1. Review of Retinal Mapping Review of Retinal Mapping Tiffenie Harris, OD Clinical Assistant Professor Clinical Assessment Fall 2005

2. Review of BIO Technique Sitting vs. Supine Sitting vs. Supine –Sitting allows folds within the RD or break to open Smooth and efficient Smooth and efficient –Systematically examine the quadrants out to the periphery –“Sweeping” views of retina –Posterior pole last Patient head position Patient head position –Stand/sit directly opposite meridian of interest –Turn the patient’s head toward the examiner/ have the patient look toward the meridian of interest Illumination Illumination –Light fundus vs. dark –Periphery vs. central

3. Review of Anatomical Landmarks Horizontal meridian Horizontal meridian –Long posterior ciliary nerves at 3 & 9 o’clock represent the anatomical horizontal meridians –divides the retina into superior/inferior Vertical meridian Vertical meridian –Short ciliary nerves seen between 10 and 2 as well as 4 and 6 o’clock represent the anatomical vertical meridians –Divides the retina into nasal/temporal

4. Long Posterior Ciliary Nerve Retinal photo of patient looking left with OD Retinal photo of patient looking left with OD

5. Review of anatomical landmarks Anterior/Posterior retina is divided by the Equator Anterior/Posterior retina is divided by the Equator –Vortex ampulla are located just posterior(approx 3mm)and there are usually 4 to 6 vortex veins –located in the 1, 5, 7, 11 o’clock meridians Ora Serrata Ora Serrata –The junction between the retina and ciliary body –Nasal ora appears “serrated” and the temperal does not Posterior pole Posterior pole –Macula and optic nerve along with the sup/inf vessel arcades

6. Ora Serrata Nasal or Temperal retina? Nasal or Temperal retina?

8. Extended Ophthalmoscopy CPT 92225 Documentation requirements Documentation requirements –A detailed sketch must be included in the medical record with sufficient labeling along with an interpretation that affects the plan of treatment –The sketch should be a minimum size of 3-4" in diameter –All items noted must be identified –Drawings in 4-6 standard colors are preferred 92225-Extended ophthalmoscopy is one of the most heaviest audited codes by medicare 92225-Extended ophthalmoscopy is one of the most heaviest audited codes by medicare

9. Limitations Considered not medically necessary if Considered not medically necessary if –there is insufficient drawing –the medical record does not document the interpretation –it replaces a routine ophthalmoscopy. –when other testing such as fundus photography gives the same information –It is not enough to link the procedure code to a correct, payable ICD-9-CM code –The diagnosis or clinical signs/symptoms must be present for the procedure to be paid.

10. Conventional Color Scheme for Retinal Mapping - Red: Light red: attached retina Dark red: retinal arteries, preretinal or intraretinal hemorrhages -Light blue: Retinal Detachment -Dark blue: Retinal veins, margins of retinal breaks, lattice is outlined in blue with inside crosslined : chorioretinal pigmentation --Black: chorioretinal pigmentation -Yellow: intraretinal or subretinal exudates -Brown: nevi, melanomas, choriodal detachment -Green: vitreous or lens opacities Opacities in media, vitreous hemorrhage

11. Example #1 28 yo 8D myopic female Cc: floaters/flashes x 3-4 days, no hx of injury DVA: 20/20 OD, 20/20 OS PERRLA, EOM: snf, Slex: C/C- clr, L/L –clr AC: C&Q, VH-Gd4

12. Example #1 What additional tests/examination can you perform? What additional tests/examination can you perform? What do you expect to find? What do you expect to find? Why are her acuities good? Why are her acuities good? Would you expect her to have an APD? Would you expect her to have an APD?

13. Example #1 CVF: FTFC – OS, superior defect noted OD, -APD CVF: FTFC – OS, superior defect noted OD, -APD +Shaffer’s sign +Shaffer’s sign –The presence of pigment granules in the anterior vitreous (Berger's space) AKA "tobacco dust," –Very significant clues to a retinal break or detachment. Hamilton and Taylor found that 98% of patients in their clinical review with this sign had retinal detachments and 60% had flat retinal holes –Failure to check for this sign on a symptomatic patient could be considered gross negligence –Red blood cells, secondary to a vitreous hemorrhage, may be difficult to differentiate from the pigment granules. However, with a red free filter (green) the red blood cells will disappear The pigment granules will not absorb the red-free light and will still be seen.

14. Example-view w/20D lens

15. Example #1-OD looking down and right - What do you see? -Where do you draw your findings? your findings?

16. ok VR consultants VR consultants

17. Example #2-view with 20D

18. Example #2-OS looking up and left Where do you draw your findings? Where do you draw your findings?

19. Example #3

20. Example #3-OD looking up and right Where do you draw your findings? Where do you draw your findings?

21. Sketch What You See Assignment Due: October 5th Clinical Assessment Fall 2005

22. Instructions Use stencils if available Use stencils if available Record locations by clock hour when appropriate Record locations by clock hour when appropriate Include anatomical landmarks to reference location Include anatomical landmarks to reference location Use labels with arrows when appropriate Use labels with arrows when appropriate Approximate size of lesion (range is allowed) use optic disc as gauge (e.g., 2 DD in size) Approximate size of lesion (range is allowed) use optic disc as gauge (e.g., 2 DD in size) Note topographical characteristics when appropriate (e.g., elevations, escavations, etc.) Note topographical characteristics when appropriate (e.g., elevations, escavations, etc.) Each item is worth 10 points of credit and partial credit will be given, 100 total points possible Each item is worth 10 points of credit and partial credit will be given, 100 total points possible

23. Case #1

24. This is a 20D view of the posterior pole This is a 20D view of the posterior pole Which eye is this? Which eye is this? Provide a list of differentials for this retinal finding (at least 5) Provide a list of differentials for this retinal finding (at least 5)

25. Case #2 This small circle is an artifact

26. Case #2 This is a retinal photo of a patient looking up and to the left with the right eye This is a retinal photo of a patient looking up and to the left with the right eye What is this retinal finding? What is this retinal finding? Provide a differential list for this retinal finding (list at least 3 conditions) Provide a differential list for this retinal finding (list at least 3 conditions)

27. Case #3

28. This is a 20D view of OS looking up and to the right This is a 20D view of OS looking up and to the right What is this retinal finding? What is this retinal finding? What symptoms do you expect this patient to experience? What symptoms do you expect this patient to experience?

29. Case #4

30. Describe what you see in this retinal photo as you would record it in a patient’s record Describe what you see in this retinal photo as you would record it in a patient’s record Provide a list of differentials for this fundus finding Provide a list of differentials for this fundus finding What is your best answer and why? What is your best answer and why?

31. Case #5

32. This is a retinal photo of OD looking up This is a retinal photo of OD looking up Provide a list of differentials for this retinal finding (at least 5) Provide a list of differentials for this retinal finding (at least 5) Bonus: What is this retinal finding?

33. Case #6 Case #6

34. Case #6 This is a 20D view of OD looking down to the left This is a 20D view of OD looking down to the left What is this retinal finding? What is this retinal finding? What are the risks associated with this finding? What are the risks associated with this finding?

35. Case #7 Case #7 The white The white spots are artifacts on the photo

36. Case #7 Describe what you see in this retinal photo as you would document it in a patient’s record Describe what you see in this retinal photo as you would document it in a patient’s record What is the retinal finding? What is the retinal finding? Provide a list of differentials (at least 3) Provide a list of differentials (at least 3) BONUS: What tests should be performed on this patient? BONUS: What tests should be performed on this patient?

37. Case #8

38. This is a 20D view of OD looking down This is a 20D view of OD looking down Provide a differential list for this retinal finding (at least 3) Provide a differential list for this retinal finding (at least 3) What is your answer and why? What is your answer and why?

39. Case #9

40. This is a retinal photo of OD looking right and slightly down This is a retinal photo of OD looking right and slightly down Provide a list of differentials for this retinal finding(at least 3) Provide a list of differentials for this retinal finding(at least 3) What symptoms might this patient experience? What symptoms might this patient experience?

41. Case #10

42. What is this fundus finding seen in this retinal photo? What is this fundus finding seen in this retinal photo? This diabetic patient has what stage of diabetic retinopathy? This diabetic patient has what stage of diabetic retinopathy? NOTE: be as specific as possible Give at least ONE differential Give at least ONE differential

43. Extra Credit Case Extra Credit Case

44. Extra Credit Case What is this retinal condition? What is this retinal condition? Why does the retina appear this way? Be as specific as possible Why does the retina appear this way? Be as specific as possible What is the expected visual acuity? What is the expected visual acuity? Is there any underlying systemic conditions associated with this retinal finding? Is there any underlying systemic conditions associated with this retinal finding?