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I.
Binocular indirect ophthalmoscopy
A. Scleral indentation
1. Anterior retina, ora serrata, pars plana
2. Evaluate peripheral retinal anomalies
3. Applying minimal pressure to the sclera
4. Maximum pupillary dilation is key to viewing scleral indentation
B. Equipment
1. Binocular indirect ophthalmoscope
2. Condensing lens (2.2, 20, 25, 28 or 30d)
3. Scleral depressor
4. Topical mydriatic solutions
C. Clinical uses of scleral indentation
1. Extends the limit of visibility of structures located in the retinal periphery.
2. Rolling of the retina adds another perspective and view of retinal lesions.
3. Provides a critical view of the vitreoretinal interface.
4. Differentiate different types of retinal anomalies
D. Retinal anomalies
1. White without pressure
2. Retinal holes with subretinal fluid
3. Lattice degeneration
4. Operculated retinal hole
5. RPE hyperplasia with vitreous adhesion
6. Retinal cysts
7. Acquired reticular retinoschisis
8. Scleral buckle (no indentation of eye with buckle - examine fellow eye if necessary)
II. Anterior segment procedures
A. Conjunctival concretion removal
1. Symptomatic patient
2. Stains with sodium fluorescein
3. Caused by build-up of calcium
4. Instill anesthetic
5. Grasp concretion from below to remove
B. Anterior chamber paracentesis
1. Increased iop s/p 1 day cataract surgery
2. Tetracaine instilled into eye and soaked swab held over entry portal for 30 seconds
3. Instill 1-2 gtts ciloxan (or equivalent) before and after procedure
C. Punctal occlusion
1. Measure puncta prior to instillation of plug
2. Dry eye
3. Recurrent corneal erosion
4. Chronic corneal conditions
5. Glaucoma efficacy
6. Soft contact lenses
D. Conjunctival cyst drainage
1. Symptomatic patient
2. Instill anesthetic
3. Use small gauge needle to puncture conjunctiva
4. Returns most of time
5. May need excision of anterior surface
III. Gonioscopy
A. Gonioscopy
1. Glaucoma suspects
2. Open angle glaucoma patients
3. Narrow angle glaucoma patients
4. Ischemic retinal disease patients
B. Angle viewing
1. Zeiss - indirect; glass; tears/saline interface
2. Posner - indirect; plastic; tears/saline interface
3. Sussman - indirect; plastic; tears/saline interface
4. Goldmann - indirect; plastic; viscous interface
5. Thorpe - indirect; 4-gonio mirrors; viscous interface
6. Karickhoff - indirect; plastic; viscous interface
C. Angle structures
1. Ciliary body
2. Scleral spur
3. Trabecular meshwork
4. Schwalbe’s line
D. Ciliary body
1. Light gray to dark brown
2. Color dependent on iris/choroid pigment
3. Iris processes arise and attach to tm
E. Scleral spur
1. Whitish-gray band
2. Composed of collagen and elastic tissue
3. Attachment site for ciliary muscle
F. Trabecular meshwork
1. Fibrocellular sheets
2. Filter
3. Anterior division - 1/3
4. Posterior division - 2/3
G. Schwalbe’s line
1. Anterior border of angle
2. Opaque white or light brown
3. Pigment deposition - Sampaolesi’s line
4. Anterior extension = posterior embryotoxin
H. Recording
1. Most posterior visible angle structure
a.
CB, SS, TM, SL
2. Amount of pigmentation
3. Angle anomalies
I. Anterior chamber angle anomalies
1. Angle recession
2. Iris processes
3. Excess pigment
4. Rubeosis iridis
IV. Fundus biomicroscopy
A. Optic nerve evaluation
1. Best way to see rim tissue and optic cup.
2. Need stereoscopic assessment to accurately judge cup to disc ratio.
3. Evaluate rim tissue for symmetry and perfusion.
4. Record anomalies for future reference.
a.
Neovascularization
b.
Collateralization
c.
Spontaneous venous pulsation
B. Macula assessment
1. Examine optic nerve first
2. While scanning posterior pole, scan over macula
3. After brief exposure to light, slowly move light over macula.
4. Differentiate macular pseudohole form lamellar or full thickness hole with the Watske-Allen test.
5. Watske-Allen test uses a long, narrow parallepiped placed over area in question.
6. If patient reports the center of the light beam is attenuated or missing, retina is damaged.
C. Posterior vitreous detachment
1. Joystick on slit-lamp closest to examiner
2. Place non-contact lens in front dilated iris or place contact lens onto cornea.
3. Move light beam over center of lens and look for red reflex.
4. Move joystick posteriorly in a slight side to side motion.
5. Focus on optic nerve head and pull joystick back slightly.
V.
Ocular injectable medications
A. Types of injection
1. Intralesional
2. Intradermal
3. Subcutaneous (Sub-Q)
4. Intramuscular (IM)
5. Intravenous (IV) injection
B. Injectable medications
1. Absorption of injected medications much faster than other routes.
a.
Good for treatment
b.
Bad for side-effects.
2. Injections into highly vascular tissue (muscles) are more quickly absorbed than injections into
less vascular tissue (epidermis and dermis).
3. Intravenous injection is fastest resulting in instantaneous absorption of the medication.
4. Absorption faster with aqueous solutions - slower with suspensions.
C. Needle / syringe
1. Typically use a ½ inch. 25 to 27 gauge needle with a 1cc syringe.
2. Used for:
a.
Intralesional injections
b.
Subconjunctival injections
c.
Intradermal injections
D. Dynamics of injections
1. Bevel side - up or down?
2. Needle tends to move away from bevel.
3. Small needles do not exert much effect.
4. Keep in mind for subconjunctival injections - bevel down.
E. Common ocular injectable medications
1. Lidocaine 2% with or without 1:100,000 epinephrine (subcutaneous anesthesia)
2. Kenalog-40mg/ml (intralesional)
3. Dexamethasone 40mg/ml (intralesional)
F. Lesional injection medication
1. Kenalog-40 (triamcinolone acetonide 40mg/ml, bristol-myers squibb) is preferred.
2. Kenalog is a viscous suspension - absorbed slowly and acts as a depot at the injection site.
3. Viscosity allows medication to remain around lesion to “melt” the chalazia.
4. Available in 5mg/ml, 10mg/ ml or 40mg/ml concentrations.
G. Lesional injections
1. Injection used after trial with hot compresses.
2. Chalazia most common lesion for intralesional injection.
3. The intralesional tissue of a chalazion is firm, only allowing a small amount of medication.
4. Use translesional technique: injection the distal, intra and proximal side of the chalazion.
5. Mark site with non-red marker if injection is halted prior to completion.
H. Subcutaneous injections
1. Used prior to skin tag (papilloma) or other dermatologic lesion.
2. Use Lidocaine 2% and inject under the lesion.
3. Prepare patient for a stinging pain (bee sting).