I suck at diagnosing CSME

[Garp]

Frustrated PGY-2 here. I know the rules: retinal thickening w/in 500um of fovea, HE's along with retinal thickening w/in 500um of fovea, and retinal thickening 1 DD in dm w/in 1 DD of fovea. blah blah blah.
My question is this: how do you tell that the retina is thickened? I often see HE's and MA's right around the fovea but can't tell whether there's edema. I've heard a bunch of answers but none satisfactory- supposedly you can narrow the beam to a slit and you will see it curve with edema...I've never gotten this to work. I don't want to seem like an idiot with my retina faculty, so does anybody have any suggestions or good links to explanations? Thanks.

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[7ontheline]

What lens are you using? I find that I can't see it easily unless I'm using a 78D lens or something with even more magnification. Also, sometimes I notice it because I'll see an area that is a little tricky to focus on. Then it becomes apparent that I have to pull back on the slit lamp a little, showing me that it's slightly elevated. Don't worry, you'll get it.

 

[JR]

I think the key is to use a macular contact lens if you are suspicious. Very hard to tell without it.

 

[Retinamark]

What lens are you using? I find that I can't see it easily unless I'm using a 78D lens or something with even more magnification. Also, sometimes I notice it because I'll see an area that is a little tricky to focus on. Then it becomes apparent that I have to pull back on the slit lamp a little, showing me that it's slightly elevated. Don't worry, you'll get it.

I agree with the post above.
My favorite lens of all though for the macula is the 60D. For macular lesions & subtle edema like mild CSR, the 60D is much much better than a 90. So often I have had junior residents (& even sometimes senior residents) not pick up subtle macular signs.
I don't use the 60 in every patient. It has downsides - it is more difficult to focus, you can't use it in small pupils. The key I think, is to recognise with the 90 when things are just not quite right & then use the 60 to make the diagnosis. Or in cases where findings don't quite add up, or you are really looking for subtle CSME, use the 60.

Theoretically the Volk Super 66 gives enhanced stereopsis. I tried it once & wasn't overly impressed, but I'm sure if I bought one & got used to it, it would be just as good, or maybe even better than the 60. It is more expensive though.

 

[Retinamark]

I think the key is to use a macular contact lens if you are suspicious. Very hard to tell without it.

Also a good idea. But if you do that, use Celluvisc or other similar gel with the lens. Nothing annoys retina attendings more than being asked to see a patient after the resident has messed up the cornea with goniosol and a contact lens
Celluvisc etc are much gentler on the epithelium than goniosol

 

[JR]

Also a good idea. But if you do that, use Celluvisc or other similar gel with the lens. Nothing annoys retina attendings more than being asked to see a patient after the resident has messed up the cornea with goniosol and a contact lens
Celluvisc etc are much gentler on the epithelium than goniosol

Ah, thanks for the tip. Although the CL our program bought for us supposedly does not require contact gel ??? I personally don't believe that, so I still use it.

Retinamark, do you know where I can buy a straight Shacket (spelling?) depressor? We were given these curved ones that no one wants or can use...

 

[Retinamark]

Hi, no I don't sorry. (& I'm not sure of the spelling either )
I know there are people who love the 3 mirror & try to indent with contact lenses, but I would really encourage you to put all your effort into getting good with scleral indentation & examining the ora that way. It is such a difficult but useful skill & if you are considering doing retina, you need to get good at indenting with the indirect for indirect lasers, cryo and scleral buckling.

Maybe though I should spend some time using the Shacket???? To be honest, I've never used it.

 

[JR]

Hi, no I don't sorry. (& I'm not sure of the spelling either )
I know there are people who love the 3 mirror & try to indent with contact lenses, but I would really encourage you to put all your effort into getting good with scleral indentation & examining the ora that way. It is such a difficult but useful skill & if you are considering doing retina, you need to get good at indenting with the indirect for indirect lasers, cryo and scleral buckling.

Maybe though I should spend some time using the Shacket???? To be honest, I've never used it.

That's OK, I'll ask Dr. Shacket tomorrow

 

[Eyesore]

That's OK, I'll ask Dr. Shacket tomorrow

It is called a Schocket depressor. I believe it is named after Stanley Schocket, rather than Andy Schachat. Just FYI.

 

[JR]

It is called a Schocket depressor. I believe it is named after Stanley Schocket, rather than Andy Schachat. Just FYI.

, your knowledge impresses me!

 

[Andrew_Doan]

Hi Garp,

Try a 60D or Superfield lens. I also recommend using a contact lens (e.g. pancake lens). If you can manage the Hruby lens, then it will also help with finding CSDME.

When in doubt, then get a FFA.

 

[Elephantitan]

Please know you aren't alone and also know that if there is one response that drives me crazy is "you'll get it some day." I'll probably say the same thing after that some day happens and a 1st yr asks me about CSME, but right now there is nothing more frustrating than someone telling you that something exists and they can see it but you can't. It's one thing to miss something b/c you haven't read or studied enough--you know why you missed it, but quite another when you have the tools (your own 2 eyes) that you've been using all your life, but still can't get it. Most frustrated I've ever been.