Undilated macula exam

[flashmyfloater]

Something has been driving me bat#@$! crazy since residency. Using my 90, I can easily see the optic nerve through a small (1-2mm), undilated pupil. I don't feel comfortable checking the "macula" off as normal in these patients, as I'm not confident I'm getting a good enough look. However, invariably an attending will follow up behind me and check the exam off as normal, or copy forward from the last note that the person has drusen. I never felt comfortable copying forward exams when I can't see the macula, and I'm surprised a lot of my attendings do.

Is everybody just better at the 90 D exam through an undilated pupil than I am? I'd be interested to see what people do here on a normal basis. For me- if it's dilated, or they have 3-4 mm undilated, I'll feel comfortable enough doing the exam. If 2 mm or less, it's tough.

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[MstaKing10]

Why don't you just dilate the pupil?

 

[DrZeke]

Something has been driving me bat#@$! crazy since residency. Using my 90, I can easily see the optic nerve through a small (1-2mm), undilated pupil. I don't feel comfortable checking the "macula" off as normal in these patients, as I'm not confident I'm getting a good enough look. However, invariably an attending will follow up behind me and check the exam off as normal, or copy forward from the last note that the person has drusen. I never felt comfortable copying forward exams when I can't see the macula, and I'm surprised a lot of my attendings do.

Is everybody just better at the 90 D exam through an undilated pupil than I am? I'd be interested to see what people do here on a normal basis. For me- if it's dilated, or they have 3-4 mm undilated, I'll feel comfortable enough doing the exam. If 2 mm or less, it's tough.

Stereopsis is minimal or absent with a 90 on an undilated pupil. Yes I can see the macula on most patients but not with both eyes. And under 2mm sometimes I can barely get in. As far as I'm concerned an undilated exam doesn't take the place of a DFE. If attendings and other residents are using that in the place of DFE that's strange to me...

And maybe even not standard of care? Anyone else have thoughts on this.

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[MstaKing10]

It's like a cardiologist putting his ear to the chest to hear a murmur. Sure it might work on occasion but why not use a stethoscope?

Not sure it's below the standard of care for an established patient without history of retinal issues on a visit for a visual field or the like. For a new patient, yearly visit or for retina check say for retinal detachment then this would absolutely be below the standard of care in my opinion. Can you imagine trying to defend in court a missed retinal detachment that was missed due to not dilating the eye? Ouch.

I should mention that OCT has changed some of this and it's not uncommon to dilate one eye (say wet AMD so the eye being injected) and not dilate the fellow eye (the dry eye) but then do OCT OU. This way the patient can drive themselves to the office. But every few visits I have them dilate both eyes to do a dry AMD check. One of the docs in our office doesn't dilate at all. Guess it's variable based on your practice.

 

[DrZeke]

It's like a cardiologist putting his ear to the chest to hear a murmur. Sure it might work on occasion but why not use a stethoscope?

Not sure it's below the standard of care for an established patient without history of retinal issues on a visit for a visual field or the like. For a new patient, yearly visit or for retina check say for retinal detachment then this would absolutely be below the standard of care in my opinion. Can you imagine trying to defend in court a missed retinal detachment that was missed due to not dilating the eye? Ouch.

I should mention that OCT has changed some of this and it's not uncommon to dilate one eye (say wet AMD so the eye being injected) and not dilate the fellow eye (the dry eye) but then do OCT OU. This way the patient can drive themselves to the office. But every few visits I have them dilate both eyes to do a dry AMD check. One of the docs in our office doesn't dilate at all. Guess it's variable based on your practice.

That's what I mean... a regularly done DFE based on the pathology - every few months to up to a year. I don't see how an undilated 90D exam should take the place of that


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[flashmyfloater]

Why don't you just dilate the pupil?

Because they don't want to dilate the patient, but I think can justify higher billing if they do an ONH, macula, vessel exam.

 

[DrZeke]

Because they don't want to dilate the patient, but I think can justify higher billing if they do an ONH, macula, vessel exam.

Hmmm.... that sounds kosher


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[MstaKing10]

Because they don't want to dilate the patient, but I think can justify higher billing if they do an ONH, macula, vessel exam.

The audit of these charts will go well! Taking shortcuts will eventually catch up to you.

from the sounds of it, the docs you are working with likely have the same crappy view as you do. I don't think they've figured out some incredible way to view the fundus, just checking something off in the chart to bill more perhaps?