# Optical Forums > General Optics and Eyecare Discussion Forum >  Who needs a dilation test and how ofter?

## dyip

More than one OD posted in this forum mentioning about doing the dilation test during regular eye exam. 

What is the main purpose of the test? 

How often does a regular person require such test? 

Will the test find out some problems that the patient him/herself does not even feel? 

Who belongs to the high risk group for this kind of test?

I do not think that a CL wearer like me belongs to the high risk group since the purpose of the test is to see something inside the eyeball while a CL will just affect the surface condition of the eyeball. However, I remember reading an article a ong time ago that people with severe near-sight are more likely to have retina detachment. Again, how severe is severe, please give some numbers or ranges?

Please educate me and correct me if I am wrong.

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## Optom

Dilation test refers to a technique of instilling eye drops into your eye which temporarily causes mydriasis or make pupils larger to enable your doctor better visualize your retina, optic nerve head and blood vessels in the back of your eye. Without dilation, the bright light from ophthalmoscope will make reactive pupils to constrict to a small size making visualization inside of your eye difficult. Personally I dilate pupils of my px on every comprehensive eye examination visit which is at least biannually. This way I gather lots of information about their eye health and detect glaucoma, cataract, macular degeneration, systematic disease like diabetes, hypertension HIV etc.
Dilation can affect your ability to drive, read and move around in bright lights for few hours, depending on type and strength of drops used and your iris pigmentation. However, the affect can be reversed with miotic drops within an hour.
The common contra indication to dilation is narrow angle glaucoma. Dilation is generally not contra indicated in contact lens wearers.
I trust this serves your question to some extent.

Regards,

S Kapasi

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## dyip

Shabbir,
Thanks for the response. Is there certain age group of people that require more than or less than a biannual exam? What is 'contra'?

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## Optom

You are welcome:) 

You and your eye doctor should determine the eye exam schedule that best meets your eye care needs.Generally you should not go beyond 2 years without your eyes examined.But, if you are on medication that may have potential side effects on your eye health,or have immediate family members with history of eye diseases like diabetes,glaucoma or hypertension check with your doctor to see if more frequent eye examination may be neccessary for you.

It is suggested that childern should have their first eye exam at 6 months with follow up exam around 2-3 years. After age of 40,one should continue to have eyes examined every 1-2 years.

counter indicated=not indicated.

Good night!

Shabbir Kapasi

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## dyip

Shabbir,

One of the posts by the member NC-OD from the thread in this forum titled Looking for thoughts from the Docs ... seems to give me the impression that good ODs are the ODs who care enough to take the extra time to do dilation (but his wordings sounded more like he was doing the dilation just to protect his butt as well as to secure his financial interest), while all the other ODs who work for chain stores wont even border to include the test in the eye exam because of the assembly line nature of the work flow, and hence are negligent to the patients potential health hazard. 

Actually, the key question in my mind after reading that post, and before I posted this thread was:As a consumer/patient, do I judge the quality of an OD by whether he/she does dilation during regular visit? However, based on your answers on this topic so far, I am wondering if dilation during periodic eye exam. is really necessary at all to detect the problems you mentioned above for a NORMAL and relatively healthy person. 

Here are my thoughts:

1)Isnt it true that glaucoma can be detected by the eye pressure test (which was done to me every time I visited the OD)? If the pressure test is negative, isnt dilation for this purpose redundant? 

2)Cataract and macular degeneration usually happen to old people, and this in general excludes the young population. What is the need to do the dilation for young folks for this purpose?

3)Disease like diabetes, hypertension, HIV (or did you mean hypertension HIV??) can be detected by other means instead of dilation. Probably these diseases have so many symptoms that they will be long be detected before the patient has the dilation. Though I agree that people with severe case of diabetes can cause blindness, and dilation is a necessary additional step. 

I just had one dilation in my whole life many years ago, and it was because I had an eye infection due to one eye in contact with dirty pool water. No other complication was detected. It was done by an OMD, and besides the copayment, the insurance covered the rest of the expense. Do most ODs charge extra and how much extra for dilation? Or do those ODs who do the dilation automatically include the dilation charge in the whole package no matter the person wants to do it or not?

All said, should I still judge the quality of an OD by whether he/she does dilation during regular visit? Again, I am talking about a normal and relatively healthy person.

P.S.,
Thank you for the tip about the miotic drops, I will sure try it after my next dilation.

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## Optom

En brief:
A good optometrist will give dilated eye exam at least once on annual or biannual visit, even to normal and relatively healthy looking person. Without dilation is it difficult to see at the back of your eye. It is like looking at the room through small hole, and looking through open door-you can see the whole room. Remember eye is mirror to your health and many systemic diseases are diagnosed through comprehensive eye examination.
In some patients dilation can be achieved without use of drops, like young myopes who have large pupils, I make them sit in darkened room for few minutes and than start ophthalmoscopic examination with low illumination.
In my part of world optometrist do not charge extra for dilated eye exam.
1)	Glaucoma cannot be detected by eye pressure test alone, repeated pressure readings, thorough optic disc evaluation, visual fields, family history needs to be investigated to establish glaucoma case.
2)	During vision screening in schools, I do pick cataracts and macular diseases in young students with dilated eye exams.
3)	I agree with you that diseases like diabetes, HIV(AIDS) can be detected other means like laboratory test, but the extent of damage these diseases has caused to your eyes can only be determined by dilated eye exam.

In concluding, I say professional eye examination should include dilation of pupils.

Regards,

S Kapasi

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## Stopper

Everyone needs a dilated exam. Most ODs don't charge extra for this. Its like looking in a room through the keyhole or with the door open. If you realy want to know what is going on you better open the door. A dilated exam also gives the advantage of binocularity during the examination. You can see weather that nevis is flat or elevated(maybe a melanoma). You can judge C/D ratios better. I can give you 100 reasons why this should be done on all patients. the point is even healthy patients need this.

Dilation is not used to detect diabetes, just the damage to the eye from diabetes that leads to a lot of blidness, most of which is preventable if detected early.

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## dyip

S. Kapasi,
If Glaucoma cannot be detected by eye pressure test alone, then why is the eye pressure test necessary. What else does the test find out?

After reading the posts from all the experts, I am convinced that dilation is important to the general public. But the fact is that I was never asked to have a dilation test every time I had an eye exam (mainly for eyeglass and/or CL lens prescription renewals) except for the eye infection incident. The ODs did take the time to peep into my pupils during every eye exam. I¡¯d seen ODs from different practices, both private and chain stores. I did not recall seeing a lot of post dilation test patients wearing the wrapped around oversize sunglasses in the OD offices neither. So I always think that dilation is some kind of unusual test reserved for certain type of people only. Most people drive in this country, you can imagine that how inconvenient it is to drive around after dilation (not only the glare, but also the out of focus vision due to the enlarged pupils). So I think that dilation test is not favorable among most people who just want to renew the prescription. 

If the ODs do not do dilation, does it mean that they are not good or responsible OD? If that is the case, that means that I'd never met a 'good' OD in my life. Either I am very 'cheap' or the 'good' OD is a rarity in this country. On the other hand, it should not take the OD extra time to do dilation. But the patient definitely needs to stay longer in the office for the test. I do not know why the NC-OD that I mentioned earlier in this post make such a big deal out of it.

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## NC-OD

Well since my ficticious cyber-world name was brought up, I guess I should respond.  I'm not sure what original post you were mentioning and I don't have a chance to search for it but I'll add my thoughts on dilating.

It will, obviously, depend on a few factors.  The OD or OMD, the philosophy of the doctor and, I imagine, the enviroment.  I have a primarily older, disease oriented practice (much to the chagrin of Homer :) ) and dilate most every patients at least every other year.  Older patients, those with diabetes, glaucoma, HIV, kidney disease, hypertension, thyroid disease, etc. are dilated on every yearly visit and many monthly or even weekly.  This list would encompass just about every senior patient in America because they all have at least one of those risk factors.  If there are any OD's or OMD's that do not dilate this population on a regular basis, then they are providing substandard care.

Now the more "fuzzy" situation are with younger people.  There are certain subsets of young people that are routinely dilated including high myopes, those with systemic disease, or trauma.

With young, healthy people, the jury is out.  Personally, I like to dilate them on their first visit.  Like someone mentioned earlier, you don't know what your not seeing if you don't dilate.  It's like the dentist only looking at your front teeth and telling you your mouth is fine.

After the initial dilation on a young person, I will dilate them again in 2-4 years.  The risk of something unusual in the periphery "growing" in a young person is very remote. With the re-emergence of Paramyd and Rev-Eyes, dilation in the younger population should be the norm.  It is in my office.  My job is to insure that they see better and that their eyes are healthy.  I just don't feel comfortable telling my patients "I don't THINK there are any problems with your eyes".  I tell them emphatically, "There are absolutely no problems with your eyes'.  I sleep better at night. 

You must realize that much of this is in response to various lawsuits over the years.   We do have to COA's.  There are alot of hungry ambulance-chasing lawyers out there. :Eek:

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## Stopper

Ditto to what NC-OD posted. If you are not having your eyes dilated then I don't think you are getting the standard of care. You might want to start looking around for a new Doc.

To answer your question about eye pressure. IOP that is elevated (above 21) increases the probability that you may have glaucoma but it is not diagnostic. Many people have elevated pressures and don't have glaucoma. Conversely, many people with normal pressures have glaucoma. IOP is just an indicator not the diagnosis. You need to look at other factors such as Optic nerve cupping and visual field testing.

Also driving around after dilation is not that bad for most people as long as you have shades and you're not an uncorrected hyperope.

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## Pete Hanlin

In Florida, Optometrists and Ophthalmologists are required by law to dilate new patients. 

Probably these diseases [diabetes, hypertension, HIV] have so many symptoms that they will be long be detected before the patient has the dilation. 
This is an incorrect statement.  Thousands of people each year are diagnosed with diabetes as a result of a dilated fundus exam.  This is because diabetes is a disease that affects small blood vessels.  The vessels that supply blood to the retina are quite fragile and are particularly prone to the damage inflicted by diabetes.

Of the doctors with whom I worked over the years, dilation was never charged as an "additional" procedure.  It isn't used to "sell" you anything (indeed, almost any anomaly found during a DFE by an OD will likely result in a referral).

If someone is extremely concerned about driving, I would suggest s/he inquire about "RevEyes" (but some ODs don't like to use these drops because some patients are sensitive to them).

Finally, my wife is what I would call a person of "normal" health.  She is in her 30's without any particular health symptoms.  However, a few years ago a DFE found a "freckle" on her retina.  Hopefully, this is simply a benign discoloration on the retina, but it merits monitoring.

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## Optom

Dyip,

Answering your questions,

1)	Eye pressure test is part of your comprehensive eye examination. If the eye pressure reading is abnormally high, it calls for further investigation to establish a case of glaucoma.
2)	I cant imagine complete eye examination without dilation. How can your eye doctor properly record in your file details seen inside of your eye without dilation? Your doctor should do at least one dilated eye exam at your annual or biannual appointment. You do not need dilation if you go to him again for prescription verification, buy new pair of contact lenses or refill your prescription.
3)	My purpose here was to explain reasons for dilation. I am unable to comment on ODs practices of your part of world.

Best regards,

S Kapasi

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## docwatson

Okay, here's my 2 cents...

The bottomline of glaucoma is damage to the eyes: to the optic nerve and the retina. The optic nerve will show a widening of the cup (a small basin like structure within the disk of the nerve that can be observed by looking in the eye), and the retina will show field defects--loss of peripheral vision--that starts in spots.

Not any one thing is going to cause the damage, particularly pressures. However, a recent study has shown that pressures do have some effect on the treatment of the disease but we still do not know why (this same study also told us that thin corneas are related to the progression of the disease! Why? Who knows). We still have no idea what causes glaucoma, how it progresses, or why it damages the nerves. We do know there's certain risk factors such as having diabetes and having other family members with the disease.

So to check for glaucoma, pressures are not the only variable. Far from it. The entire history must be assessed, both the family and the patient. The optic nerve, retina, and anterior chamber of the eye must be examined closely. This is only the minimum. If anything is suspect, hence the term, "glaucoma suspect," further testing is warranted. 

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About dilation...

Dilation is only a means to an end. It is important only in that it makes it easier to see into the eyes. Remember: A doctor can still see into an undilated eye! It just makes it a bit harder to see detail because there will be less available light, the optics of the lens and ophthalmoscope (tools that we use to see into the eyes) must be aligned better than when dilated (a very steady hand is helpful), and the field of view is typically smaller requiring more work to see the whole retina.

However, with that said, dilation is important. I like getting the best view possible. But some patients already have large pupils in bright light so dilation is not entirely necessary. Children have such clear eyes that even with small pupils a good view of the retina may be obtained. It seems to come down to either wanting to get a better view and the legal aspects of dilation, which is why you won't find too many O.D.s and M.D.s who will publically admit that they don't dilate everyone.

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## EyeManFla

I can't even count the number of times the doctors that I have worked with have spotted serious problems in a patient by doing a DFE.
In my office we equate refusal to do a DFE with going to your GP and saying that you are ill, please help me...and then refuse to give a blood or urine sample.
As Pete has pointed out, DFE is required in Florida as part of the exam. Even though a number of insurance companies will pay you seperately for the DFE from the refractions, we will only drop doing the DFE only if there is some sound practical reason to do so, but still require the patient to come back at a later time for follow up and DFE.
I would have no pity for the doctor that would not do the DFE because a patient refused to do it....only to have that patient's lawyer come back a year later in a lawsuit over the disease that the doctor missed.

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