Using the extra eyes within your exam room

May 18, 2017

Article

I don’t have periscope eyes, so I can’t peek around blind corners. Plus, my neck is stiff after years of hunching over a slit lamp. As a result, I can’t turn my head as well to get a good look around.

The views expressed here belong to the author. They do not necessarily represent the views of Optometry Times or UBM Medica.

There are times when I wish I had eyes in the back of my head.

A good example is when I’m trying to back slowly out of a parking space while flanked by a pair of ginormous SUVs.

No matter how slowly I creep, a pedestrian or speeding vehicle always seems to cross my path.

Previously from Dr. Brown: It’s not easy seeing green

New technology

Enter my new sedan with all its safety features, including a pair of forward-facing “eyes” that help me stay on the road and avoid hitting vehicles in front of me, a blind spot monitor, and a high-resolution backup camera that seems to have as good a view as many military night vision scopes.

But my favorite of all is the cool “cross traffic” alert that sounds an alarm when I’m in reverse and pedestrians or vehicles are about to pass behind me.

Even if I were to have a total brain fart or lose my hearing (both increasingly possible) and keep backing up, the safety system completely takes control of the car and brings it to an abrupt stop before I do something I regret.

The designers of my car knew that no matter how good a driver I fancy myself to be, I’m not infallible. The extra technology fills in some of the gaps that my aging gray matter and synapses fail to connect.

A similar scene played out in my exam lane during a recent encounter with a patient who had diabetic retinopathy.

Extra eyes within the exam room

I’ve always prided myself on my ability to visualize clinically significant macular edema (CSME) and passing that skill on to my students and residents.

“Don’t look at the retinal pigment epithelium (RPE),” I tell them. “Look in front of it.”

With the enhanced stereopsis enabled by precorneal lenses, one can see elevation of the clear, sensory retina. Sometimes, you can even appreciate the perception of dot hemorrhages and lipids “floating” in the middle of the sandwich created by the internal limiting membrane and the RPE.

This particular patient had a few microaneurysms in one eye, but his vision was 20/20. My first impression was that the macula was flat and dry-I didn’t perceive any sensory elevation.

Or did I?

The dot hemorrhages weren’t flying toward me like red balloons in a pop-up book, but something didn’t seem quite right either.

Back in the 1990s, I might have photo-documented and actually written with a pen in a paper chart the words “Borderline CSME” and “RTC 3 months, repeat DFE” and moved on.

But why settle for a cliffhanger when a more definitive answer is available with the state-of-the-art optical coherence tomographer (OCT) just down the hall? A high-resolution optical cross section of the retinal layers is a blind corner that I’ll never see around with my own eyes.

The scan validated my initial, “Hey, wait a minute!” moment during ophthalmoscopy.

There was an area of subtle macular thickening and a cluster of cysts just temporal to the fovea that were difficult to appreciate even when I went back and looked again.

Like the designers of my car, the geniuses behind OCT knew that no matter how smart a doctor I am, or how adept I may be with a precorneal lens, a little artificial intelligence and an extra set of eyes never hurt.

Using new and traditional technologies

Of course, technology is not 100 percent perfect, either. I can’t expect my car to drive itself (yet, anyway), and neither should I let my autorefractor, OCT, or the latest and greatest Star Trekky thingamajig do all my thinking for me.

There’s still a need to learn and refine traditional exam techniques-and to use your own brain-while appreciating the extra edge that modern diagnostic technology affords. The ability to discern CSME and subtle optic disc changes are evergreen skills that will never become obsolete.

So students, get back in that exam lane, look again, and stop whining!

I jokingly call my new sedan my first “old man car” because I’m hoping the plush ride and all those bells and whistles will keep me comfortable and safe behind the wheel for a while longer.

Likewise, expanding technology in eye care may extend my career and enable me to keep driving my slit lamp for years to come-but I’m going to need a lot of good old-fashioned neck rubs to go along with it.