 Hi, I'm Dr. Andrew Davis. I am a vitro retinal surgeon, currently employed here in Salt Lake City at Salt Lake Retina. And glad to be with you guys today. We're going to go through the basics of doing an ophthalmic exam, focusing specifically on the posterior segment exam of the eye and the retina. I'm a retina specialist, so that's what I do is I look at retinas. And what I'm going to try to do during this process is to give you little keys on how to manipulate the slit lamp and the instrumentation that we use in ophthalmology to be able to fine tune in to different parts of the retinal exam. And by taking the time to learn how to use the instrumentation, the lenses, the indirect, the slit lamp, it'll help you as the eye specialist to be able to properly diagnose diseases. Importantly, by doing things in a step-by-step process, you'll better be able to follow patients and having seen them once. Next time you see them again, you'll be able to monitor for progression. Hopefully, positive changes, although you'll also be able to see negative changes. And so it's worth the time to learn how to use the instruments properly. And so in our discussion today, that's what we're going to do is I'm going to focus on how to use the instruments and hopefully give you a few keys that you can practice with in the clinic and while you're in your training program. So let's go. We have our patient here. Any time you see a patient, they're, at least in my world, they're going to be dilated. And so some of the parts of the end, the vision, the pressure, the pupils will already have been done. So I'm going to skip past those. I think one of the important concepts of doing an eye exam is to do it the same way every single time. So most things in ophthalmology, when we do the exam, we go from left to right. So every part of the exam, from outside the eye to all the way to the back, you're just going to start on the left side, go to the right side. And I think that's important so that you form a repetitive pattern that you follow every single time. And by doing so and doing the same, the exam the same way every time, you're less likely to miss things. And the concept is to try not to miss things because we want to diagnose things and then help people. So vision, pressure, pupils, everything has already been done. My patients are usually dilated. And so we'll start into the slant lamp exam. So first thing you're going to do is you want to make sure your patient is somewhat relaxed. Patients will be very anxious. You want to let them know that you care about them. And so I always kind of tell patients that we're going to be in a slant lamp exam. And I try to make sure they're comfortable. My patient population is generally a little bit more elderly. And so you want to make sure that their back, their neck and things aren't contorted. If they're comfortable in the slant lamp, you're going to be comfortable and be able to find, to be able to spend more time trying to find the diseases. So first thing you'll do is bring the slant lamp over towards the patient. You'll kind of look where they are. The chin rest, I always eyeball where their chin is and I'll bring it down to their level. However, you'll see a black mark here on the slant lamp. That needs to be level with the lateral canthus or the lateral part of where the two eyelids come together. So you're going to be lining that up so that it'll be their right eye is lined up with this black mark. And so that's one of the first key parts of getting a patient into the slant lamp. So you ask them to please come forward here, chin down in here, forehead up against the head rest. It's important they try to keep their head up against the head rest. You don't have to hound it too much. It's not the end of the world. And then I'm looking, you can't see it right now, but I'm currently looking at that black mark on the right side. And I'm looking at the patient's lateral canthus, and I'm going to make sure it's lined up and it's nicely lined up right there. So next thing I'll do is there are different settings on the power of the beam itself. I usually set it on the half. There's a half and a one. You don't need to blast them with light, but at the same time you brought them here to do an eye exam so you might as well make sure you have enough light to be able to see. Sometimes patients will be light sensitive. Their pupils are dilated. They may have inflammation or redness, or for whatever reason they may be light sensitive, but I do think it's important to make sure you use enough light so you can see and then just be patient with the patient to make sure that you don't blast them with light too bad. So as a general rule, you're going to start with the right eye first and then do the left eye. And you'll look at the eyelids and then you'll look at the conjunctiva and then the cornea and then the anterior chamber and then the iris and then the lens and then you go back to the thumb part of the exam, the retina exam. So make sure you concentrate on those first initial things but as a retina specialist I look at those areas to make sure they look okay and then I'm really thinking about getting back to where the fun starts which is behind the iris. All right so first things first you'll notice on the slit lamp there's a joystick down below that can make bring things into focus by moving it forward and back and also you can move it left to right and then you can spin it and spinning it raises it up and down so you can get the eye and level. Also on the slit lamp these are the main two knobs you're going to use this upper knob that controls the the lateral movement of the beam, the side to side movement of the beam, it also increases the width and so by spinning the knob and you can actually go all the way in and all the way out and spin it all the way around you you widen the beam and so at different parts of the exam you're going to widen or narrow the beam depending on what you're looking at. Also at the top here it gives a size of the beam so this increases the width this increases the height, the knob that's up here at the top increases the height of the beam. On the slit lamp itself it actually gives a millimeter measurement so let's say that you're measuring the size of a corneal abrasion or more importantly for me as a retina specialist if you're looking at the size of a of a hyphaeema which is blood build up in the anterior chamber you can actually measure the size of that hyphaeema or how tall it is and then record that down so that later on you can record that oh it was five millimeter hyphaeema this week and then a week later went down to three millimeters so obviously having less hyphaeema is better than more hyphaeema so you can track that that's especially important with looking at corneal ulcers or corneal abrasions or things like that but in retina the retina world we we use it especially to measure the size of hyphaeemas or blood in the anterior chamber so so i'm just going to start her exam on her right eye i start out by looking at her eyelids and then i look at the conging tiva and then the cornea when you come to your cornea exam that'll be a time where you start to narrow the beam after the cornea you're going to look at the anterior chamber and in the retina world we do a lot of uveitis or inflammation inside of the eye exams and so to look in the anterior chamber you're going to narrow the beam you're going to make it thin and narrow and focus in on the iris and once you have the iris border or the pupillary border nice and focused you can pull back a little bit also you want to turn the beam up and that will allow you by focusing on the iris border having a focus and then pulling back just a little bit or focusing out that will allow you to see if there's any inflammation in the anterior chamber and this patient doesn't have any inflammation in her anterior chamber so after looking at the cornea in the anterior chamber the iris itself then you'll look at the lens and look for signs of cataractis changes in the lens and then after the lens well you'll look back into where like I say where the fund starts in the posterior segment exam of the eye one of the things with patients that I will always look at and I think is critical in doing a retina exam is to look at their vitreous and you can see the vitreous and the fibers or the collagen fibers of the vitreous right in the space behind the iris is a good place to see that it'll allow you to look for blood there inflammation and also for age related or syneurotic changes of the vitreous and I'll look at that every single exam no matter what I'm doing and that can give me signs of or an idea of there may be some sort of pathology back by the retina one of the common exams that we do in the retina world is when a patient has a new onset of flashing light and floaters and when if they were to have a terror in the retina the terror the retinal terror would release pigment cells or rpe cells into the vitreous and that would look like a tobacco dust or little teeny cells floating in the vitreous behind the lens or a Schaefer sign it's called and so how you look for a Schaefer sign is you're focusing on the lens narrow the beam and make sure it's nice and bright and then you tell the patient to look up look down and look straight ahead and then as they're doing that you move the joystick backward and forward until you can see the little collagen fibers and intertwined or floating around those collagen fibers could be those pigment cells or the tobacco dust cells from a retinal terror or inflammation or blood or something like that and so after seeing that then you're going to go to the posterior segment exam of the eye commonly there are two main types of lenses that you'll use the purpose of lenses and doing a a retina exam is to be able to magnify the images in the back of the eye the common common ones that are used are a 78-dopter lens and a 90-dopter lens i'm using a 78-dopter lens and there's some little tricks to be able to pick up the posterior segment of the eye of the retina using this lens first and foremost i like to do my posterior segment exam using the 78-dopter lens and i like to do it with my beam not shifted to one side or slanted to one side of the other but straight on i feel like that helps me to focus it also what i do is i make my beam a little bit taller and i make it a little bit narrower narrower and then once i have the nerve and the blood vessels and the maculine focus then i'll change the size a little bit i'll shorten the beam down and i'll widen it just a little bit and that gives me a a lit up area that's a little bit easier to see and then that'll help me to focus in on the nerve and the blood vessels and and that sort of thing so again when doing the funnest exam from the slit lamp it's good to start out with a little bit narrower beam a little bit taller beam until you get the nerve and the maculine the blood vessels and focus and then shorten it and widen a little bit to start examining around as a general rule you're going to hold the lens with two fingers your pointer finger and your thumb and then you're going to use your pinky and a lot of times your ring finger either resting on the patient's forehead or on the forehead rest itself the plastic forehead rest and then the trick of how to do this is you're going to put it up in front of their eye without touching it but just in front of where their eyebrow is and then you'll look in through the slit lamp and once you find their pupil you're going to pull back a little bit to you see the orange beam come in focus okay when the patient is dilated it's much easier to do on a non-dilated patient it takes a little bit more side to side and up and down movement be able to get the the the nerve and the retina and the macula into view and into focus so first things first now that i've got the nerve and the maculine focus i'm going to narrow the beam shorten it widen it just a hair first thing you do when you look in the back of the eye is to look at the nerve of the eye you'll look at the size you'll look at the optic cup and you'll look at the borders of the nerve and you'll look at the blood vessels coming out of the nerve in the retina world we commonly see patients that have diabetes and that have macular degeneration or vein occlusions there's inflammation there's all sorts of other things but each of these disorders are commonly associated with something going on with blood vessels and the blood vessels in the retina most of them come from or originate from the optic nerve or travel through the optic nerve and so you're going to make sure as you look at the nerve of the eye to look at what the blood vessels are doing there too so we focused in on the nerve of the eye and after seeing the nerve and looking at the blood vessels you are going to pull towards the patient's nose all right and that will shift the beam over towards the macula the macula and the phobia are the high price real estate that's where the majority of vision occurs and where the majority of retinal diseases have their source and macular degeneration diabetes when patients have issues with these disorders and many other disorders when they're swelling or bleeding in the macula it will be the thing that affects their vision and why they came in to see you with vision complaints and so again the key is and i guess a good point to bring up with that is that these lens reverse the images up and down and side to side so the macula is always located temporal or lateral to the nerve of the eye anatomically however when you're doing your exam to see it you're going to pull nasal or towards the nose to be able to get those into view so after you see the nerve you're going to pull nasal and swing the slit lamp over towards the macula to get a good view after looking at the macula then generally i will swing and look at the blood vessels i'll travel along the superior temporal arcade and the inferior temporal arcade and get a good look at the blood vessels and then i'll look a little bit past that in general with the 78-dopter lens and the 90-dopter lens you can see into the mid periphery past the macula a little bit from there you're going to take over with your indirect ophthalmic exam and so those are the basics of the slit lamp exam looking at the posterior segment of the eye and now we'll switch over and go to the indirect ophthalmoscopy alright so we have completed our slit lamp exam and our posterior segment exam using the 78 and 90 and the 90-dopter lens and now that we've looked at the posterior segment the nerve the blood vessels the macula the mid periphery we're going to try to look out farther into the retina so more out in the periphery of the retinal exam and in order to be able to do this we commonly use some different tools one is called the indirect ophthalmoscope this is the indirect ophthalmoscope and then we use two main lenses a 20-dopter lens and a 28-dopter lens and these lenses are sets that allows for a less magnified but more wide field view of the back of the eye thus being able to see out into the far periphery of the retina and so first of all again key concept in learning this is to take the time to learn it and get comfortable by making sure that the beams the head positioning the width of the your your two eye pieces are in the right location so that that you're comfortable you're going to better be able to to assess and view the patient's posterior segment and out into the periphery of their eye so i'm going to go ahead and spin so the cords on my other side and and then in in doing this you're going to put it on the upper knob will uh shorten the height of this sitting on your head and and you want to make sure the eye paces are level with your eye the back knob will tighten it in general you never have to really touch this one it's usually set right and you just un tighten and un tighten it to get it onto your head so i just turned a counter clockwise which loosens it and then i'll turn it back clockwise to tighten it the two eyepieces are set correctly they're about level with my eye if you can see that and and then there's a knob here on the left that turns the beam on and off okay you want to turn the beam on bring the eye the piece here so it's just touching your nose that generally ends up being about the right location not that it's mushing it but it's just touching your nose that way the the kind of horizontal position is located correctly in relationship to your eyes all right and then as you look through you're going to see a beam of light i'm going to turn that up to its highest because we're kind of lit up here in this room in a dark room it'll be a lot easier to see the beam has different sizes there's a wide beam a medium beam and a small narrow beam so three different sizes in general you're not going to use the narrow one very often if there's a very very small pupil you might use the narrow beam but it gives a very small view into the retina so i basically never use that little teeny beam the medium one i use for a lot of my exams except for when i'm doing a scleral depressed exam when i'm doing a scleral depressed exam i'll use the wide beam here okay sometimes in starting out obviously with more of a beam you get more light into the eye sometimes it makes the focusing in and out the field of view a little bit better you may want to start out using the wide beam and then shift over to the medium beam as you do your exam but again i generally use the medium sized beam for most of my periphery exam except when i'm doing a scleral depressed exam and then i use the wide beam and but you'll just have to to to play with it and decide what what each of you like to do best so first things first as i look at my beam and i'm looking through my oculars the beam is a little bit down towards the bottom of my view i want it right in the center if you put it up here you're not going to be able to tell you got to put the beam a little bit away sometimes i'll shine it on the patient do it or sometimes i'll hold out my hand okay and so i've got it there there's a knob here on the left that moves the beam up and down okay so just move it so it's right in the center of your oculars also i open and close each of my eyes to make sure that the beam itself is located in the center for each eye and it's actually going to be the center a little bit left for the right eye and the center a little bit right for the left eye but this is a critical concept a critical concept depending on the distance between your own two pupils you want to make sure in each eye that you can see the entire beam okay and that way when the two eyes work together it'll give you the widest feel the view or it may cut off part of the view on on one particular side and that'll make it harder to focus in on that area so again make sure the beam i literally every exam i open and close each of my eyes and i make sure that that beam is nice and centered for each eye it'll be shifted a little bit nasal for each and then as you open up both eyes it should be right in the middle i think that's a critical step i literally do it thousands of exam thousands of time doing that i make sure that that's centered right because i know that'll help me to get my best possible view of the periphery of the patient's retina okay so that's basically the the nuts and bolts of getting the the indirect ophthalmoscope ready so next i'm going to go to my patient who's been patiently waiting for us so again key concept start do the exam the same way every single time all right i start with the right eye i go to the left eye what i'm going to do and what i do is i first of all i and there's different ways this can be done but what i do is i start superior and i go lateral every single time so i go temporal and i do that with both eyes so on the right eye i'm going counterclockwise and the left eye i go clockwise and by doing the same exam every single time when i note changes there's a change at nine o'clock or there's a change at two o'clock or four o'clock by doing the exact same rotation every single time hundreds of times over i then don't have to think twice about where i saw a particular change so when i write it down on my exam or i type it into my emr or i put it on to my drawing because i do my exam the same every time it helps me to remember where i saw the changes i personally think that's a critical step in doing the ophthalmic posterior segment far peripheral exam do the same thing every single time because let me tell you when you have to start drawing stuff in and writing stuff down and if you see multiple changes in the eyes it can become very complicated and you don't have to get up and do the exam over and over again so the patient will stay nice and relaxed it'll be like they're at the barber shop or the beauty salon because you're going to position their head around a little bit and so i'll start with the right eye i'll tilt their chin just a little bit to the left all right key concept in holding this it's like the 78 or the 90-dopter lens you're going to use your thumb and your pointer finger to hold the lens you use your pinky and your ring finger okay to rest on the patient's chin or their cheekbone and then the key in getting the retina in view is you're going to put the lens in front of their eye you'll be able to actually see in pretty good clarity their cornea and iris and you'll see an orange red reflex when you see that also notice how my head is positioned okay depending on where your head is and you'll learn to adjust this back and forth in relationship to the lens there'll be a distance that will be perfect for you depending on your size your arm length curvature of your hand there'll be a certain distance between those two that is that is perfect for you of where every single time you'll get that retina in focus so i'm used to it i know kind of where mine is and so again you'll focus in you'll see the cornea the iris and clarity you'll see an orange reflex orange red reflex when you see that with your thumb and your pointer finger you're going to pull that lens out towards your eye here sometimes you have to move in a little bit sometimes you don't in general it's a good habit to learn to where to keep your head distance the same and just learn to move this lens in and out once you have the 20 or the 28 doctor lens in the position where the view fills up the whole inside of the lens so you'll see the whole retina inside of the lens not part of it or not over here but filling up the whole lens that's the right location and then you learn to look at all parts of the retina with the view itself being filled with the retinal exam so first thing i do again pinky on the cheek i already know where my head position is i look at the cornea the iris i see my orange reflex of the posterior segment i pull backwards until the retina is in view then i tell the patient to look up same thing i'm moving the lens forward and back my head generally stays still because i know where that proper position is i see the orange reflex i pull backwards one of the little subtleties of this you'll learn to be fluid with your fingers because as you pull back because it's a round surface you're going to have to turn it too a little bit that's okay so you'll pull and turn and you'll you'll you'll pick up the subtlety of that so forward i see the orange reflex i pull back with my fingers it's turning clockwise just a little bit i look up at her superior retina and then you look up into the right so this is her right i always start superior and then work temporal so up into the right and then look over to the right all right to see down into the right really well you can come from up here even from the other side of the patient all right look down into the right so in i see the orange reflex i pull back there's a nice view of her retina look straight down down into the left sometimes let me tell you another key thing sometimes there may be a language barrier we have a lot of patients that speak other languages here in the Salt Lake Valley we also have a very large Hispanic population so learning Spanish is a very nice thing and sometimes if there's a little bit of a language barrier if you just gently tap we didn't have to say you're tapping you just tap especially patients that that can't hear also you just tap in the location you want them too lightly they will naturally look there it works very well and if you have a patient you feel like you're just not communicating with it i don't want to hear you just tap before you focus and they'll they'll just naturally look in that location so look down into the left and then over to the left and i'll just kind of tap where i want it too lightly you don't want to pound them obviously look up into the left and then i have them at the very end look right at me now that right at me exam i get a good view of the nerve the blood vessels the macula again and then that's the exam for the right eye as i'm going i will make a note of where i saw change well i saw a little retinal defect or a retinal tear up at 10 o'clock in my head i think retinal tear off at 10 o'clock all as i'm going i've learned i'll kind of repeat that in my head okay saw a tear at 10 and i'm keep going to my zam remember you have a tear at 10 and that way when i get down i'm going to record my findings i'll write them down but there's a lot of things to think about so now i do the left eye so same thing i'll make sure their head is in the right position i'll have them look straight up and then i work temporal up into the left over to the left down into the left straight down at your toes very good then for this you can rotate to the other side of the body it's easier or you can turn their head this way then look down into the right over to the right up into the right very good and so that's the posterior segment exam the other thing that we'll commonly do is to do scleral depression and that's where you use a little scleral depressor you give them a numbing drop and then you do that same peripheral exam with the scleral depressor around the side of the eye that allows you to see out to the aura serata so the posterior segment of the eye is like a fishbowl where you have an opening in the top and just like when you look down on the fishbowl you can see everything that's straight back well you can't see what's up underneath the rim of the fishbowl unless you stuck your head in there and looked up there and so the scleral depressor allows you to press in underneath that lid of the fishbowl so you can see way out to the side of the eye and that's commonly where disease processes occurs out by the aura serata that's the indirect exam