Help with scleral depression

[Cdnophthalresident]

Hey guys - just wanted to ask a quick question about scleral depression, for those of you who have mastered it or developed the skills a bit more.
I've done a search previously in the forum for it, I know that I'm supposed to keep practicing (practice makes perfect!) and such but just want to see where to go next.
I have one of the josephberg depressors (with the round paddle). I can see the mound when I depress for some patients and I can "roll" the mound while looking through the indirect. I'm starting to get a sense to move anteriorly, but I still can't consistently see the ora. The glare from the indirect light also gets a bit in the way, as the view isn't that good. I feel like I'm also not "filling the lens" with the full image. It's frustrating that I did depress in an area in one patient but I missed a tear.

Can anyone advise me on what I should do next? I would like to be able to depress effectively and not miss tears as best as I can.

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[DrQuakerJack]

I could be wrong but I think we all struggle with this. Im a second year (almost 3rd year) and I still have troubles seeing the bump and still get lots of glare at times.

It also seems that we are working in degrees of certainty and even the best retina specialists can miss small holes. For better or worse, I rely on schaeffers sign, presence of vitreous hemorrhage and history to help triage when I can't find any retinal pathology.

Would also be interested to see what general ophthalmologists do when they aren't confident in their peripheral exam as well.

 

[speyeder]

Until you do a retina fellowship most ophthalmologists have a hard time with scleral depression. Below are some general pointers that may help with your exam:

• Numb the eyes
• Recline the patients back until they are parallel to the floor
• Have the patient look in the opposite direction of where you want to depress. If you want to look @ 6:00, have them look at 12:00
• Slide the depressor over the lid, then have the patient look @ 6:00
• Place the depressor more posteriorly when first starting out. A common mistake is to have the depressor positioned too anteriorly
• Make sure you, the depressor and your lens are in a perfect line
• Look more posteriorly to see the hump. A common mistake is looking too anteriorly. You may miss the hump
• Once you see the depressed retina, move your depressor anteriorly, posteriorly and laterally. Scleral depression if done correctly is a dynamic exam

 

[MstaKing10]

All good tips except I’m confused on gaze. I do the opposite. If I want to look at 6:00 I have the patient look at 6:00 and depress at 6:00 but position myself at 12:00. I would find it difficult to do the opposite. Can you clarify?

Also the AAO proffered practice patterns recommends scleral depression for ALL cases of PVD. So general ophthalmologist should definitely learn this skill. Or refer to retina 🙂

 

[speyeder]

All good tips except I’m confused on gaze. I do the opposite. If I want to look at 6:00 I have the patient look at 6:00 and depress at 6:00 but position myself at 12:00. I would find it difficult to do the opposite. Can you clarify?

Also the AAO proffered practice patterns recommends scleral depression for ALL cases of PVD. So general ophthalmologist should definitely learn this skill. Or refer to retina 🙂

Yes I also stand opposite of where I want the patient to look. If I'm looking at 6:00 I stand at 12:00.

I just mean I have the patient look at 12:00 first to allow me to slide the depressor underneath the lid at 6:00.

 

[Iladelphia]

Great tips from everyone.
Here is another question for you (perhaps more geared to any retina specialists in the forum): what do you think of a 3 mirror contact lens evaluation of the peripheral retina in place of indirect with sclera depression? I’ve found a few holes/tears with the former. Also seems a little more tolerable from a patient perspective. Can this be used in place of a indirect/scleral depression, not only medically but legally in the evaluation of a PVD?

 

[skarim]

I agree with Speyeder's tips, they are all very good. Most important tip is to lie them all the way back flat. otherwise you have no chance. Also very important as mentioned, stand 180 from where you are trying to see so you end up circling the head of the patient during your depressed exam. When learning, most people press too hard, and that's why it's uncomfortable.

Superotemporal is easiest to initially to learn to depress as best exposure. Also, easier on phakic patients so not trying to look around/through IOL edge. For the first few times while learning, if you think the patient can tolerate it, you can numb the eye and depress directly on sclera, maybe even use a speculum. It is much easier when you don't have to deal with the lid. Can try this a few times in ST quadrant until you know what to look for.

Inferior is difficult. Ask the patient to look half way down. Most times they look too far down and the sclera is buried.

Nasal and temporal is also a little tricky because patients are most sensitive here and because of the lid. You don't need to depress directly on the sclera to see 3 and 9 o'clock. You can depress on the lid and then slide over to see those positions.

Vast majority of breaks can be seen at the slit lamp if looking carefully and with high suspicion. I use the volk digital widefield and its rare that there is a break on scleral depression that wasn't suspicious or seen with the digital widefield. Breaks are easier to see with the higher magnification at the slit lamp

I don't know if the 3 mirror lens would be sufficient legally. It would be kind of a hassle to turn 360 to look at the whole eye. occasionally I may use a contact PRP lens such as the superquad 160 gives you a view of the whole eye at once.

In no time, you'll be ready to do cryo/pneumatic retinopexies and scleral buckles!! 🙂

 

[Cdnophthalresident]

I agree with Speyeder's tips, they are all very good. Most important tip is to lie them all the way back flat. otherwise you have no chance. Also very important as mentioned, stand 180 from where you are trying to see so you end up circling the head of the patient during your depressed exam. When learning, most people press too hard, and that's why it's uncomfortable.

Superotemporal is easiest to initially to learn to depress as best exposure. Also, easier on phakic patients so not trying to look around/through IOL edge. For the first few times while learning, if you think the patient can tolerate it, you can numb the eye and depress directly on sclera, maybe even use a speculum. It is much easier when you don't have to deal with the lid. Can try this a few times in ST quadrant until you know what to look for.

Inferior is difficult. Ask the patient to look half way down. Most times they look too far down and the sclera is buried.

Nasal and temporal is also a little tricky because patients are most sensitive here and because of the lid. You don't need to depress directly on the sclera to see 3 and 9 o'clock. You can depress on the lid and then slide over to see those positions.

Vast majority of breaks can be seen at the slit lamp if looking carefully and with high suspicion. I use the volk digital widefield and its rare that there is a break on scleral depression that wasn't suspicious or seen with the digital widefield. Breaks are easier to see with the higher magnification at the slit lamp

I don't know if the 3 mirror lens would be sufficient legally. It would be kind of a hassle to turn 360 to look at the whole eye. occasionally I may use a contact PRP lens such as the superquad 160 gives you a view of the whole eye at once.

In no time, you'll be ready to do cryo/pneumatic retinopexies and scleral buckles!! 🙂

Thanks so much for the tips!!

Can I ask about the sclera being buried - wouldn't that be easier to see the far periphery? I'm just trying to visualize it in my head and I thought the further someone can "look" the easier it is for the lens to be in position to view the far periphery (+/- with depression).

Also quick question - I see some of my retina attendings sometimes "tilt" the lens. I'm always unclear on what this does or helps with exactly?

 

[skarim]

Thanks so much for the tips!!

Can I ask about the sclera being buried - wouldn't that be easier to see the far periphery? I'm just trying to visualize it in my head and I thought the further someone can "look" the easier it is for the lens to be in position to view the far periphery (+/- with depression).

Also quick question - I see some of my retina attendings sometimes "tilt" the lens. I'm always unclear on what this does or helps with exactly?

If they are looking too far eccentrically, you’re not giving yourself enough of a pupillary opening to look through.

I’m not sure why some retina attendings would tilt the lens. The only thing I can think of is maybe it reduces some glare.

 

[ophtho838]

Also try different head positioning. Tilting the head/chin can sometimes help you get a more tangential view without straining your back/neck. Raising and lowering the height of the chair can also help. Practice really does make perfect though.