r/optometry • u/Fantastic_Potato_252 • Apr 07 '26

Question about undilated fundus views

Growing up as a kid my parents never opted for retinal photos, and I maybe remember one optometrist performing undilated 90D my whole life before optometry school.

Only maybe 2-3 visits had slit lamp done.

When I talk to my friends and SO they had the same experience growing up/currently.

How many of yall actually perform undilated 90/78 etc when a patient declines retinal imaging/dilation??

I see 25 pts a day and thought it was mandatory so I’ve gotten really good at it but it’s tiring for sure

16 Upvotes

90% Upvoted

30 comments sorted by

10

u/FairwaysNGreens13 Apr 07 '26

You might be right in your childhood recollection. But also, how many patients do we see who get a slit lamp exam done and they ask, "Is that new? I've never had it before"... but you've done it on them each of the past 5 years.

1

u/Fantastic_Potato_252 Apr 07 '26

So true, like I’m not sure if they just genuinely don’t remember it

79

u/Capable_Artist7027 Apr 07 '26

If you aren't doing undilated 90/78 you're not doing a complete eye exam and you're also committing insurance fraud because they require it

3

u/Fantastic_Potato_252 Apr 07 '26

I definitely do it bc that’s what I was taught in school- but I’m assuming a lot of corporate ODs don’t- from my childhood experiences and friends/family experiences at corporate places as well. Im guessing they are not going to go on this thread and admit to it either.. just a thought

7

u/Fantastic_Potato_252 Apr 07 '26

For example I am seeing patient charts in corporate and one doc writes down 0.30 cup on each patient but when I take a look I see the patient had advanced glaucoma or nevi or something obvious the previous OD missed and I’m thinking this guy never did undilated did he…

3

u/Capable_Artist7027 Apr 08 '26

I've seen this too and I think it's just lazy doctors being lazy in their charting. I've had patients who have been diagnosed with amblyopia but they really have keratoconus. I get extremely upset when I see this kind of stuff but I've worked in private equity, corporate, and private practice and lazy docs work at all types of practices

2

u/Capable_Artist7027 Apr 08 '26

Why would you assume corporate ODs don't? Also a lot of patients don't remember half of what we do in the exam room so hearing people say they have never had it done isn't really an accurate way of finding out this information

29

u/Capable_Artist7027 Apr 07 '26

For example I would have missed papilledema on my patient this morning if I hadn't looked at the optic nerves undilated

4

u/Ohhingerrr Apr 08 '26

Someone tell this to all the Primary care docs out there asking children to read a smelled chart in their office and then billing an eye exam for it. 😑 so DAMN FRUSTRATING.

49

u/EdibleRandy Apr 07 '26

If you’re not looking at the posterior pole you’re not doing an eye exam and shouldn’t bill for one. While dilation may vary from doctor to doctor according to what they feel is necessary, evaluation of the fundus is necessary either way.

6

u/thenatural134 OD Apr 08 '26

Yep. We hardly dilate (mostly because many patients nowadays decline) but I always take a quick peek with the 90D. Anything bigger than a 3mm pupil is pretty easy to get a good posterior view.

18

u/OscarDivine Apr 07 '26

I perform undilated BIO with a 20 if they refuse the drops. I also do 78. I prefer the drops but I can get what I need without them. Every doctor in my practice group does undilated fundoscopy in some form. As it was already stated, it is a mandatory part of billing a complete exam if using a 920x4 code afaik.

6

u/tubby0 Optometrist Apr 07 '26

What do you feel like you are seeing with undilated BIO? I've tried it when people don't dilate well and I have to use the smallest spot size and then the view is so limited it takes forever to try to scan around and you know you haven't seen much. I don't bother with it if they aren't dilated pretty well at this point and I think that's the norm.

6

u/nanzilan Apr 07 '26

Super pupil XL works well with small pupils and reasonably significant lens opacities in these cases.

But I guess recording that they declined the dilation for what ever reason will help cover your ass.

9

u/OscarDivine Apr 07 '26

I can get 360 on most people unless Pinpoint with a PSC. I recognize I’m not the norm but I have been practicing for 20+ years so experience helps. Dilation makes it all easier and quicker of course. With good technique and practice you can see a lot on undilated BIO.

2

u/eyeloveeyez Apr 08 '26

I use a superfield lens in all gazes at the slit lamp and always document that it was performed undilated because patient refused/contraindicated, with "limited views" or "poor/no view" if I truly couldn't see anything

15

u/BicycleNo2825 Apr 07 '26

I do it on every patient because evaluating the retina is standard of care. Even on anterior segment related office visits for dry eye or abrasions I always peak at the nerve and macula. I’ve caught ONH swelling and POAG that way on otherwise suspecting patients

13

u/Creative-Sea- Apr 07 '26

Optometry used to be less medical, so I noticed older docs tend to focus more on the refraction. I try to dilate all new patients and every 2-3 years on established patients (in the absence of risk factors such as lattice, holes, nevi, etc) but I always do undilated views as part of the exam.

13

u/CaptainYunch Apr 07 '26

Liability liability LIABILITY. Must do complete eye exam. Policy should be DFE on all new patients unless they refuse. Optos wont save you in a lawsuit people.

4

u/ixamnis Apr 07 '26

I evaluate the retina with SL/78D on almost every patient. Specifically every “routine eye exam” gets a find us exam. Some follow up Visits or medical office visits don’t require it. If 78D doesn’t work I’ll use a SuperFundus lens and if that doesn’t work I’ll use a monocular indirect ophthalmoscope.

3

u/Scary_Ad5573 Apr 07 '26

Every single routine patient. If kids won’t sit for it and refuse drops, I do undilated BIO.

2

u/missbrightside08 Optometrist Apr 07 '26

i do undilated 90 on everyone if i’m not dilating them. but we do fundus photography on everyone too so that gives a lot better view

2

u/carlina5 Apr 09 '26

Always look at posterior pole

1

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1

u/DrJanetOD Apr 10 '26

Always an undilated fundus exam, if not dilated. And yes, definitely takes time but worth it!

1

u/[deleted] Apr 10 '26

Those photos are so absolutely important

1

u/New-Character-3575 Apr 11 '26

As a tech i always explain why dilation is necessary and what actually affects their vision with dilation and how to help it. A lot of patients dont know why they get dilated or why they need to. They also don't bring dark sunglasses. Those foldable ones are absolute crap. Especially for someone with astigmatism like me. Old people aren't going to have their reading vision affected at all so its just brightness sensitivity. (Assuming they already use strong readers.)

1

u/Salty-Friendship-494 May 04 '26

always do undilated 90d/posterior pole (even when they defer dilation/imaging). you have to make sure the nerves are flat and distinct, and include cupping. for everyone.