real world advice on dilating

[ODstudent]

I would like to know how practicing ODs work dilation into their routine. In other words, how long is an average exam, what is your preferred testing sequence, when in the exam are they dropped.... looking for efficiency. What works out there in the real world?

Gracias.

[Ory]

I would suggest you head over to odwire.org and ask there.

It really depends on how many exam rooms you work out of and how much time you spend per patient.

:cheers:

[MarcE]

go to optometricmanagement.com and go to the archived management tip of the week. There is a good one there.

[chip anderson]

Had a post lasik patient in last week for bifocal soft contacts, fitted and dispensed 20/20 J-1 (patient was just in from the doctor's office dilated).
Came back for follow up and needed +1.75 over one eye for same result.

Chip

[Bezza]

In our practice it is usual for patients that require dilation to have the drops inserted at the end of the eye exam and then be seen again once the optom has seen his/her next patient (we offer them tea/coffee while they wait or if they require glasses they will speak with a dispensing optician in this time)

Since we also do diabetic screening, patients requiring dilation for this are seen initially by a clinical assistant or dispensing optician for VA's, drops etc and the retinal photos are sent via network to the laptops in the exam rooms where the optom can review them and call the patient in to discuss any relevant details.

[FVCCHRIS]

Our Dr's typically drop them after the subjective is finished, then they can be helped to choose glasses while they wait. Longer selections result in bigger sales since the price tags soon become illegible to them!:D Just kidding, usually by the time the Optician is done the Dr's ready to take them back in. We dilate almost everyone now, a much higher rate compared to 22 years ago when I started. Many more Lawyers now than then Chris.. Good luck in your career.

[orangezero]

I would agree with most. I'll pass on a little hint. I worked at a place where the other doc (on my day off) liked to dilate them after checking VA and pupils. It certainly wasn't all of them, but I did see a decent amount of people back later who wanted a recheck on their glasses because they thought the whole refraction was a bit fuzzy and they just weren't sure about these glasses. Looking back in their chart, several had best corrected of 20/25- or worse, odd, hey? I ended up changing the prescription on most of those, btw.

I know there are docs who do it and I know there are some optometric gurus writing in some journals who think its good for patient flow and doesn't negatively affect the refraction. Still, if it was my money going in to the remake, I'd rather make the patient wait an extra 5-10 minutes and do the refraction without partially dilated pupils, corneas exposed to anesthetic, and patients wondering about what just happened.

Of course, others don't see a problem with it at all, and couldn't even phathom why there would ever be. must be the pd off...

2c

[steff]

I don't dilate everyone... (ok, I'm waiting for the flame war to begin, with that declaration), but I do dilate quite a lot.

When I dilate, I get them back for another appointment. I like to do all the normal tests undilated, as this is their 'normal visual state'. When I get them back, I recheck their IOPs, and angles, then put their drops in. I then send them away whilst I see 2 patients, then get them back in.

I dont' like refracting whilst they are dilating, as I think that refracting whilst their accommodative status is changing isn't the most accurate thing in the world, and I find that with dilated pupils, they never really get a good 6/6, let alone a good 6/4.5, however I often do fields whilst they are dilating.

I'd second the ODwire thing too. It's a great site for information (esp clinical) but I think optiboard is a lot more fun!
That's my $0.02 anyhow

steff

[Happylady]

Speaking as an optician, it can be difficult for the patient to choose eyeglasses once the drops are put in. I like it when the doctor does the refraction and then brings the patient out and allows me to help them choose a frame. Then I put the drops in and finish up with the glasses.

Meanwhile the doctor is seeing her next patient. Then the doctor finishes the exam on the dilating patient. This works extremely well unless it is the last patient of the day.

I find that if the doctor puts the drops in and bring the patient out to choose eyewear, within just a few minutes the patient can no longer see. Often they decide to come back and who knows if we will ever see them again.

[orangezero]

Speaking as an optician, it can be difficult for the patient to choose eyeglasses once the drops are put in. I like it when the doctor does the refraction and then brings the patient out and allows me to help them choose a frame. Then I put the drops in and finish up with the glasses.

Meanwhile the doctor is seeing her next patient. Then the doctor finishes the exam on the dilating patient. This works extremely well unless it is the last patient of the day.

I find that if the doctor puts the drops in and bring the patient out to choose eyewear, within just a few minutes the patient can no longer see. Often they decide to come back and who knows if we will ever see them again.

I think thats a good option as well. The only downside is the few extra minutes it takes, but I doubt that would be a big deal.

I know a lot of places already have the patients pick out frames before they even see the doc

[ilanh]

Here's something that I developed over the years. As an ophthalmologist I need to dilate everyone. However, we use different drops for different types of patients. We reverse everyone with pilo 0.25% after dilation unless they are high myopes. Our cocktails are premixed as follows:

-"weakest" Neo 2.5%
-"weak dilation" Neo 2.5% mixed in with Mydriacil 0.13%
-"strong dilation" Neo 2.5% mixed in with Mydriacil 0.26%
-"super" Neo 2.5% mixed in with Mydriacil 0.5%

-For vision plan patients, blue eyed patients, young patients with clear media etc we use the Neo 2.5%.
-For patients with central pathology such as glaucoma, macular degeneration etc we use weak dilation on almost all patients.
-For patients with peripheral issues eg: complaints of flashes, floaters or high myopes we use weak or strong depending on skin color.
-For very dark patients with possible pathology we will often need to use strong or super.

Note that our "weakest", "weak" and "strong" mixes contain much less mydriacil that one usually sees in most practices. Yet it works very well and patients are very happy with the fact that they are not incapacitated.

[drk]

How do you mix it, Ilan? Do you have special containers? You are the "maestro" of dilation...Can your staff keep up?

I second the use of phenylephrine 2.5%. I use 2gtt right after SLEx (or every eye is miraculously "white"). Won't affect accommodation and is slow enough that you can even get a contact lens fitting done before mydriasis becomes a visual factor (at least 20 mins). No complaints about that, ever, for routine examinations under age 60.

Nonetheless, everyone 60 and older or with pathology get's the 1/2% tropicamide. By that age, most people's visual sensitivity is slightly reduced, anyway, and I usually refract in 1/2D steps. At that level, a little anaesthetic or mydriatic-induced epitheliopathy, cycloplegia, and increased spherical abberation isn't going to factor in that much. In fact, the large pupil size increases the accuracy of the refraction due to reduction in depth of focus. Plus, the risk of pathology outweighs precision of refraction at that level.

We don't get a lot of heavily-pigmented diabetics, etc., but if necessary we combine the two.

[Fezz]

What about reversing the dilation?

I am under the impression that the reversing drops are no longer on the market.

Will this affect your dilating procedures?

[drk]

Rev-eyes (dapiprazole) was not that popular, due to shelf life, stinging and redness, and cost. It worked best in combination with Paremyd (parahydroxyamphetamine w/ tropicamide), but that's expensive too.

Not only that, but it was, per reports, only somewhat effective...it reduced the duration of the mydriasis, but I think not the cycloplegia (?).

Ilan, I've been under the impression that creating a fixed, mid-dilated pupil with a cholinergic agonist (pilo) and a anticholinergic (tropicamide) sets the stage for ACG. Thoughts on that?

[ilanh]

How do you mix it, Ilan? Do you have special containers? You are the "maestro" of dilation...Can your staff keep up?

I second the use of phenylephrine 2.5%. I use 2gtt right after SLEx (or every eye is miraculously "white"). Won't affect accommodation and is slow enough that you can even get a contact lens fitting done before mydriasis becomes a visual factor (at least 20 mins). No complaints about that, ever, for routine examinations under age 60.

Nonetheless, everyone 60 and older or with pathology get's the 1/2% tropicamide. By that age, most people's visual sensitivity is slightly reduced, anyway, and I usually refract in 1/2D steps. At that level, a little anaesthetic or mydriatic-induced epitheliopathy, cycloplegia, and increased spherical abberation isn't going to factor in that much. In fact, the large pupil size increases the accuracy of the refraction due to reduction in depth of focus. Plus, the risk of pathology outweighs precision of refraction at that level.

We don't get a lot of heavily-pigmented diabetics, etc., but if necessary we combine the two.

I usually mix them in eye drop bottles (eg: artificial tears or others) by combining 2.5% neo and 0.5% Mydriacil in concentrations that will ultimately yield a mixture of 0.13 or 0.25% Mydriacil. For example, 4cc of 0.5%Myd and 16cc of 2.5%Neo will yield a solution of 0.1%Myd

[HarryChiling]

wow, great thread.

[Da Hammer]

I usually mix them in eye drop bottles (eg: artificial tears or others) by combining 2.5% neo and 0.5% Mydriacil in concentrations that will ultimately yield a mixture of 0.13 or 0.25% Mydriacil. For example, 4cc of 0.5%Myd and 16cc of 2.5%Neo will yield a solution of 0.1%Myd

I have always kept away from mixing my own dilation drops due to the sterile issue. I have also read the same in many publications. What steps do you take to get around this when mixing your own drops?

[ilanh]

The bottles of Neo, Mydriacil or sterile tears that are commonly used in offices are not "sterile". They have been opened and used 20-40 times a day on multiple sets of eyes. Therefore, they have preservatives and buffers that helps prevent bacteria and fungii from growing within the bottle. When you mix these drops those preservatives and buffers are unchanged since they are transferred as well.

Secondly, infection is only a serious issue when there is a disruption of the corneal epithelial layer or the patient is postop. Otherwise, think about the water that you get in your eyes when you're in the pool, shower, tub, beach etc. That water isn't sterile either yet one rarely sees eye infections.

I guess one can argue it either way but I've been mixing my own drops for 14 years and using them on 40 patients a day without a single reported infection.