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Why the Fundus is on My Mind

Do you ever stay awake at night wondering, "What is a fundus exam?" I do. Granted, this question is not of the weighty sort typically associated with pondering the meaning of life, the universe, and everything, which Mr. D. Adams of Cambridge, England, determined was 42, but it still packs a wallop.

I invest my dark hours contemplating the fundus because of the onslaught of all sorts of new devices designed to make life easier for you and me. When I was a thin, young physician I slipped each patient a strong dilating cocktail, trapped him in a dark room and studied the recesses of his eye with a powerful lamp strapped to my dark-haired head. So fearful was I to miss the undiagnosed oddity that I lost all sense of the miserly yield from such compulsion.

As the years passed I drifted away from my trusted indirect and embraced a new seductress, the 90-diopter lens. This lightweight gem let me peer into less dilated eyes and study in detail the optic nerve and the posterior pole. I could still revert back to drops and 20 and check out the periphery when a situation demanded it, but for the routine look the 90 stole my heart.

As my skills with the little belle improved, I could perform my exam with less dilation, and none in many cases. What a relief for so many patients to be able to resume life after examination without fear of accident. I couldn't share this happiness with all patients -- those with diabetes, flashes, floaters, or other symptoms still got the works -- but I made plenty of friends nonetheless.

A Step Forward for the Back of the Eye?

So, returning to the subject of my wakefulness, I must confess that I'm confused by the myriad of imaging devices that seek to simplify my life by relieving me of the burden of looking at all. For the routine patient, dare I send forth my technical staff to digitally image the retina, allowing me to study it from a safe distance, avoiding the patient's breath as he avoids mine? Will unhurried impersonal evaluation of a static image be more precise than getting right in there and quickly checking it out myself? Will adequacy of evaluation, patient communication, and quality of care be enhanced by retinal imaging in asymptomatic patients? Perhaps.

But we must determine the risk/reward, safety/morbidity, and cost/benefit ratios for these devices and decide if they are they demonstrably favorable. Novelty must not impede progress, but it must be established that it is progress.