July 27, 2023
In his insightful article on dilation, Dr. Mark Dunbar sheds light on an essential aspect of eye exams. As the market welcomes new medications for presbyopia treatment, it becomes crucial for optometrists and ophthalmologists to consider the use of dilation in their practice. Having interviewed numerous professionals in the field, I discovered three key topics that warrant attention: pan retinal photography vs. dilation, choice of dilation drops, and when to consider skipping dilation.
Pan retinal photography, undoubtedly a valuable tool, has become an integral part of my practice, and I strongly advocate its use for all my patients. Rarely does any patient refuse this procedure, understanding its significance in a comprehensive eye examination. However, it is important not to mistake the inclusion of pan retinal photography as a replacement for dilation. Dilation remains irreplaceable in detecting certain retinal issues. Several cases where retinal holes progressed to retinal detachment (RD) and tears were missed even after initial dilated exams with no complications after a posterior vitreous detachment (PVD) exemplify this point. Evidence-based studies affirm that the best possibility of diagnosing retinal problems occurs when both dilation and pan retinal photography are utilized, providing a valuable medical record for future reference. The recommendation, therefore, is to utilize both methods for optimum results.
Regarding dilation drops, the commonly used mydriacyl is adequate for most patients. Personally, I prefer combining mydriacyl with 2.5% phenylephrine, as this combination offers a wide-open pupil, granting a better view of the peripheral retina. Additionally, it facilitates viewing the macula and optic nerve with appropriate slit lamp lenses. While a comprehensive list of patients requiring two drops exists, a few obvious cases include those with myopia over 3 diopters, PVD, glaucoma, family history of eye issues, abnormalities detected through pan retinal photography, visual field defects on screening tests, systemic ocular complications, and diabetes.
An important question arises: should we dilate every patient annually if we possess a pan retinal camera? The answer is no. Of course, dilation is always the standard of care. It is important we do not become cavalier in making the decision to skip a tear or so of dilation. With advancements in technology and efficient pan retinal photography, it is possible to extend the interval between dilations for certain healthy patients. However, this applies only to patients who show no signs or indications that would warrant dilation for a comprehensive eye exam. Certain conditions, such as greater than 3 diopters of myopia, a family history of RD, or so many other issues should never be overlooked, and the established protocol of dilation should be strictly adhered to.
Lastly, I would like to acknowledge the contributions of esteemed leaders such as Murray Fingeret and Mike Chaglasion, who recently represented optometry at the World Glaucoma Society meeting. Their involvement highlights the crucial role optometrists play in glaucoma management, and I encourage everyone to read their review of the meeting’s proceedings.
Furthermore, I am proud to have been a board member of the GPLI for over a decade. I have extended an invitation to the GPLI to provide an editorial on their organization’s work and the reasons why everyone should consider joining this exceptional group.
