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GettingaBetterViewoftheFundusCarolineB.Pate,OD,FAAOandElizabethA.Steele,OD,FAAO GettingaBetterViewoftheFundus (2HourWorkshop) CarolineB.Pate,OD,FAAOandElizabethA.Steele,OD,FAAO TheUniversityofAlabamaatBirminghamSchoolofOptometry 1716UniversityBoulevard Birmingham,AL35294 (205)9966635 cbeesley@uab.edu Abstract Withallofthefunduslensesavailabletodayforbiomicroscopy,whichoneisthebestforyou? Consideringfactorssuchasimagequality,magnificationandfieldofview,itisimportanttounderstand thebenefitsofeachlens.Inthishandsonworkshop,attendeeswillbecomefamiliarwithvarious optionsoflensesforbiomicroscopyandtheirusesinclinicalpractice.Patientpreparation,procedure andinterpretationofthefundusexaminationwillbecovered.

d.Participantswillhavetheopportunityto gainexperiencewithavarietyofnoncontactandcontactfunduslenses.Attendeeswillbeprovided withdilatedsubjectsforthisworkshop.Standardsofcareareaddressedandclinicalpearlsprovided. LearningObjectives Attheconclusionofthisworkshop,attendeeswill: 1. 2. 3. 4. 5. 6. Enhancefundusexaminationskillswiththeuseoffunduslenses. Gainfamiliaritywithvarioustypesofnoncontactfunduslenses. Gainfamiliaritywithvarioustypesofcontactfunduslenses. Recognizetheclinicalsituationsinwhichaparticularfunduslensismoreuseful. Understandwaystomaximizeaparticularviewoftheretina. Becomefamiliarwiththedisinfectionoffunduscontactlensesusingtheglutaraldehydehigh leveldisinfectionsystem.

Outline I. Introduction A. Descriptionofthevarioustypesoffunduslensesavailableandtheclinicalsituationsin whichparticularlenseswouldbebeneficial II. Procedures A. Attendeeswillbedividedintosmallgroupsof24,eachassignedtoaslitlampwitha teachingtube,andadilatedpatient 1. Thebenefitofteachingtubesand/orvideorecordinganddisplayofprocedures willbeavailableforgroupanalysisandinterpretation 1

GettingaBetterViewoftheFundusCarolineB.Pate,OD,FAAOandElizabethA.Steele,OD,FAAO 2. Eachattendeewillhaveahandsonexperiencewithavarietyofnoncontact andcontactfunduslenses,featuredbelow,andwillbeabletocomparetheir viewswiththatofatraditional60D,78D,and/or90Dlens. 1. Manufacturerslensspecifications: Lens Magnification FieldofView View Other (Static/Dynamic)
Volk60D 1.15x 68/81 indirect 13mmworking distance;highmag idealfordetailed ONHandmacula 8mmworking distance;good compromiseb/w FOVandmag 7mmworking distance;idealfor smallpupil examination

Volk78D

.93x

81/97

indirect

Volk90D

.76x

74/89

indirect

III. Station1:NoncontactFundusLenses A. ManufacturersFeaturedLensSpecifications: Lens Magnification FieldofView (Static/Dynamic)


VolkSuperPupil XL .45x 103/124

View
indirect

Other
Optimalsmallpupil capabilitythrough apupilassmallas 12mm Widefield,pan retinalexamination andsmallpupil capability(34mm) Highresolution withawidefieldof view(pastvortex) Idealforopticdisc measurementsand

VolkSuper Vitreofundus

.57x

103/124

indirect

VolkDigitalWide Field

.72x

103/124

indirect

VolkDigital1.0x

1.0x

60/72

indirect

GettingaBetterViewoftheFundusCarolineB.Pate,OD,FAAOandElizabethA.Steele,OD,FAAO
ImagingLens VolkDigitalHigh Mag 1.30x 57/70 indirect slitlampphotos Highresolution, highmagnification imagingofthe centralretina Widerfieldofview comparedtoa classic78Dlens

Ocular Instruments OsherMaxField 78D Ocular Instruments MaxField120D

.77x

98/155

indirect

.50x

120/173

indirect

Widefield,pan retinalexamination andsmallpupil capability(2mm)

B. PurposeandIndications 1. Performastandarddilatedfundusexaminationusingaprecorneallensthat enhancesyourmagnification,resolution,and/orfieldofview a) Useaparticularprecorneallensinordertooptimizeyourviewofan areainquestion b) Maximizeyourfundusexaminationthroughanundilatedpupilfor situationsthatdonotallowforpupillarydilation C. InstrumentationandProcedure 1. SlitLamp 2. Teachingtubeand/orvideorecordinganddisplayofprocedure 3. Oneoftheaboveprecornealfunduslenses 4. Patientwithcompletepupillarydilation 5. Patientwithundilatedpupil(forcomparison) D. Interpretation 1. Theimageprovidedineachoftheabovelensesisinvertedandlaterally reversed E. ClinicalPearls 1. Patientsgazecanbealteredinordertomaximizeviewofgivenarea 2. Eachlenshasitsownuniqueworkingdistancetoallowformaximal performance IV. Station2:ContactFundusLenses A. ManufacturersFeaturedLensSpecifications 3

GettingaBetterViewoftheFundusCarolineB.Pate,OD,FAAOandElizabethA.Steele,OD,FAAO Lens
VolkFundus 20mm(with flange) Ocular Instruments Yannuzzi FundusLens Ocular Instruments Fundus Diagnostic Lens Centrallensof 3mirror1

Magnification
1.44x

FieldofView (Static/Dynamic)
25/30

View
direct

Other
Flangehelpsprovide stabilityoflenson cornea Flangehelpsprovide stabilityoflenson cornea

.93x

36

direct

.93x

36

direct

Theflatfrontsurface ofthiscontactlens providesadirect imageofthe posteriorpole 15mmcontact diameter;Noflange optionisidealfor useoninfantsor patientswithnarrow palpebralfissures Highmagnification andresolutionof posteriorpole Lensofchoicein eyeswithpoor dilation(canbeused inpupilsassmallas 3mm) Extremeperipheral retinalexamination

1.06x 1.08x

3mirrors: (Volk60/66/76) (Ocular Instruments 59/67/73) 74/88

direct

VolkHigh Resolution Centralis VolkEquator Plus

1.08x

indirect

0.44x

114/137

indirect

VolkHigh Resolution WideField

0.5x

160/165

indirect

Additionallensesavailableforfundusviewingon3mirror(positionlensopposite fromwhereyouneedtoexaminee.g.,toviewlesionlocatedinbetweentheequator andoraserratainthesuperiorretina,positiontherectangularlensinferiorlyonthe eye):


Centrallens: Direct,magnifiedviewof posteriorpole(approx. central3036) Highminuslens:64D

Trapezoidshapedlens: Largest usedtoexamineretina adjacenttotheposterior poleouttoapproximately equator requiresdilation

GettingaBetterViewoftheFundusCarolineB.Pate,OD,FAAOandElizabethA.Steele,OD,FAAO

Dshapedlens: Smallest Usedforgonioscopyif pupilsareundilated Usetoviewparsplana ifpupilsaredilated

Rectangularlens: mediumsized usedtoexamine retinafromthe equatorouttoora serrata

B. PurposeandIndications 1. Useaparticularcontactfunduslensinordertooptimizeyourviewofanareain question 2. Clinicaluses: a) Enhancingviewofmacula 1) Edemaindiabetic,ARMD,orPOHS 2) Epiretinalmembrane 3) Macularhole 4) Cystoidmacularedema 3. Dilatedfundusexaminationinanuncooperativeorphotophobicpatient 4. ToobtainamoremagnifiedviewofaperipheralretinallesionnotedduringBIO C. Contraindications 1. Severecornealtrauma 2. Penetratingocularinjury 3. Severeanteriorsegmentinfection 4. Hyphema D. Instrumentation 1. SlitLamp 2. Teachingtubeand/orvideorecordinganddisplayofprocedure 3. Oneofabovecontactfunduslenses 4. Patientwithcompletepupillarydilation 5. Patientwithundilatedpupil(forcomparison) 6. BufferingsolutionsuchasGoniosol,RefreshCelluvisc,orGentealGel 7. Anesthetic 5

GettingaBetterViewoftheFundusCarolineB.Pate,OD,FAAOandElizabethA.Steele,OD,FAAO 8. Glutaraldehydeforhighleveldisinfection SetUp 1. Preparedisinfectedlensbycleaningofdebrisandfingerprints(soapandwater, oranRGPcleansingsolutioncanbeused) 2. Place23dropsofbufferingsolutionintolenswell a) Lenseswithoutaflangemayrequirelessornobufferingsolution 3. Anesthetizepatientscornea(s) Procedure 1. Instructpatienttolookup 2. Obtainlowerlidcontrol(maynotbenecessaryifusingalenswithoutaflange) 3. Insertthelowerportionofthelens/flangeintothepatientsinferiorculdesac 4. Pushthelensdownwardandrotatethelensontothecornea.Upperlidcontrol canbeobtainedifnecessary. 5. Instructthepatienttolookatyourfixationtarget(knob,ear,etc) 6. Pullbackontheslitlampjoystickinordertoobtainafocusonthedesired target. 7. Lensremoval a) Carefullybreaksuctionbetweenlensandtearinterface b) Lenseswithoutaflangewillhavelessornosuctionandlenscanbe gentlypulleddirectlyawayfromtheeye 8. Lavageifnecessarybasedonbufferingsolutionused 9. Disinfectionofusedlenswithglutaraldehydehighleveldisinfection Interpretation 1. Directview:viewseenishowitappearsanatomically 2. Indirectview:viewisinvertedandlaterallyreversed ClinicalPearls 1. Patientsgazecanbealteredinordertomaximizeviewofgivenarea

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