How To Get a Thorough Eye Exam Series: Dilation and Retinal Evaluation

My first hub in this series discussed your evaluation with the technician, including vision testing and refractions for glasses. The next hub in the series will explain the second half of the eye exam. This is the part when the technician checks your pressure, dilates your eyes and then you see the ophthalmologist. In my 15 years as a tech, I spent quite a bit of time as a scribe, in the room with the doctor and the patient. I found it frustrating when the doctor would not fully answer questions or tell the patient what test he was doing and why. This hub will explain all that and more.

The pressure check involves the technician anesthetizing the eye with a yellow dye/anesthetic combination drop known as fluorescein. This drop will sting when instilled until the anesthetic takes over. My recommendation to all my patients is to blink or bat your eyes as quickly as you can. This distributes the drop and allows the anesthetic to numb the eye more quickly than holding the eyes shut would. It will also ensure the eye is sufficiently numb for the tonometer probe. It is difficult to do since the drop stings quite a bit and the natural reaction is to shut the eyes. It’s mind over matter here. You CAN do it.

After the yellow dye, the technician will align you in the slit lamp. Technicians who are new to the field, will just go straight to the pressure check, using the blue-lit tonometer probe (see photo). Technicians who have been doing this for eons will always check your eye first to make sure the cornea is clear. This is important to make sure there is nothing on the cornea that will affect the reading or make it unsafe to use the tonometer.

They will also check the angles of the anterior chamber (the space between the cornea and iris-see diagram) to make sure it is safe to dilate your eyes. They will then move the tonometer in place, turn on the blue light and have you look at a specific spot. They may or may not hold your lids. I rarely had to hold my patients’ eyelids open but I was also quicker than the majority of techs I worked with. It’s more accurate if you do not hold a patients eye open during applanation because there is no risk of putting pressure on the globe (eyeball) which would artificially create a high pressure reading. Sometimes you have no choice. The easiest way to hold your eye open for this test is to tap your fingers on your leg and concentrate on doing it while the tech checks the pressure. It’s tough to do, but it will distract your brain from what’s happening to your eye.

Once you are dilated, you’ll be taken to see the doctor. He will examine the eye with a slit lamp like the one the tech used to check your pressure. He will also use a small magnifying lens to look at the optic nerve. This little lens can cause the light of the slit lamp to be very bright, which can be painful and cause your eye to water. Try your best to keep your eye open; this part of the exam will be over more quickly if you are able to keep from blinking or moving your eye.

After to pressure check, the tech will instill dilating drops into both eyes and then have you sit in a waiting area while your eyes dilate. This can take anywhere from 10 to 30 minutes. Those with dark irises will take longer to dilate and may need several applications of the dilating drop. To speed up the process, keep your eyes closed. This forces your eye to dilate allowing the drops to penetrate the iris muscles faster. Dilating drops can take anywhere from three to 24 hours to wear off.

You may hear the doctor rattle of some medical lingo to his assistant. This is what he sees in the eye as he examines it. He calls out the information to the scribe (assistant) for him or her to record in the chart. It will typically sound something like this “cornea clear, anterior chamber deep and quiet, lens two plus NS, cup to disc ratio .5.” Don’t be alarmed by this. This is only the doctor describing the anatomy of the eye to the scribe.

After the slit lamp exam, the doctor will put a device on his head that I like to call the space helmet. It’s called an indirect ophthalmoscope, but it looks alien. It has a light on it and mirrors so the doctor can view the retina clearly. He will use a larger lens this time for magnification and this will cause the light to be very bright. If you can’t stand it, let the doctor know. He can turn the light down a bit, but he needs the light to view the retina properly. It’s best to grin and bear it and try to keep your eye open.

He will ask you to look in eight different directions: up and right, up, up and left, left, down and left, down, down and right, right and then finally straight ahead. This is so he can view all the peripheral areas of the retina. Sometimes the doctor will use an instrument called a scleral depressor to push the walls of the globe in to see the most peripheral areas of the retina. This can be very uncomfortable, but it’s rarely done unless there is the possibility of a retinal detachment. The doctor will let you know prior to performing scleral depression so you’ll know it’s coming. I’ve only seen a general ophthalmologist perform this a couple times. Once was on myself because I asked him to do it. (I’m a glutton for punishment.) It is typically only done by retinal specialists.

After this examination, the doctor will make a few notes, and then address your eye health with you. This whole procedure only takes about three minutes. With managed care insurance plans the way they are today, it is difficult for the doctor to spend more than five minutes with a patient. But if you have questions, you need to ask them. Most good doctors will ask you if you have any questions before he tells you when he would like to see you again and excuses himself.

If you aren’t satisfied that the doctor has answered your questions, voice your concerns. As a medical professional, I’ll be honest, we hate it when patients say they’d like to speak to the doctor again merely because it throws a wrench in the schedule, but that’s our problem. As the patient, you are entitled to answers to your questions. Being honest again, you will be better off asking for the most experienced tech available to ask your questions. The doctor will have a difficult time putting things into easily understandable terms for you, its just not what they do. An experienced technician; however, will be able to explain things more clearly because this is their job. I say to ask for the most experienced tech because they are the ones with the most patience and understand what you’re asking and why. If anyone seems to become impatient with you, call them on it. They may not realize how they are acting, especially if it’s a very busy day. On the other hand, you may also be asking the same question repeatedly which is frustrating on both sides. This is why I recommend an experienced tech. An experienced technician will be able to anticipate any repeated questions and explain things thoroughly, preventing any frustration.

I would also like to mention wait times. I know how frustrating it is to wait in a doctor’s office. I’ve waited for four hours before. But as a medical professional, I also understand why this happens. The technicians and doctors can only work as fast as their patients will let them. Patients who have medical complaints that require unforeseen, additional testing take longer, and when appointments are scheduled, no one knows what tests will need to be done. It’s just a fact, we aren’t mind readers. Keep in mind, if you are getting frustrated by waiting, this just means the staff is taking the time each patient needs and will do the same for you when you are finally called back. Getting impatient and becoming irate will only make the staff want to get you out of the building as quickly as possible and you won’t get the care you need. You catch more flies with sugar than with vinegar.

That said, on occasion, patients are over looked. If you think this may be the case, don’t be afraid to ask the front desk about it. They’ll be able to tell you if they mistakenly forgot to put your chart back, or if the techs are just really busy. Again, sugar works better here than vinegar. The nice, understanding patients will be taken care of much more quickly than those berating the staff will.

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