A few weeks ago, a 43-year-old white male presented to the office of optometrist Dawn Bearden. The patient reported that his acuity was clear, but “something’s off.” He said that he had never had an eye exam.

“I found on confrontation fields that he was missing the whole temporal side of his visual field,” Dr. Bearden says.

When she dilated him, she found an amelanotic melanoma taking up about 30% of the inside of his eye.

Dr. Bearden, whose practice adjoins a LensCrafters in Pembroke Pines, Fla., immediately sent the patient to a retinal specialist. From the retinal specialist, the patient went to Bascom Palmer Eye Institute, in Miami. Eventually, his eye was enucleated.

This 43-year-old patient presented with an
amelanotic melanoma at his first eye exam.

“He went from his first eye exam to enucleation in three weeks,” Dr. Bearden says. “I’m pretty sure a dilated eye exam [performed earlier] could have saved his eye.”

Had the patient visited Dr. Bearden earlier, he would have received not only an eyeful but an earful. “I’m a big believer in dilation,” she says. “If I’ve never seen you before, I dilate you. That’s the state law in Florida, so I follow that law. But not everybody does, unfortunately.”

Even though she forthrightly states her dilation policy, some patients still try to beg off. They say they don’t like the blur, they don’t like the photophobia, and they don’t want to be dilated, period. “Usually when people refuse, I put on a video for them to watch,” Dr. Bearden says.

The video, also available through Dr. Bearden’s website ( www.visionaryeyecareonline.com) and on the practice’s YouTube channel ( www.youtube.com/watch?v=HNhUkA5TSwQ), is a convincing patient testimonial from a woman named Starlene Carter.

“I did not want to get dilated,” Ms. Carter tells the camera. But Dr. Bearden eventually convinced Ms. Carter. Upon dilation, Dr. Bearden discovered a large horseshoe retinal tear, and referred Ms. Carter to a retinal surgeon for laser treatment. (“It’s always the patients who give you a hassle, they’re the ones you find problems with,” Dr. Bearden says.)

So, in the video, Ms. Carter makes a strong case for comprehensive eye exams. “She’s the walking billboard for dilated eye exams right now,” Dr. Bearden says.

“Testimonials from other patients hold a lot of weight.”

How Often is Often Enough?

But how often should you dilate your patients? Is it often enough?

“In our office, our recommendation is an annual comprehensive examination for everyone, and that includes a dilated fundus exam,” says optometrist Robert Cole, of Bridgeton, N.J. “We don’t have to do it every year, but we plan to do it every year.”

This is certainly more true in patients with eye disease or those at risk for eye disease. Indeed, more than two-thirds of O.D.s say that patients with eye disease (such as glaucoma or diabetes) require dilated fundus exams at least every year, according to Review of Optometry’s most recent Diagnostic Technology Survey (‘Making Strides’ With New Technology, August 2010).

Clinical guidelines classify who should be dilated, and how often. According to the AOA’s Clinical Practice Guidelines (CPG) for open-angle glaucoma, “Every patient diagnosed with glaucoma should be seen at least every six months. A dilated fundus examination … should be performed at least once per year.”1 (See “When to Dilate Patients with Glaucoma,” below.)

For patients with diabetes, “Early diagnosis of diabetic retinopathy coupled with annual dilated eye examinations will identify patients at high risk and who will benefit most from intensified therapy, both ocular and systemic,” says the AOA’s guideline.2 (See “When to Dilate Patients with Diabetes,” p.46.)

Dilation and Diabetes

Despite the clinical guidelines, patients with diabetes are notable for not receiving dilated eye exams frequently enough. “About half of adults whose diabetes puts them at risk are not receiving timely and recommended eye care to detect, diagnose, and treat diabetic retinopathy,” the AOA’s guideline says.2

Even with a push for better proactive and preventive care for people with diabetes, the numbers of dilated eye exams—or at least the numbers reported—are actually going down. For example, the U.S. government’s Healthy People 2010 (HP2010) initiative aims to increase the percentage of adults with diabetes who get an annual dilated eye examination, with a target goal of 75%. But, “this HP2010 objective was not being achieved for the total population as of 2006, and no significant trend was found in the data.”4 As of 2008, only 62% of adults with diabetes received annual dilated eye exams—about the same percentage as a decade earlier.5 

“As primary care optometrists, we’re on the front line, so we need to let the general internist or endocrinologist know how the patient is doing,” says optometrist and certified diabetes educator Tina MacDonald, of Los Angeles. This communication, she says, “emphasizes what we do—that we’re not refractionists. We take care of the health of the eye.”

Furthermore, she asks, “If dilated exams are not being done, or not being reported, for patients with diabetes, what does that say for the patient who doesn’t have diabetes? It doesn’t bode well for them.”

Young and Healthy?

What about dilating those seemingly healthy patients? There are no strict clinical guidelines for them.

“On one hand, you have the patients at risk—the glaucoma patients, the diabetic patients. They need to be dilated,” says James L. Fanelli, of Wilmington, N.C. “But what do you do with the people at the other end of the spectrum—the young, healthy 2.00D myope who has no medical history, no ocular history, no trauma? Do you inconvenience that patient and dilate him or her every time?”

Despite its crucial importance, very few journal articles have investigated dilation itself. However, this particular question—How often do healthy asymptomatic patients need to be dilated?—was examined by researchers more than a decade ago. Their conclusion: Routine dilated exams yield clinical fundus findings in about 5% of asymptomatic patients without risk factors.6 Few of these findings are beyond the view of the direct ophthalmoscope. And, the prevalence of fundus abnormalities increases tenfold with increasing patient age.

In other words, do you routinely dilate 100 young, healthy patients just to catch a few with a “clinical fundus finding,” only a fraction of which are peripheral?
Broadly speaking, the answer is yes. “One of the most important reasons to dilate is not necessarily to look at the peripheral retina where pathology is rare, but to look at the optic nerve stereoscopically,” says Paul Ajamian, O.D., of Atlanta. “And you can only do that through a dilated pupil using a fundus lens, not with a monocular direct ophthalmoscope or camera.”

Dr. Ajamian concedes that not every single patient needs to be dilated every year, but he maintains that O.D.s just aren’t being rigorous enough about dilated exams.

Dr. Fanelli says, “my personal feeling is that every patient needs to be dilated on the first visit. But the next year—assuming the patient has no complaints, his history hasn’t changed, he has no obvious signs, and you’ve dilated him the year before—I think it’s acceptable to not dilate that patient at that next visit.” 

However, Dr. Fanelli says, not doing a dilated exam “doesn’t mean you don’t look in the eye. It just means you look through a non-dilated pupil. You still have to take a look inside with a fundus lens, not with a direct or monocular indirect ophthalmoscope.”

In healthy, asymptomatic patients, he often opts for a non-dilated fundus exam for this “off-year” visit. (See “A Good Fundus Exam Without Dilation,” p. 49.) By doing this, he says, “you’ve accomplished two things: you did not inconvenience the healthy patient; but you also did not shirk your responsibility of looking at the fundus, including the peripheral retina.”

The Optomap Question

Speaking of non-dilated fundus exams, “there are some doctors that I’ve seen who offer the Optomap (Optos) as a substitution for a dilated exam,” Dr. Fanelli says. “I do not think that an Optomap is a substitute for a dilated fundus exam. Yes, it gives you a wide field of view, but clinically you need to take a look in the eye in real time. You can’t rely on a digital picture to make a diagnosis.”

Dr. Bearden, who used to have an Optomap, echoes this sentiment. “It’s an enhanced retinal photo, but I don’t think it replaces dilation,” she says. “Optomap may buy you another year or two without dilation, but it’s not going to get you out of dilation for the rest of your life.”

Bruce Clarin, O.D., uses the Optomap to take fundus photos on about 25% of patients in his Miami practice. “What it’s good for is this: If I take a picture of someone and I see something, then I can dilate them and I can look more specifically at it with all kinds of lenses,” he says. “So it’s not only good to follow people to watch for changes, but it’s also good that if you see something, you can actually look at it more closely.”

In a few patients, for example, the Optomap picked up very small peripheral hemorrhages that couldn’t be viewed with an indirect ophthalmoscope, Dr. Clarin says. One instance led to a diagnosis of hepatitis B.

Do Your Job

Most patients’ concerns about dilation center on the blur that occurs with dilation, Dr. Fanelli says. “The blur is usually caused by the cycloplegia that accompanies the dilation of the pupil. For our purposes, we want the pupil dilated, not necessarily the eye cyclopleged,” he says. “So, in patients with light irides, you can get a good dilation and no cycloplegia with two drops of 2.5% phenylephrine.”

But, no matter how easy you make it for patients, they still resist when you say “dilation.”

“Somehow, we as optometrists think of dilation as a negative, and that attitude gets transmitted to patients,” Dr. Ajamian says. “We present dilation as a bad thing, but there’s nothing bad about it. When they tell me they don’t want to be dilated, I say, ‘Then we have to end the exam right here. I can’t do my job. I need to look at the back of your eyes. Why don’t we just get it done today instead of rescheduling you for another day?’”

Their typical answer? “‘OK, go ahead and do it,’” Dr. Ajamian says. “It’s that simple.”

1. American Optometric Association Consensus Panel on Care of the Patient with Open Angle Glaucoma. Optometric Clinical Practice Guideline: Care of the Patient with Open Angle Glaucoma. 2nd ed. St. Louis, Mo.; 2002:52,130.
2. American Optometric Association Consensus Panel on Comprehensive Adult Eye and Vision Examination. Optometric Clinical Practice Guideline: Comprehensive Adult Eye and Vision Examination. 2nd ed. St. Louis, Mo.; 2005:4.
3. American Diabetes Association. Executive summary: Standards of medical care in diabetes—2009. Diabetes Care. 2009 Jan;32 Suppl 1:S6-12.
4. California Department of Public Health. Healthy California 2010 Progress Report: Objective 5-13: Annual Dilated Eye Examination. 2009 Feb. Available at: www.cdph.ca.gov/data/indicators/goals/Documents/Objective0513.pdf (accessed October 6, 2010).
5. Centers for Disease Control and Prevention, Division of Diabetes Translation. Age-Adjusted Percentage of Adults Aged 18 Years or Older with Diagnosed Diabetes Receiving a Dilated Eye Exam in the Last Year, United States, 1994–2008. Available at: www.cdc.gov/diabetes/statistics/preventive/fX_eye.htm (accessed October 5, 2010).
6. Pollack AL, Brodie SE. Diagnostic yield of the routine dilated fundus examination. Ophthalmology. 1998 Feb;105(2):382-6.