The College of Optometrists

This is more of a query to find out what other people are doing. I have recently been using my 90D volk on most patients rather than direct as i prefer the peripheral view (although tending to also use the direct quickly to view macula). Are many people tending to use the volk rather than direct? Is anyone finding any limitations doing it this way?

Direct used for pupil reactions + corneal reflexes only.

Fundus exam with 60D + 90D

the direct comes in use with young childrena nd thats about it..90D is good for everyone else. more than adequate view undilated. the patients like it as it does not invade their space" as much and also means your not bending your back most of the day...

hmm--

Lots of thoughts on this!

I use both on just about everyone!

The problem of direct is

not very bright

poor field of view

can't get beyond central retina easily.

Advantage - easy to use

produces results on everyone

good magnification (you can't see fine detail with low mag)

can use colored filters (handy!)

The Volk balances this nicely as:

better field and better into the mid periphery and the chance of stereo with biggish pupils - handy for overall view.

Brighter (this can be a problem if not dilated)

snag is poor magnification - so you won't see many microaneurisms or fine detail. the other snag is that you feel you see better with a Volk than you actually do - so you can miss things and feel you have not.

Answer for me: I do both on just about everyone - if Volk is not practical - then I use an indirect monocular oph -

Mind you : my direct (based on a Keeler specialist) has been rebuilt just the way I like it and gives superb results.

palfio

remember : know which side of the ophthalmoscope the fool goes!

Like it ;-)

I use a superfield on everyone. (except domis)

Qualified about 20 years ago. Started using SuperVitreo lens about 3 years ago! I now use it on everyone (undilated mostly). I really hate using my Ophthalmoscope now, except to visualise Cataract, or people with postural dissiculties who can't get into the Slit Lamp.

However, for looking THROUGH a Cataract, it beats direct hands down. Similarly, with a small pupil - if you're careful, you'll always get a meaningful view, instead of the mass of reflections that the Ophthalmoscope gives.

I prefer to use the term guessing stick for a direct.

direct probably only used on kids and domi's. .. even then prefer to dilate (domi's). detail from volk far exceeds direct and as stated above even on small pupils can get reasonable views by directing the px to gaze appropriately.

Like the difference between shining a torch round a dark room, or switching on the light !!

Thanks for all the replies. I was particularly interested by Palfi's point about thinking that you see more than you actually do - I had been getting a suspicion of that. In which case, how can that be improved other than by doing both direct and volk on every patient? Would getting a different lens with more magnification help, or would i still end up missing the fine detail?

I routinely use a volk superfield and achieve adequate results with most pupils. Can anyone suggest other lenses which may be more beneficial

get a nice 60ds and you balance the 90ds nicely. But it depends on how much you want to spend. A Volk is useless on a unless dilated pupil - and the lower powers are even more restricting unles dilated. Volk is not a magic answer and only as good as the slit lamp you use - and I do feel you have to use two different techniques on everyone if you can. I was wondering which optom I would trust to do me, looking at the replies above. Hmm - I suppose you only know that by how many referals they make and problems they see.

May be I need some help, but I can see next to nothing with a volk unless dilated, and the patients hate the intense brightness. have been on several courses, none of which helped me master it. Sdaly, my old Hamblin Morton ophthalmoscope recently died, and I have had to buy a specialist - this is a horrible piece of kit, and not a patch on the Hamblin for clarity, aperure size and resolution, so may be that is why people prefer Volk these days. Saving grace is having an Optos for the periphery on everybody.

If you're willing to dilate routinely, then 60D is great. Much better mag compared with 90D/superfield, and great stereo view. If you have a high mag slit lamp you can usually increase mag even further, without losing the image on an undilated pupil.

If not dilated, it's a bit trickier. I feel with undilated volk you end up with the same problem as the direct, as you have to work your way around the periphery, and can never quite be sure if you've missed a bit, especially with smaller pupils!! I think I would tend to compromise with routine fundus exam using DO, and 78D undilated to look at disc.

I sat in with a Consultant Ophthalmologist a couple of years ago (sadly now deceased, died young) & he actually used a Direct Ophthalmoscope to, briefly, assess a cataract - the first time I have seen an Ophthalmologist use a direct in years. I sometimes think we dismiss Direct Ophthalmoscopy as being untrendy. I agree with the great sage palfi when he/she says we should do both. There is time to look with both if you make it & using say a super-pupil or 90 VOLK means you can see through most pupils without dilating, although dilating is much preferable.

while using volk routinely, I don't waste time with DO, if I feel my view is inadequate, as I will dilate. As mentioned above you are more likely to see round opacities with volk than through that bright reflection from DO. Yes it has other uses as noted by mlc but with a decent slitlamp it has to be first choice.

Keith, I'm glad I'm not the only one who finds volk difficult unless dilated.

It's very good on the young with big pupils but I do find it v hard on the older pxs(60+)Brilliant though for looking through lens ops as said earlier.Also very good for small naevi,saw one today with volk very clear but very difficult to see with direct.A bit worrying really !

If given a choice of only one, I would plump for slitlamp BIO.

I do, however, selectively use a direct ophthalmoscope.

- Unable to use slitlamp (wheelchair/doms)

- Young children (use with 20D lens for monoc indirect, though headset BIO better if available)

- Detect venous pulsation (spontaneous or induced with globe indentation) in disc with fuzzy margins). If present, rules out papilloedema.

- Assess fixation in amblyopes, eg. if 6/9 after patching and EF, then further patching unlikely to be of benefit.

- Hirchberg and Bruckners test in young children

Regarding sltlamp BIO undilated, its usually better than direct, but why settle for less than optimum - dilate. Tell the patient why in practice literature with pictures and charge a nominal fee so that its superiority is appreciated, then patients will ask for it, rather than you having to slip it in on the sly and make meek excuses about the bright light. When empowered with information, most patients prefer the bright light to having sight threatening pathology missed (most tumours are asymptomatic, and some RDs are - particularly in young patients) - wouldn't you want to be dilated?

do you want to sell the Hamblin, Kieth -I would love to own one -even it is dead. My email is meyndad@hotmail.com

Re Hamblin Keith Holland/palfi - remember my comment about the lift-shaft survival requirement. Hamblin Ophthalmoscopes do not die they merely go into hibernation. Palfi, we all know is a genius, constructing ophthalmic instruments of remarkable precision from the most innocuous ingredients.

... I only wanted to have a look :-)