Comment on: 'Direct ophthalmoscopy should be taught to undergraduate medical students'

Sir,

We read with interest the controversy surrounding direct ophthalmoscopy.^{1, 2} Purbrick and Chong suggests substituting direct ophthalmoscopy with fundus photography.¹ Non-mydriatic fundus photography remains expensive and therefore difficult to disseminate internationally and smartphone applications such as PEEK require more detailed assessment. Although these technologies may hold promise for the future, they do not replace the need for clinical ophthalmic assessment. Perhaps rather than replacing direct ophthalmoscopy, fundal photographs could be used to supplement and aid the teaching of this important clinical skill.

We have shown by using a simple patient assessment tool that in-patients referred to neurology were not appropriately examined—in particular, omission of ophthalmoscopy—before referral.³ We feel this data should not be used as an excuse to stop examining patients. Instead we agree with Yusuf et al² that despite advances in non-mydriatic fundus photography, basic skills in ophthalmic assessment are essential and advocate that there is no substitute for appropriate clinical examination.^{4, 5}

It is unrealistic to expect undergraduates to be competent at direct ophthalmoscopy at the end of their short ophthalmology attachment. Instead, these skills should be taught early in the clinical curriculum so that they can be practised, reinforced, honed, and (most importantly) assessed during further attachments in neurology and general medicine. This requires the support and collaborative efforts of ophthalmologists, physicians, and educators at undergraduate and postgraduate levels to ensure these important clinical skills are engrained for the benefit of our patients.