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Seven Clinical Pearls for Examination of the Retina

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Examination of the retina can offer a spectrum of difficulties. It can be straightforward and easy in the young, cooperative patient without coexisting ocular disease, and it can be extremely challenging in some patients who are less cooperative and/or have coexisting eye diseases that preclude optimal examination.

The following are seven clinical pearls for examination of the retina that I have learned during my fellowship and continued to refine and teach during my last four years in practice.

  1. Position the patient carefully for biomicroscopy. Make sure the patient is comfortable in the slit lamp during biomicroscopy. I encourage patients to use the handles on the slit lamp to ensure that their forehead and chin are positioned correctly and comfortably.
  2. Keep in mind the patient’s comfort while adjusting the lighting for biomicroscopy. Patients will often have difficulty adjusting to the bright lights. You may decrease the light intensity as much as the patient is comfortable, while still providing you with an adequate view of the retina. Despite these efforts, patients may still have trouble, at which point I encourage them to keep both eyes open and focus on a point at or beyond my ear while I work quickly and efficiently through the exam.
  3. Choose your lens for biomicroscopy wisely. Use the lens that you are most comfortable with during slit lamp biomicroscopy. The 78-diopter lens or the super-field lens offers good stereopsis in the dilated eye, particularly when one is attempting to detect retinal thickening. The 90-diopter lens works well in the undilated patient when looking at the optic nerve.
  4. Displace the slit beam during biomicroscopy. One trick that I often use is to rotate the slit beam from a vertical to a horizontal beam. Then I will tilt the slit lamp a few degrees toward the patient. This will help displace the glare and reflection of light and offer a much better binocular view.
  5. Perform indirect ophthalmoscopy in cases with scleral depression. Patients who complain of flashes or floaters or who have a history of retinal tears or detachment should receive indirect ophthalmoscopy with scleral depression. When performing scleral depression, make sure the patient is comfortably lying flat. Be sure to forewarn the patient that the exam is often uncomfortable, with a pressure sensation on the eye.
  6. Perfect your technique for scleral depression during indirect ophthalmoscopy. Apply topical anesthesia. Use your thumb and forefinger to hold the 20- or 28-diopter lens with one hand while resting your little finger on the patient’s forehead. With the other hand, use the scleral depressor (or cotton tip applicator) to apply pressure to the eyelid and sclera. Be sure to ask the patient to look initially in the direction opposite where you are pushing, apply pressure, then ask the patient to look in direction of scleral depression. This takes practice, practice, practice.
  7. Position the patient appropriately for indirect ophthalmoscopy without scleral depression. This can often be done effectively while the patient sits up and leans forward on the front end of the exam chair. I sit while the patient looks up to visualize the superior retinal periphery and I stand while the patient looks down, so I can examine the inferior retina. I will often ask patients to turn their head to the right while looking at the right temporal and left nasal retinal periphery and I will ask them to turn their head to the left while visualizing the right nasal and the left temporal periphery.

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About the author: Manju Subramanian, MD, is an assistant professor at Boston University School of Medicine and a member of the YO Info editorial board. She completed her residency at the University of Kansas Medical Center, followed by a vitreoretinal fellowship at Tufts/Ophthalmic Consultants of Boston, completed in 2004.