For a variety of reasons, patients may not want to be dilated during their current examination.  These reasons may include having to take a test an hour after the dilated examination, discomfort with having to drive themselves while dilated, or simply not wanting to be dilated this year.

In all cases, you should strive to complete as much of the examination as possible, including screening visual fields, IOP (using iCare or NCT, so that you don’t have to consult prior to IOP), and un-dilated retinal examination.  Document “NOT ASSESSED” in the Periphery section of the Posterior tab.

All of these tasks, as well as a complete assessment and plan and determine of fees, should be performed prior to your first (and, hopefully, only consult).

Introduction

Patients often elect to forego dilation during an examination due to a variety of reasons.  Assume that the patient will not return for a DFEx (even if they state they will) and follow the process below to help establish the most complete possible examination for these cases.

Indications

Patient unwilling to undergo dilation secondary to

1. Desire to delay dilation for immediate reasons – test in two hours, unwilling to drive while dilated, etc.
2. Desire to not be dilated during the current examination cycle

Contra-Indications

None

Setup

Discuss the reasons the patient doesn’t want to be dilated, and document them in the chart.  Discuss the benefits of dilation with the patient in an effort to compel them to undergo a DFEx.  Realize, though, that ultimately the patient determines whether or not they get dilated.

Prior to First Consult

After performing all normal examination elements, including recording your CPT codes, and prior to your first and only consult

1. Perform screening visual field (Matrix, FDT, etc.)
2. Perform IOP measurement using iCare or NCT.  Doing so allows you to circumvent the need to discuss the case with your consultant, as no drops will be instilled.
3. Perform an un-dilated examination of your patient’s posterior pole with direct ophthalmoscope or 78D/90D indirect biomicroscopy (preferred).  Document “NOT DILATED” in the Periphery section of the Posterior tab
4. Finalize your assessment and plan and fee sheet

On Return to Clinic for DFEx

Gather an appropriate history

1. D or N blur with/without Rx?
2. Did they get Rx from prior visit, and if so, are they happy with it?
3. Any changes in systemic health?
4. Any changes in medication?
5. Any changes in allergies?

An example of how to record this is as follows:

“Patient reports no D or N blur with new Rx; patient happy with new Rx.  Patient reports no change to VA, ROS, MEDS, ALLERGIES”

Perform appropriate examination elements, generally as below, but make changes as appropriate

1. Visual acuities
2. Pupils
3. Anterior segment examination
4. IOP measurement
5. Posterior segment examination

Complete your assessment and plan, and ensure CPT codes and RTC date are recorded