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Peripheral Fundus Examination in the Pseudophakic Eye
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peripheral fundus examination In the pseudophakic eye Donald E. Dickerson, M.D. Santa Monica, California The examination of the peripheral fundus of an eye containing an intraocular lens is commonly stated to be very difficult. One of the reasons for the initial lack of enthusiasm for lens implantation was the fear that retinal problems would be extremely difficult to diagnose and treat. This clinical study was undertaken to determine how difficult peripheral fundus examination is in the presence of an intraocular lens. The examination was done with the patients' pupils undilated to reduce the hazard of dislocating the intraocular lens. Obviously, this would shorten the office detention time for the patient and the doctor. If examinations were successful, then surgical intervention might also be undertaken with an undilated pupil. We were interested in the problem of fundus examination in those eyes whose pupils cannot dilate because of such reasons as synechiae to the intraocular lens. Finally, in addition we were interested in developing techniques and instruments to facilitate small pupil examination. Protocol All patients with intraocular lenses that had been in place over three months were examined by me on an unselected basis. Only lenses manufactured by Medical Workshop or by Mr. Kurt Morcher had been used in.these patients. Results Seventy-five eyes were examined in this study (Table 1). Fifty-four had undergone an intracapsular procedure and twenty-one had undergone extracapsular surgery. TABLE I TYPES OF SURGERY INTRACAPSULAR 1. Medallion -2 loop Suture Lens 2. Binkhorst -Federov Lens 3. Medallion -Plantina Lens
34 17 3
PHACOEMULSIFICATION 1. 2. 3. 4.
Medallion -2 loop Suture Lens Iridocapsular Lens Binkhorst -Federov Lens Medallion -Platina Lens
9
6 4
2
75 34
Table 2 summarizes the examination results. The additional information about the visualization of the ora serrata superiorly was given because of the frequency of serious retinal tears in th'e superior quadrants of the eyes. The equator was seen in all eyes in this series. The ora serrata was seen in 90% of the intracapsular series and in 85% of the extracapsular series. This series, of course, had no major complication problems, but not all the eyes had perfectly clear media and not all the patients were fully cooperative. TABLE"
SUMMARY OF EXAMINATION
INTRACAPSU LAR Equator Seen Ora Seen Without Depression With Depression Superior One-Half - Ora Without Depression
100% 90% 20% 70% 53%
PHACOEMULSIFICATION Equator Seen Ora Seen Without Depression With Depression Superior One-Half - Ora Without Depression
100% 85% 5% 80% 9%
Discussion Several practical observations were noted. It seemed to be easier to examine after intracapsular surgeries. Although the series is small and the percentage difference was not significant, the presence of a posterior capsule made the peripheral fundus more difficult to examine. The type of lens seemed to be important and the Medallion two loop suture lens was more frequently associated with successful viewing of the ora serrata. It must also be stated that the types of lenses used prohibited the pupil from constricting smaller than 2mm. square. This made the diagonal distance approximately 2.8mm. I believe these distances are significant for successful peripheral fundus examination. Scleral depression had to be very accurate in that one had to be exactly 180 degrees opposite or-else the depression could not be seen. Obviously, when looking through a small pupil, the opportunity to find the area of scleral depression was limited. After trying three other types of indirect ophthalmoscopes, I finally found the examination was definitely easier with the use of the "small-pupil" ophthalmoscope designed by O. Pomerantzeff and manufactured by Medical Instrument Research Asso-
ciates. This was the only "small-pupil" instrument available to me at the time of the study. Summary The examination of the peripheral fundus of an eye containing an intraocular lens is not an impossible task. This portion of our care should not be neglected. With the use of a small pupil indirect ophthalmoscope and patience on the part of the doctor, 85-90% of all cases can have their ora serrata examined without dilating their pupils. Successful diagnosis and treatment of retinal problems should be possible despite the initial opinions and fears of the ophthalmic community. References: 1. Howland, K.R., Elzeneiny, I.H., Schepens, C.L.: Clinical Evaluation of the Small-Pupil Binocular Ophthalmoscope. ARCH. OPHTHAL. - Vol. 82, Oct. 1969.
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peripheral fundus examination In the pseudophakic eye Donald E. Dickerson, M.D. Santa Monica, California The examination of the peripheral fundus of an eye containing an intraocular lens is commonly stated to be very difficult. One of the reasons for the initial lack of enthusiasm for lens implantation was the fear that retinal problems would be extremely difficult to diagnose and treat. This clinical study was undertaken to determine how difficult peripheral fundus examination is in the presence of an intraocular lens. The examination was done with the patients' pupils undilated to reduce the hazard of dislocating the intraocular lens. Obviously, this would shorten the office detention time for the patient and the doctor. If examinations were successful, then surgical intervention might also be undertaken with an undilated pupil. We were interested in the problem of fundus examination in those eyes whose pupils cannot dilate because of such reasons as synechiae to the intraocular lens. Finally, in addition we were interested in developing techniques and instruments to facilitate small pupil examination. Protocol All patients with intraocular lenses that had been in place over three months were examined by me on an unselected basis. Only lenses manufactured by Medical Workshop or by Mr. Kurt Morcher had been used in.these patients. Results Seventy-five eyes were examined in this study (Table 1). Fifty-four had undergone an intracapsular procedure and twenty-one had undergone extracapsular surgery. TABLE I TYPES OF SURGERY INTRACAPSULAR 1. Medallion -2 loop Suture Lens 2. Binkhorst -Federov Lens 3. Medallion -Plantina Lens
34 17 3
PHACOEMULSIFICATION 1. 2. 3. 4.
Medallion -2 loop Suture Lens Iridocapsular Lens Binkhorst -Federov Lens Medallion -Platina Lens
9
6 4
2
75 34
Table 2 summarizes the examination results. The additional information about the visualization of the ora serrata superiorly was given because of the frequency of serious retinal tears in th'e superior quadrants of the eyes. The equator was seen in all eyes in this series. The ora serrata was seen in 90% of the intracapsular series and in 85% of the extracapsular series. This series, of course, had no major complication problems, but not all the eyes had perfectly clear media and not all the patients were fully cooperative. TABLE"
SUMMARY OF EXAMINATION
INTRACAPSU LAR Equator Seen Ora Seen Without Depression With Depression Superior One-Half - Ora Without Depression
100% 90% 20% 70% 53%
PHACOEMULSIFICATION Equator Seen Ora Seen Without Depression With Depression Superior One-Half - Ora Without Depression
100% 85% 5% 80% 9%
Discussion Several practical observations were noted. It seemed to be easier to examine after intracapsular surgeries. Although the series is small and the percentage difference was not significant, the presence of a posterior capsule made the peripheral fundus more difficult to examine. The type of lens seemed to be important and the Medallion two loop suture lens was more frequently associated with successful viewing of the ora serrata. It must also be stated that the types of lenses used prohibited the pupil from constricting smaller than 2mm. square. This made the diagonal distance approximately 2.8mm. I believe these distances are significant for successful peripheral fundus examination. Scleral depression had to be very accurate in that one had to be exactly 180 degrees opposite or-else the depression could not be seen. Obviously, when looking through a small pupil, the opportunity to find the area of scleral depression was limited. After trying three other types of indirect ophthalmoscopes, I finally found the examination was definitely easier with the use of the "small-pupil" ophthalmoscope designed by O. Pomerantzeff and manufactured by Medical Instrument Research Asso-
ciates. This was the only "small-pupil" instrument available to me at the time of the study. Summary The examination of the peripheral fundus of an eye containing an intraocular lens is not an impossible task. This portion of our care should not be neglected. With the use of a small pupil indirect ophthalmoscope and patience on the part of the doctor, 85-90% of all cases can have their ora serrata examined without dilating their pupils. Successful diagnosis and treatment of retinal problems should be possible despite the initial opinions and fears of the ophthalmic community. References: 1. Howland, K.R., Elzeneiny, I.H., Schepens, C.L.: Clinical Evaluation of the Small-Pupil Binocular Ophthalmoscope. ARCH. OPHTHAL. - Vol. 82, Oct. 1969.
35