Related to the article Teaching ophthalmoscopy to medical students (the TOTeMS study) by Dr. Biousse and her colleagues, we wish to share our experience in teaching direct ophthalmoscopy.

Typically, students were told, “Instruct the patient to look forward at a distant target, use your right eye and right hand to examine the patient’s right eye. Set the diopter power to 0 (in case of emmetropia). Slowly move closer to the patient to locate the retinal blood vessel.” In this way, most students complained they saw nothing and felt frustrated after trying several times.

To increase the students’ confidence and efficiency in learning direct ophthalmoscopy, we first assured the students that “both you and I have normal vision. If you do exactly what I do, you will see what I see.” Then students were instructed to perform the following steps:

• 1.
  

  Instruct the patient to look forward at a distant target. Set the diopter power to 0 (in case of emmetropia).

  
  
• 2.
  

  Stand by the right side of the patient, holding the ophthalmoscope in your right hand, with the index finger located on the lens wheel. Place your left hand on the patient’s eyebrow.

  
  
• 3.
  

  Get the ophthalmoscope in touch with your right eye and look through the ophthalmoscope.

  
  
• 4.
  

  At arm’s length from the patient, aiming your ophthalmoscope at your patient’s right eye at an angle of 15-20 degrees temporally from the patient’s line of sight, you will see a reduced image of the external eye. In the center of the image, you will see a red reflex from the pupil.

  
  
• 5.
  

  Keeping the red reflex in your view, slowly move closer to the patient; you will see the retinal blood vessel. The closer you are to the patient’s pupil, the better view you will get.

In this instruction, we tell student exactly what we felt and saw during the process of getting closer to the patient to locate the retinal blood vessel.

We applied our strategy in 394 junior medical students with informed consent. About 30 students in each small class had 2 hours to practice direct ophthalmoscopy. At first, the students were instructed in the traditional way. In the middle of the class, the number of the students who saw the retinal blood vessel was recorded. Then the students were instructed to follow our precise description steps. At the end of the class, the total number of the students who saw the retinal blood vessel was recorded. Of the 394 students, only 32 (8.1%) students could see the retinal blood vessel in the middle of the class after following the traditional instruction, whereas 350 (88.9%) students could see the retinal blood vessel at the end of the class after following our precise description steps.

Once the students could see the retinal blood vessel, they were willing to spend more time to locate the optic disc and macula. Our precise description strategy tremendously improved the students’ confidence and interest in the practice of direct ophthalmoscopy.