1. Binocular Indirect Ophthalmoscopy with Scleral Depression, Eight Rules for Success
James W. Walters, PhD, OD
2011

3. Both hands should be used to stabilize the lens, controlling the lids and holding the depressor when necessary. The lens should always be stabilized by bridging from the forehead, check, or both, never the nose.

4. The 7 Habits of Highly Effective People Stephen R. Covey
Habit 2: Begin with the End in Mind.
What this means for BIO is that a clinician is best advised not to develop one set of habits for BIO without scleral depression and then try to unlearn them and develop new set habits for BIO with scleral depression.

5. Binocular Indirect Ophthalmoscopy Some Basic Principles
How to maximize the fundus view and get the most out of scleral depression

6. In a minute the rules but first a word about dilation and optics.

7. Dilation Instillation technique Drug type and strength Lid action
Interval
Drug type and strength
Parasympatholytics
sympathomimetics

8. Drug type
Tropicamide: (Tropicamide, Mydriacyl, Tropicacyl) available in 0.5% (used in premature infants) and 1%. Duration of action: up to 6 hours.
Sympathomimetics Phenylephrine: (Ak-Dilate, Dionephrine, Mydfrin, Prefrin Liquifilm, Spersaphrine). Drops available as 2.5% and 10% (Should never be used in children under 4 years. Duration of action 3-6 hours.

9. Cautions
Do not use phenylephrine if your patient has used linezolid (Zyvox) or procarbazine (Matulane), or if they have taken a monoamine oxidase inhibitor (MAOI) such as furazolidone (Furoxone), isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) in the last 14 days. Serious, life-threatening side effects can occur if you take phenylephrine before these other drugs have cleared from your body.

10. Cautions continued heart disease, heart rhythm disorder;
high blood pressure;
circulation problems (such as Raynaud's syndrome);
diabetes;
glaucoma;
a thyroid disorder;
kidney disease;
an enlarged prostate or urination problems;
sleep problems, anxiety; or
mental illness such as bipolar disorder.

11. The Goal (Begin with the End in Mind)

12. The forgotten Optics (Begin with the End in Mind.)
When doing BIO you are building 2 optical systems, these are:
The illumination system
The viewing system
Both must be aligned properly in order to obtain a view.

13. Viewing Optics

14. Illumination Optics
Personal observation: When ever I have experienced glare in the condensing lens I have been able to eliminate it by focusing the beam inside of optical infinity e.g. 6ft or so. The newer BIO head sets often do not allow this adjustment.

15. The Keeler Fison located in minor surgery

16. Keeler Fison image of filament at 6ft

17. Lens Options

18. Alternative to the 20 D lens wider field of view shorter working distance

19. NOW TO THE RULES OF BIO In real estate the rules are related to…..
LOCATION

20. When doing BIO the rules are always related to……
POSITION
POSTION

21. If you fail to see an indentation when doing BIO it will never be because you are not depressing hard enough. It will always be because you have broken one of the “position rules.” Jim Walters, PhD, OD

22. Help in forming these rules came from the book Binocular Indirect Ophthalmoscopy by John W. Potter, Leo P. Semes and Anthony Cavallerano (May 1988)

23. First Position Rule
For maximizing viewing of the peripheral fundus the patient should be supine and elevate.
In this position the doctor has a range of motion of approximately 170 degrees around the head.
Obliquity of view should be obtained by rotating the patients head (not the eye) when ever possible.*
* See rule 8

24. Second Position Rule
The examiner should always strive to remain in as an erect position, well balanced on 2 feet.
The more distorted ones postures becomes the less likely it can be maintained in the dark with minimum visual ques.

25. Third Position Rule
The condensing lens should be held such that the pupil of the patient is a focal distant from the lens. For a 20 D lens this would be 5 cm. for a 25 D lens 4 cm etc.
If the examiner has small hands they should explore using a 22D, 24D, or perhaps a small 20D lens.
All practitioners with a serious interest in seeing the peripheral retina should have a range of lens between 20D and 30D.

26. Fourth Position Rule

27. The alignment must be exact!

28. Fifth Position Rule

29. Sixth Position Rule
When examining the superior fundus, the indenter should be applied to the superior lid just above the superior border of the tarsal plate.
When examining the inferior fundus the indenter should to the margin of the lid which serves to move the lid away from the pupil when the eye is in a downward gaze.

30. Sixth Position Rule

31. The Seventh Position Rule
The position of the scleral depressor should range for .7 cm to 1.4 cm from the limbus.
The first 7 mm for the limbus is occupied by the ciliary body and pressing on it will be painful to the patient and do nothing to enhance the BIO view.
I good rule of thumb is to keep the depressor tip approximately 1 cm (10mm) from the limbus at all times.

34. The Eighth Position Rule
Obliquity of view should be obtained by rotating the patients head (not the eye) when ever possible.
This allows for more scleral exposure on the side of the depressor making it easier for the depressor to be placed at the correct distance from the limbus.

35. The Eighth Position Rule (cont.)
This technique is most important, and the easiest to implement, when viewing nasal retina.

36. The Eighth Position Rule (cont.)
Another way of stating the eighth rule is to keep as much scleral show as possible on the side that is being depressed.
This means that the habit of having the patient “look at the depressor” should be a method of last resort when trying to obtain the necessary obliquity of view for scleral depression.

37. Alternative Viewing Methods

38. Alternative Viewing Methods HAAG-STREIT depressor lens