Direct ophthalmoscopy should be taught to undergraduate medical students

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It is with great interest that we read your controversy regarding whether or not direct ophthalmoscopy should be taught to medical students.1, 2

We feel that direct ophthalmoscopy is a fundamental skill that all doctors should be able to perform. However, the skills in ophthalmoscopy must be complemented by a complete ocular examination and not consist of ophthalmoscopy alone (particularly visual acuity measurement, examination of pupils, visual fields and basic eye movements). For example, a doctor may feel that an optic disc appears to be swollen; however, it is only after complementing this assessment by proving the presence of an RAPD that their strength of conviction would grow.

Direct ophthalmoscopy can form part of final year examination assessment at Medical School and several post-graduate membership examinations. Eye problems represent 1.5% of presentations to GPs3 and consultation rates for GP and eye casualty have been recorded at 71.8 per 1000 population per year.4

Bruner5 developed the theory of the spiral curriculum whereby complex ideas can be taught at simple levels early on and then re-visited at more complex levels later on. This idea of spiral learning underpins many medical school curriculums and encourages independent problem solving. Therefore, one can be exposed to the technique of direct ophthalmoscopy early on during medical school clinical teaching and re-visit situations when the direct ophthalmoscope would aid diagnosis and management in later clinical years. This technique currently underpins much of current clinical teaching today. For example, most medical students learn the ‘nut-and-bolts’ of a cardio-respiratory examination in the first year of medical school but only contextualise this in later years.

Ideally, when examining a fundus we would want to dilate the pupil and this is rarely done outside of the ophthalmology clinic, because of the fear of inducing angle closure glaucoma. Knowing that the risk of such an event occurring with Tropicamide eye drops is negligible should re-assure doctors. Guidance needs to be integrated within the curriculum allowing use of mydriatics to allow adequate examination. Not doing this would be akin to expecting detection of a murmur through multiple layers of clothing.


  1. 1

    Yusuf IH, Salmon JF, Patel CK . Direct ophthalmoscopy should be taught to undergraduate medical students – yes. Eye (Lond) 2015; 29: 987–989.

  2. 2

    Purbrick RMJ, Chong NV . Direct ophthalmoscopy should be taught to undergraduate medical students – no. Eye (Lond) 2015; 29: 990–991.

  3. 3

    Sheldrick JH, Wilson AD, Vernon SA, Sheldrick CM . Management of ophthalmic disease in general practice. Br J Gen Pract 1993; 43 (376): 459–462.

  4. 4

    Sheldrick JH, Vernon SA, Wilson A, Read SJ . Demand incidence and episode rates of ophthalmic disease in a defined urban population. BMJ 1992; 305: 933–936.

  5. 5

    Bruner J . The Process of Education. Harvard University Press: Cambridge, MA, USA, 1960.

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Correspondence to I Jawaid.

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Jawaid, I., Hill, S. & Amoaku, W. Direct ophthalmoscopy should be taught to undergraduate medical students. Eye 30, 326 (2016) doi:10.1038/eye.2015.224

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