Peripheral Retinal Exam

[linevasel]

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Following Dr. Zeke's lead here....

One of the most frustrating parts of residency is figuring out what you can learn on your own and what is best taught in the "class" setting under supervision. I'm curious what has been the pathway at your respective residency programs to mastering the peripheral retina exam. Did you guys just start subjecting your PVD patients to scleral depression and kind of learned by the seat-of-your-pants. Was there some sort of formal process. I'm halfway thru year one and can't depress = Worried!

 

[OPPforlife]

I don't think you can reliably depress until fellowship. But then again I'm just a first year resident


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[DrZeke]

Following Dr. Zeke's lead here....

One of the most frustrating parts of residency is figuring out what you can learn on your own and what is best taught in the "class" setting under supervision. I'm curious what has been the pathway at your respective residency programs to mastering the peripheral retina exam. Did you guys just start subjecting your PVD patients to scleral depression and kind of learned by the seat-of-your-pants. Was there some sort of formal process. I'm halfway thru year one and can't depress = Worried!

Hey linevasel. My goal for this year is to see everything as far as I can really well, consistently. Like see at least the edge of most lattice, or degenerative changes anterior to the equator. I plan on buying a depressor at the end of 1st year and getting more into it during second year. I heard it takes all of residency to master. Also, I asked a few ppl in my residency how they learned and they mentioned a couple of attendings who showed them. I'm waiting for that rotation to bug that attending for tips. Then I think it's just like gonio... Keep trying on all lattice, symptomatic pvd, anyone w flashes... Identify those patients who are good at following commands and don't freak out. Lol

 

[TheLesPaul]

I don't think you can reliably depress until fellowship. But then again I'm just a first year resident


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DISAGREE. If you go into it with that attitude, you definitely won't. It's like anything - it takes practice and patience. Being able to see the ora 360 by mid-2nd year is a good goal to shoot for.

 

[pianist]

make sure that the patient is lying back as flat as possible. You immediately give yourself more view when the patient is reclined as much as possible.

you don't need to press with much pressure. If you can't see your depressor, almost 100% likelihood you aren't looking anteriorly enough.

Temporal and nasal you can depress right on the sclera, or depress on the lateral/nasal lid, then slide down.

Inferior can be more difficult. Ask your patient to look half way down, not all the way down. Most patients tend to look way too inferiorly.

With a lens like the digital widefield or superfield, you can pretty much see everything with careful examination at the slit lamp.

 

[RestoreSight]

Viewing the far periphery consistently is a skill that takes years to master. My first high-quality depressed exam was in the OR performing EUA's. Remember the ora is more prominent nasally. That is a good place to start, but also most uncomfortable for the patient. Lots of docs depress through the eyelids, but this obscures the anatomy. I recommend bare sclera depression with lots of proparacaine when you are starting out. On call you can also depress patients more than in a busy clinic because you have more time. Its good to start with a standard 20 D lens. Make sure the patient is well dilated and completely reclined. The patient's head should be waist high. Minimal pressure is needed. Find your bump posteriorly first then move more anteriorly keeping the axis of your lens and light source parallel. The patient should be looking 180 degrees away from where you are positioned as far as possible. One attending told me once during first year, "its not the equipment's fault you can't see the periphery."

 

[Slide]

You can definitely learn how to depress well during residency, but it's tough to do as a first year. I never really got it until the end of 2nd year, and even then I still have trouble sometimes. Some things that have helped me:
-For obvious reasons, the more dilated the patient, the easier it is.
-Remember your anatomy; the ora serrata is at least 6mm posterior to the limbus (depends on the eye you're seeing). Seems simple, but I've made the mistake of depressing too anteriorly early on.
-The patient needs to look 180 degrees from where you're at. Just like looking through the slit lamp, focus the light rays on the edge of the pupil opposite of where you want to look.
-Depressing is both a tangential and rolling motion. Roll your depressor side to side; it'll help you figure out where you're at, and it also helps to determine if you're looking at a retinal tear, hole, or just normal anatomy.
-A cotton tip/Q-tip works great when you have nothing else, but having the proper tools works best. I bought a scleral depressor (this pic is a good example: http://stephensinst.com/wp-content/uploads/2013/10/S4_1236-_both.jpg) with a round paddle end so its more comfortable for the patient. My exams have become so much easier after getting one of these. It's not too expensive and it's not necessary, but if you really want to maximize your ability to depress, the right tools help a lot.
-Don't get frustrated, and keep practicing. Like anything else in ophthalmology, it's a skill that requires practice over and over again.

 

[MullerCell]

You can learn how to depress as a resident and be serviceable such that you won't miss obvious pathology, but you won't be good at it. You might think you are good, but if you do a retina fellowship, and then practice for several years, you will realize you weren't even remotely good as a resident. Of everyone that refers to me (> 100 MDs and ODs), there is 1 gen ophthalmologist that is able to do what I would consider a reasonably good depressed exam. I think many people actually become worse at it after residency when they don't do it very often/ever. You won't be good at it until you do it extensively in the OR during buckles and vits and then take this experience and depress several patients per day in clinic every day for a long time.

 

[JMK2005]

spend a lot of time on established patients who's had a good exam and good documentation. you can gauge how good you are by looking first, looking at old notes, then recheck to see if you saw what was described.

 

[DrZeke]

You can learn how to depress as a resident and be serviceable such that you won't miss obvious pathology, but you won't be good at it. You might think you are good, but if you do a retina fellowship, and then practice for several years, you will realize you weren't even remotely good as a resident. Of everyone that refers to me (> 100 MDs and ODs), there is 1 gen ophthalmologist that is able to do what I would consider a reasonably good depressed exam. I think many people actually become worse at it after residency when they don't do it very often/ever. You won't be good at it until you do it extensively in the OR during buckles and vits and then take this experience and depress several patients per day in clinic every day for a long time.

I love posts like this. It makes me feel better about the douchery involved when people pretend they see everything. Or when people tell the attending "yes I saw it" when they didn't.

 

[TheLesPaul]

I love posts like this. It makes me feel better about the douchery involved when people pretend they see everything. Or when people tell the attending "yes I saw it" when they didn't.

There's a great Radiolab episode about how expectations can influence reality. I'm not saying that as a resident, you will pick up every subtle finding or understand exactly what you're seeing how an attending would see it, but you should feel comfortable being able to see the ora 360 in most patients and be able to find almost, if not every, tear that the retina fellow finds given enough time.

 

[DrZeke]

There's a great Radiolab episode about how expectations can influence reality. I'm not saying that as a resident, you will pick up every subtle finding or understand exactly what you're seeing how an attending would see it, but you should feel comfortable being able to see the ora 360 in most patients and be able to find almost, if not every, tear that the retina fellow finds given enough time.

I completely agree with you. But I'm a first year... The Ora is not my priority right now as much as some other things in the indirect exam. I commend the 1st years who have that high on their priority list. I'm not afraid to admit that I'm not a retina wizard just yet. When I set my mind to something I can usually do it. When I finally decide to scleral depress I will remember this thread and keep at it.

 

[MstaKing10]

I think retina in general is tougher to grasp as a resident than other fields. This includes the exam, pathology, pathophysiology, pharmacology etc. That said, spending time trying to learn as much as you can as a resident will serve you well down the road, even if you don't do a fellowship in it or choose to go another direction completely (ie peds, plastics...).

For me, the best way to learn the depressed exam was practice, and lots of it. I tried depressing pretty much every patient I examined during my retina rotation. The first time I actually saw my depressor was huge accomplishment! I got better with time but still missed a lot of stuff. I really didn't get good until well into my retina fellowship.

Few pearls: 1. learn from prior exam notes. A treated tear can be seen more easily due to laser/cryo scars. Use this as a landmark and spend as much time as you can finding the tear that was already treated. 2. Use a depressor, not cotton tip. A good depressor will cost you a bit but you will use it for the rest of your career. 3. I almost always press on the eyelid, not the actual eyeball. Unless the tear is in a really funny spot (usually nasal). 4. Lie patient flat, place yourself on opposite side of the part of the eye being examined and have patient look in that direction. Find the red reflex, then spot the retina, then place your depressor. 5. You don't need to push too hard!! If your depressor is in the right position and you have the patient look in the correct direction, there is very little pressure needed to depress the eye. 6. Though nasal retina is more posterior, it is much harder to depress nasally. Easiest to depress is temporal, superior, inferior then nasal due to the anatomy of the eye, orbit etc. imho. 7. When all else fails use a 3 mirror lens. This is kind of a crutch but better to find the tear than miss it and end up with a retinal detachment. Some of these digital lenses claim to get out to the ora but I'm not so sure. Nothing beats a good depressed exam though.

Glad residents are spending some time with this, it will pay off in the end!

 

[DrZeke]

I think retina in general is tougher to grasp as a resident than other fields. This includes the exam, pathology, pathophysiology, pharmacology etc. That said, spending time trying to learn as much as you can as a resident will serve you well down the road, even if you don't do a fellowship in it or choose to go another direction completely (ie peds, plastics...).

For me, the best way to learn the depressed exam was practice, and lots of it. I tried depressing pretty much every patient I examined during my retina rotation. The first time I actually saw my depressor was huge accomplishment! I got better with time but still missed a lot of stuff. I really didn't get good until well into my retina fellowship.

Few pearls: 1. learn from prior exam notes. A treated tear can be seen more easily due to laser/cryo scars. Use this as a landmark and spend as much time as you can finding the tear that was already treated. 2. Use a depressor, not cotton tip. A good depressor will cost you a bit but you will use it for the rest of your career. 3. I almost always press on the eyelid, not the actual eyeball. Unless the tear is in a really funny spot (usually nasal). 4. Lie patient flat, place yourself on opposite side of the part of the eye being examined and have patient look in that direction. Find the red reflex, then spot the retina, then place your depressor. 5. You don't need to push too hard!! If your depressor is in the right position and you have the patient look in the correct direction, there is very little pressure needed to depress the eye. 6. Though nasal retina is more posterior, it is much harder to depress nasally. Easiest to depress is temporal, superior, inferior then nasal due to the anatomy of the eye, orbit etc. imho. 7. When all else fails use a 3 mirror lens. This is kind of a crutch but better to find the tear than miss it and end up with a retinal detachment. Some of these digital lenses claim to get out to the ora but I'm not so sure. Nothing beats a good depressed exam though.

Glad residents are spending some time with this, it will pay off in the end!

Thanks 🙂

BTW I got to depress in the OR the other day and it was really awesome.

 

[dantt]

Don't be discouraged. The peripheral retinal exam is hard. Even fellows and attendings are unsure of their findings until they get into the OR and try to repair the detachment.

 

[MullerCell]

Agree completely with MstaKing. A couple of other tips: 1. Don't have the patient look in extreme gaze while depressing, have them look about 75% of the way. 2. I really like this depressor: http://lombartinstrument.com/product.php?productid=16889 it is smaller, has a nice curvature that allows you to slide it posterior more easily, and it is easier to manipulate without causing a patient discomfort. I used the cylindrical end of the double ended shocket depressor as a resident and 1st half of fellowship, but this one works much better. 3. If you have a photophobic patient that is squinting and won't look where you tell them, nobody on the planet can get a complete exam.