Peripheral retinal viewing: BIO with scleral depression vs contact lens

[The Doctor]

Hey guys, I was hoping to solicit advice from attendings and retina folks. At my program when there is a retinal tear, new flashes and floaters, new PVD, or RD the standard of care is to do a detailed slit lamp exam, check for pigment/heme in the anterior vitreous, and then do BIO with scleral depression. Now, I know that scleral depression is a useful skill and I plan to continue practicing this over my last year of residency.

With that said, I am also thinking of the example of a general ophthalmologist that I worked with who used a wide-field PRP contact lens to view out to the far retinal periphery in patients with new flashes and floaters.

I'm thinking ahead to how I might deal with these chief complaints when I'm in private practice. I like using the indirect, and I will probably wear a portable indirect as I like to examine patients using the indirect sitting up to get a quick bird's eye view of the retina. However, you get a good view with the PRP lens and this could be more efficient rather than carrying out a separate SLE and depressed exam. As a tall guy, positioning patients for a depressed exam is also somewhat uncomfortable even with good positioning, and if the patient could remain at the slit lamp for a similar view, this seems preferable.

Would it be unreasonable to use a PRP lens to screen the retinal periphery in patients with worrisome symptoms or with peripheral pathology and then use scleral depression to further evaluate any abnormalities?

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[taco bell]

Do you have any experience with a 3-mirror exam? Although I am still developing my scleral depression skills, I think using 3 mirror lens is an ideal alternative as well. I have never thought of using a PRP lens for a peripheral view

 

[The Doctor]

Do you have any experience with a 3-mirror exam? Although I am still developing my scleral depression skills, I think using 3 mirror lens is an ideal alternative as well. I have never thought of using a PRP lens for a peripheral view

That's a good point. I have used a 3-mirror lens before and like it, though I have a separate 6-mirror gonio that I use for viewing the angle. My thought about the PRP lens is that it gives a full view of the periphery without needing to rotate the mirror and would be more efficient. PS - Taco Bell is awesome.

 

[MstaKing10]

Do you use a gel like goniosol with the lens? If so would be hard to depress afterwards as that gel sticks around and limits the view even after a good washing.

If all you want is a Birdseye view then use whatever lens you want but then please refer the patient to a retina specialist for a depressed exam. I think those lenses are ok but not ideal. There are no shortcuts in medicine, much less ophthalmology, much less retina. With practice a depressed exam will only take a few minutes. I'm not sure using a contact lens would be any quicker. And if you find something now you have to rinse the eye and depress anyways? Where is the efficiency in that? Can you see the Ora with a PRP lens? I'm not sure about that, even with a three mirror this is difficult.

I think it's good to have multiple tools and skills so no downside in learning different ways of doing things. But ultimately I would recommend learning and becoming efficient with a good depressed exam. My 2 cents.

 

[speyeder]

What kind of prp lens do you use? A super quad? That only allows a 160 degree view of the retina, oftentimes with peripheral distortion. You could probably see more of the retina with an indirect exam.

The 3 mirror gonio lens would allow you to see more anteriorly, sometime to the ora but it's more time consuming.

I know a few general ophthalmologists who use the digital wide field lens and can see up to the ora by having the patient look in different gazes.

Ultimately an indirect exam is the gold standard. Usually I can see the ora or most of the ora just with good dilation and a 28d lens. The key is laying the patient back on an exam chair and positioning yourself at the proper angle.

As a general ophthalmologist, if you do an earnest indirect exam, that is good enough for me. You are not expected to see far peripheral retinal pathology. I don't expect a non-retina specialist to be very adept at scleral depression. I truly didn't learn until I did a retina fellowship.

 

[MullerCell]

Agree with above. There really is no replacement for a skilled depressed exam. If you aren't depressing, you will miss things even if you can see to the ora. The whole point is the dynamic nature of moving the depressor and elevating the retina to unveil small breaks that you otherwise will miss. Additionally, you will be able to see much better through vitreous heme and can indent retina into the clear portion of your view in pseudophakes with opacified peripheral capsule and this can't be achieved with a 3 mirror or any slit lamp lenses. Very few general ophthalmologists can do anything more than a basic depressed exam and if there are vit cells or overt heme and you don't see a break you should have a retina person look.

 

[Dusn]

I'd do both a detailed exam at the slit lamp with a digital widefield lens (I can often see up to the ora with it) and then do a depressed exam with BIO. Despite quite a bit of practice at this point, I still worry that I could miss a small, translucent retinal tear with the minified view on the BIO and so I still do the slit lamp exam first.

I've found the super quad with the patient looking slightly in each direction gets me further peripherally than even the mirrored lenses but the view is not always so clear and once you've put gonio on the eye it's hard to wash that stuff off the cornea.

 

[Pinkertinkle]

In an ideal world every ophthalmologist would be good at scleral depression and would put multifocals only in appropriate candidates. But we live in the real world and I would say most general people are not good at scleral depression.

 

[Visionary]

No substitute for a depressed exam, due to the dynamic nature of the depression. Second best is a 3-mirror exam. You really need to use one of those two. Otherwise, you'll miss pathology. I will sometimes go back with my DWF after scleral depression for a closer view, but using that primarily is impractical, as you will need patients to change directions of gaze.

 

[clayito]

No substitute for a depressed exam, due to the dynamic nature of the depression.

Completely agree. Just had a patient this week with a retinal hole that I could not find (he was symptomatic) until I scleral depressed. No substitute for this exam - practice, practice, practice.