OSLI Retina

February 2021

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Practical Retina Incorporating current trials and technology into clinical practice 58 © Ophthalmic Surgery, Lasers & Imaging Retina The Depressing Part of Retina: A Review of Scleral Depression and Scleral Indentation by Joseph Raevis, MD; and Eric Shrier, DO A timely, thorough dilated fundus exam with indirect ophthalmoscopy is of ut- most importance in detecting important peripheral vitreoretinal pathology in symptomatic patients. Is the "standard of care" to perform a dilated fundus exam with scleral depression in every patient? In 2008, the AAO published guidelines regarding the examination and treatment of patients with symptoms of peripheral retinal pathology. An expert panel of retina specialists ex- tensively reviewed the literature at the time and formu- lated a "Preferred Practice Pattern" for examination and treatment of patients with symptoms of peripheral retinal pathology. Indirect ophthalmoscopy with scleral depression was considered vital to the exam, though only supported by "lowest strength of evi- dence." It seems intuitive that examining the periphery, where retinal breaks char- acteristically occur, by combining scleral depression with indirect ophthalmoscopy should improve the detection of retinal breaks, but there is surprisingly little peer- reviewed evidence that this is so. "Standard of care" is a legal term, not a medical term, and varies in different lo- cations and settings, evolving over time. The standard of care does not mandate scleral depression in all patients or even just because a patient has retinal detach- ment "risk factors." The use of scleral de- pression often adds another perspective to suspicious areas in the retina and may help clarify if a particular area is the cause of the associated symptoms that warrants further evaluation or treatment. Drs. Raevis and Shrier provide us with a thorough review of scleral depression. They will discuss various depressors, patient discomfort, indications, contrain- dications, and various lenses that can be used. I am certain their insights will be most valuable to our community. Scleral depression, also known as scleral indenta- tion, 1 is a technique used to evaluate the periph- eral retina. By rolling the scleral depressor anterior/ posterior and radially, one can view the periph- eral retina, ora serrata, and pars plana at alternative angles in a dynamic nature. Depression also allows for increased contrast within the indented region between the choroid, retinal pigmented epithelium, and retina. 2,3 This procedure does not need to be performed on all patients, but it is important for many. A survey of vitreoretinal specialists revealed that the use of scleral depression is symptom driven. In symptomatic patients with flashes or floaters, 88% of respon- dents stated they would perform scleral depression compared to 22% with new asymptomatic patients. 4 TECHNIQUE Maximum pupillary dilation is important to give the best peripheral view, and this can usually be accomplished with of phenylephrine 2.5% and tropicamide 1% for 20 to 30 minutes. At times, multiple administrations of phenylephrine 10% or cy- clopentolate 2% can be beneficial. The ora serrata and equator are located 7 mm and 14 mm pos- terior from the limbus, respectively, and the depressor is placed between these regions. 3 Standing directly 180° away from the re- gion of examination is helpful as the depressor, condensing lens, and indirect ophthalmoscope all must be in line for visualization. Sixty percent of retinal specialists use topical anesthesia pri- or to scleral depression. 4 Scleral depression may be performed either through the eyelid or directly on the bulbar conjunctiva. 3 If depression is performed on the conjunctiva, topical anesthe- sia should be used. When we use a cotton-tipped applicator, wetting it with artificial tears or anesthetic drops improves com- fort. Placing the depressor directly on the bulbar conjunctiva is beneficial in the directly temporal and especially the nasal region due to eyelid anatomy. Joseph Raevis Eric Shrier doi: 10.3928/23258160-20210201-01 Seenu M. Hariprasad Practical Retina Co-Editor

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