituitary tumour) |
| Homonymous hemianopia | Optic tract, radiation, or occipital cortex (contralateral) |
| Upper quadrantanopia | Temporal lobe (Meyer's loop) |
| Lower quadrantanopia | Parietal lobe |
3. Pupils
Assess with the PERLA acronym: Pupils Equal and Reactive to Light and Accommodation.
Relative Afferent Pupillary Defect (RAPD)
The swinging flashlight test: swing the torch from eye to eye every 2-3 seconds. In a normal response, both pupils constrict when light is shone into either eye. A RAPD is present when both pupils dilate as the light is swung to the affected eye, indicating reduced afferent input (optic nerve or extensive retinal disease).
4. Fundoscopy — DVMP Framework
🧠 Mnemonic
DVMP — Disc, Vessels, Macula, Periphery
- 1Disc: colour (pink is normal, pale = optic atrophy), margins (sharp or blurred = papilloedema), cup-to-disc ratio (under 0.5 normal; enlarged in glaucoma)
- 2Vessels: arteriole-to-venule ratio (normal 2:3), silver wiring, copper wiring, AV nipping
- 3Macula: ask patient to look at the light to centre it; look for exudates, haemorrhages, macular degeneration (drusen)
- 4Periphery: neovascularisation, pigmentation, retinal detachment
Common Fundoscopy Findings
Diabetic Retinopathy
| Stage | Features |
|---|---|
| Background (mild NPDR) | Microaneurysms (dots), dot-blot haemorrhages, hard exudates |
| Pre-proliferative (moderate-severe NPDR) | Cotton wool spots, flame haemorrhages, venous beading |
| Proliferative (PDR) | New vessels at disc (NVD) or elsewhere (NVE), vitreous haemorrhage |
| Diabetic maculopathy | Hard exudates within 1 disc diameter of fovea — causes central visual loss |
🧠 Mnemonic
Background = Bleed and Dots. Pre-proliferative = Cotton wool. Proliferative = New vessels.
Hypertensive Retinopathy (Keith-Wagener Grades)
| Grade | Features |
|---|---|
| 1 | Silver wiring of arteries |
| 2 | AV nipping (arteriovenous crossing changes) |
| 3 | Flame haemorrhages, cotton wool spots, hard exudates |
| 4 | Grade 3 plus papilloedema (malignant hypertension) |
Papilloedema
Blurred disc margins, disc elevation, loss of venous pulsations, venous engorgement. Bilateral papilloedema = raised intracranial pressure until proven otherwise. Causes: space-occupying lesion, idiopathic intracranial hypertension, malignant hypertension, meningitis, hydrocephalus.
Optic Atrophy
Pale white optic disc with sharp margins. Causes: MS (optic neuritis), ischaemic optic neuropathy, glaucoma, compressive optic nerve lesion.
How to Present Fundoscopy Findings
"On fundoscopy the optic disc was clearly visible with sharp margins and a normal cup-to-disc ratio. There were multiple dot-and-blot haemorrhages and hard exudates in the posterior pole with microaneurysms visible. There was no neovascularisation. These findings are consistent with background diabetic retinopathy without maculopathy. I would refer to the diabetic eye screening programme and optimise glycaemic and blood pressure control."
"What is DVMP and what do you look for at each stage?"
DVMP is a systematic approach to fundoscopy: Disc (colour, margins, cup-to-disc ratio), Vessels (AV ratio, silver wiring, AV nipping), Macula (exudates, haemorrhages, drusen), Periphery (neovascularisation, retinal detachment). Examining in this order ensures that no important finding is missed.
"What are the stages of diabetic retinopathy?"
Background (non-proliferative): microaneurysms, dot-blot haemorrhages, hard exudates. Pre-proliferative: cotton wool spots, flame haemorrhages, venous beading. Proliferative: new vessel formation at the disc or elsewhere, with risk of vitreous haemorrhage and traction retinal detachment. Maculopathy causes central visual loss and can occur at any stage.
"What is a relative afferent pupillary defect?"
RAPD is detected by the swinging flashlight test. When the torch is swung to the affected eye, both pupils dilate rather than constrict, indicating reduced afferent signal from that eye. It signifies optic nerve or extensive retinal disease on the affected side. A cataract or refractive error does not cause RAPD.
"What causes bilateral papilloedema?"
Bilateral papilloedema indicates raised intracranial pressure. Causes include space-occupying lesions (tumour, abscess, haematoma), idiopathic intracranial hypertension (classically young obese women), malignant hypertension, meningitis, and hydrocephalus. It is a clinical emergency requiring urgent CT head and neurosurgical review.
Related guides: [Ophthalmology History OSCE](/blog/ophthalmology-history-osce) | [Cranial Nerve Examination OSCE](/blog/cranial-nerve-examination-osce) | [Blood Results Interpretation OSCE](/blog/blood-results-interpretation-osce)