The College of Optometrists

I have used a Px on my case record who has choriodal naevus which was flat, no vascularisation. I have requested for a years recall. Is that ok or would i be required to see the Px sooner? would i also require to notify the GP?

has this naevus been seen before? was the Px aware of it? Has it been seen by an opthalmol in the past? Was it discharged for annual review? If not, has it been examined dilated? how big was it cf disc?

Choriodal naevus 2DD @ 12 o’ clock from disc. Size 0.50 DD by 0.25 DD – flat , no vascularisation.

no drusen. It was the Px 1st sight test and the Px was not aware of it before this. The naevus was clearly visable with indirect ophthalmoscopy as Px had large pupil therefore was not dilated.

You may well be asked interesting questions in your case records exam about differential diagnosis, risk factors did you take a photo, how can you tell it is unchanged if you monitor it in practice etc.

It is brave of you to not refer for Ophthalmological assessment at your level of experience! I hope the examiners think it is brave and not foolish!

I had the supervisor check it and she said it was ok. Thanks for the advice Tim

No criticism intended in this case but as a general point, "my supervisor said it was OK" will not stand up to scrutiny in any of the exams. You will always be expected to justify your actions on evidence base rather than your supervisors say so.

Could you not justify it in the exams by saying 'whilst a pre-reg I know that I am testing under my supervisors registration and therefore if they don't mind checking it in a years time then I'm happy with that. But if I was qualified and registered myself I would have referred due to my lack of experience.' Covers all the bases?

If I was unhappy with the management decision blaming it on your supervisor when they are in your case records and therefore a reocrd of YOUR management decisions would not help.

You should not make a diagnosis through an undilated pupil.

Has - did you get a good look with any form of stereopsis? If not how can you be sure it is flat?

Hamy - if lesion clearly visible through undilated pupil why dilate? Don't forget too -we don't officially "diagnose" we only detect signs of pathology!

Just playing Devils Advocate here...

Yes, i had a look with indirect bio microscopy. No elevation seen. I had a good clear view. The Px was also driving.

There's no such thing as a "good" or "adequate" view through an undilated pupil.

I still can't quite believe that the question "why dilate" is still asked.

Patients with 6/5 or 6/6 even 6/7.5 will usually only drop one line logmar on dilation with 0.5% trop. They don't usually notice too much glare either. Unless a patient is leaving the practice to drive some distance, I will not hesitate to dilate a driver. (Proviso - that undilated VA is as noted above) I verbally warn on use of sunvisor and allowing a little extra distance between themselves and car in front.

Using driving as an excuse for not dilating is a "cop out". And in a case like this what's wrong with dilating one eye? About time a final year project was done on dilation and its effects on vision.

The effects of dilation on driving can be VERY significant. Trying to drive in bright sunlight following dilation is very difficult and dangerous. Dark sunglasses can solve the problem in most cases, but, patients may not have access to these if the're not told they will be dilated B4 their eye exam.

I agree that visual acuity in emmetropes or corrected ammetropes is affected very little by dilation. But VA can be significantly reduced in uncorrected ammetropes (both hypermetropic and myopic)

Patients must be informed of the potential effects of dilation on driving. Safe driving following dilation (wearing sunglasses) is possible in many cases but certainly not all.

In most hospital clinics patients are advised not to drive after dilatation. In such a case why not bring the patient back when they are not driving?

There is published literature that patients should be advised not to drive after dilation.

Goel S, Maharajan P, Chua C et al. Driving ability after pupillary dilatation. Eye 2003:17;735-738

The study to which you refer has a number of flaws in it and does not relate to everday optometric practice.

Firstly, no account was taken of the effect on the cornea of Proxymetacaine which is far more significant than the effect of dilation in my experience with an elderly population.

Secondly, no account was taken of the presence or absence of lens opacities or uncorrected hypermetropia and thirdly no sun protection was issued to patients.

In routine optometric practice where the best corrected va's, lens status and uncorrected refractive error are known and a quick shade is provided there is very little problem with most patients.

My experience of 25,000 dilations in the past ten years suggests that around 10% will be better dilated when collecting their new specs (to give better va) and 10% should probably not drive.

This is simliar to the 14% quoted in the article to which you refer which on its own figures suggests that 86% of patients can drive following dilation.

A reasonable number of patients dilated in practice have lens opacities, a reason for dilation, or sub-optimal prescriptions, as the new Rx will not yet have been issued. The majority of high street opticians do not provide sun protection following dilation.

I agree there is room for improvement in the methodology in this paper.

Whether you accept the published data or the ‘guesstimate’ above, 1 in 10 patients should not drive after dilation.

Should a patient be involved in an accident following dilation and you have told them they can drive you must be able to defend your advice, should they complain.

The college website guidance is not to drive for 6 hours after instillation of tropicamide. Patients attending the local eye clinic are advised not to drive and are not dilated if they are. There is no clinical need / urgency to dilate on that day in this case, the patient could return when not driving.