hoomer

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Mar 8, 2008
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Hi,
im a first year ophthalmology resident and i'm having some doubts when ibspecting/visualizing the whole retina.
I'm confortable using the slit-lamp (usualy i use a 90D lens), the 3 mirror lens and the Indirect Microscope (with 2.2 lens).
My question is: when im inspecting a retina i can't ever be 100% sure i visualized the intire area. When using the 3 mirror lens i never know if i missed an (circunferenced) area between the 2 mirrors and whith the indirect ophthalmoscope i tend to ask te patient to look up, up and left, left, down and left, down, down and right, right, up and up and right; however i never know for sure if i missed an area between the lookin up and up and left or an area between the looking left and left and down, and so on.
Are there any anatomical landmarks u use to be certain you aren't "jumping" any of these areas?

Thanks alot
 

Mirror Form

Thyroid Storm
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If you use the indirect and a 2.2 or 20D lens, you should have no problem visualizing the entire retina after you've practiced a lot. You get a feel for how much of the retina you're visualizing with each view by seeing the same lesion in different angles. Eg., if you have the patient look right and see a lesion, and then have the patient look and down and right and see the same lesion, you start getting a feel for how much of the retina you're visualizing at any given time. In high myopes you'll be seeing more of the retina in each view, which makes things a bit easier. But looking in 8 sectors is enough to see the whole thing in any patient.

Basically, the indirect exam is just very practice dependant. A lot of first year residents try and skimp on it b/c it can be time consuming early on and you don't want to provoke the wrath your attending by getting too far behind in clinic. But as you get better at it, it'll go really fast. So just keep practicing and dilating most of your patients.
 

toulouselautrec

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Nov 9, 2007
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I agree, the 8-view approach should be sufficient because each view overlaps the adjacent ones. A lesion at 3 o'clock should be viewable in at least 2 consecutive views, for example. When I was starting out, I used the vortex veins and the ora serrata as landmarks to assess how far peripherally I was seeing. It also depends on the patient, how well that patient can rotate the eyes, position of the globe within the orbit, and your own head position and height. Directing the patient properly is very important (but not always possible). As for accurately assigning clock-hour location of a lesion, you'd have to carefully assess where your patient is looking and then assess where you see the lesion in your view.

The Goldmann 3-mirror is helpful for viewing a peripheral lesion at a higher magnification at the slit lamp, but you should aim to decrease your reliance on it to assure that you've covered everything.

How do you know if you've adequately gotten the skill down? I just saw a patient yesterday with 8 clock-hours of extensive, double-row lattice degeneration in BOTH eyes that was missed and not documented by one of my classmates who had examined her about a year ago. That stuff did not pop up over the past year...
 

EyeBaller

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To make sure I don't miss any areas of retina I do as stated above, visualize the same lesion/landmark from at least two other clock hours. Also I usually start out with the most peripheral view (ora) and then move more centrally keeping my view until I get to the arcades. This way I know I have covered everything from ora to the arcade in that clock hour, and not missed something in the mid-periphery.
 

362.04

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I can only add that sufficient mydriasis is often necessary.
 

papilledema

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I wonder if the examiner moving around the patient would give more 'continuity' to the retinal exam? I understand that you cant do a 360 degree turn without floating over the patient but wouldn't moving around the patient with the eye in various positions reduce the 'jumps'?