15 November 2011
Posted in Pearls in Ophthalmology
by Michael Javaheri, M.D.
Vitreoretinal Diseases and Surgery
Los Angeles, CA
One of the most frustrating aspects of beginning residency is learning and mastering the peripheral retinal examination. With the myriad of new concepts presented to the beginning resident, the complexity and importance of a complete peripheral retinal exam should not be overlooked, as there will be many complex patients presenting with flashes and floaters. For these patients, the ophthalmologist’s main job is to determine whether a retinal tear is present. The most efficient way to do this is with a peripheral retinal examination with dynamic scleral depression. Here are some tips to help make your examination skills better:
Learn the Anatomy
As a beginning resident, you have to know what you’re looking at. Use an atlas to learn where all the major landmarks are and what they correspond to. For example, you have to know where and what the ora serrata is before you can visualize it on an exam. Also, get used to the unique anatomic terminology of the eye. For example, the ora serrata is located anterior to the equator. In order to help you, pick a few retinal atlases to help you identify major landmarks and significant pathology.
Developing the Skills
The importance of becoming comfortable with a scleral depressed exam cannot be understated. Although a contact lens exam can complement indirect ophthalmoscopy, it should not replace it, mostly due to the fact that a contact lens exam cannot visualize the ora serrata, especially in a pseudophakic patient. Start with your co-residents and examine and scleral depress each other (try not to hurt each other). Listen to feedback from your co-residents as to the amount of comfort or discomfort they experienced. In addition, if you see a patient with a normal retina, try carefully scleral depressing them to examine normal anatomy. This gives you a sense of what is and isn’t normal, so you develop the ability to know when something is wrong. Pick a few patients a day and within no time, the exam will be more comfortable for you.
Keys to Comfort
It is extremely important to establish a comfortable environment for both yourself and your patient. If you are not comfortable, then your ability to perform an adequate exam will be diminished. Tilt the patient backwards to make the examination easier. Use a drop of anesthetic prior to the exam, as it makes the scleral depression easier to tolerate for the patient. Also, make sure the pupil is adequately dilated. This decreases the amount of pressure needed to visualize critical structures. Lastly, explain to the patient what you will be doing and why you will be doing it. This will help make things easier and eliminate surprises. The patient will also gain confidence in you.
Points of Examination to Remember
1. Make sure the room is dark enough to achieve sufficient contrast. Avoid ambient lighting.
2. Use a lower level of light and turn it up for questionable areas only.
3. Develop a system for sequential examination of each quadrant. Use the same system each time. Give clues as to where you want the patient to look: Look up and left, look down and right, or look at your left shoulder.
4. Look around first, and then use magnification if needed.
5. Document your findings with a clear drawing. This will make following patients easier and will eliminate surprise findings.
When following patients with peripheral changes in the beginning of your training, don’t hesitate to bring patients back sooner than you would normally would. And remember to always look to your seniors or attendings for input.