eye exams---to dilate or not to dilate?

[shortbread9]

Hi there...
I work in a very academic hospital with every specialty that could possibly exist. it is common knowledge that we do not dilate any patients eyes for an eye exam and let the ophtho residents take care of it. the mentality is somewhat confusing...ive heard things from "we are not qualified?, to the ophtho residents are the experts, to we may induce acute angle glaucoma"
my questions is what is the consensus in the real community world (as attendings)and other residency programs.....Do you dilate your patients eyes for what would seem to be a more accurate exam??
some of my attendings feel we should be able to get a great view of the vessels and optic nerve in an undilated eye....which after working with an ophthomologist seems pretty difficult and unnecessary.
My concern is that i will be going into community EM as of next July and if i dont have ophtho in case.....should i risk dilating a patients eye? What are the real concerns...etc.
thanks!

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[xaelia]

Getting a view of the optic disc for papilledema ought to be achievable with dedicated effort in nearly every cooperative patient in an undilated eye. Looking for the absence arteriovenous pulsations...oof, I never can see that. I've also never used the Panoptic more than a handful of times; perhaps that makes the undilated exam easier.

I'm really not sure what the dilated exam would add. I actually feel like I could do a decent indirect exam of the center of the retina at the slit lamp with the 90D, 78D or a Super 66, but obviously direct ophthalmoscopy with the 20D is beyond the scope of everyone but well-practiced ophthalmologist. If I were worried about a retinal detachment and couldn't get a good view for whatever reason...I'd probably almost feel more confident getting the ultrasound machine.

 

[kungfufishing]

Can't think of a time when this has really mattered in terms of what I needed to do/needed to know. I mean, I do use cycloplegics from time to time for patient comfort but dilating for an exam is just not a common problem.

 

[Jeff698]

Nope, no dilation for this community guy.

Take care,
Jeff

 

[dchristismi]

Me either.

 

[bartleby]

Dilation is potentially harmful (acute angle closure glaucoma, the potential to precipitate the prolapse of some implanted prosthetic lenses) and adds little to the non-ophthalmologist's eye exam. If you are so concerned about someone that you feel that a dilated exam is necessary to rule out an acute retinal process like detachment, then that is a sign that you should probably be involving an ophthalmologist in the case.

 

[deleted109597]

Also, dilating adds a fair amount of time, requires you to provide them with sunglasses so they can drive home, and any number of other problems.

Of course, ophthal uses cycloplegics on everyone, and you'd think that if they can handle acute angle closure in their office, we could do it in the ED.

 

[roja]

Nope, no dilation here.

 

[NinerNiner999]

No dilation here either (and I know where you are training....)

 

[southerndoc]

Two words: PanOptic Ophthalmoscope

 

[shortbread9]

Yes NinerNiner999.....i do know you know where i train!! hahaha. but in 11 months when im out of this crazy place i fear i will be faced with questions like this.....(we are actually seeing lots more ophtho patients since wilmer er is closing!)

 

[WilcoWorld]

I never dilate.

But I ALWAYS document visual acuity, I keep a low threshold for checking intraocular pressures, and I try to remember central causes of vision loss.

I recently had a patient transfered to our ED for ophtho consult because a rural ED doc suspected retinal detachment. Ophtho met the guy at the door (I think I heard the theme for the Twilight Zone playing when that happened), did their exam and said he was fine and should be discharged before I even got to see him. He had a not entirely distinguishable visual field cut on my neuro exam so instead of trying to figure out a lesion neuroanatomically I ordered a low-yield non-con head CT... BIG ol' tumor.

The poor guy was a scientist in a field where vision is important.