Documentation & drawing in Ophthalmolgy
From the days of Hippocrates documentation has been a cornerstone of clinical science. But somewhere down the line this has become a lost art rarely ever practiced by many of us. We tend to ignore or to say correctly run away from it under many pretexts like its time consuming, it’s of no use etc etc……….. And surprisingly this resistance to document is prevalent not only among juniors but spans across the whole spectrum of practitioners. So at times we really ponder is documentation really necessary?
The answer is an emphatic yes – the reasons being
- It’s a standard clinical practice worldwide
- Follow up is possible only if you can compare with your previous records.
- Will help you medico legally
- Last but not the least unless you are documenting it you have not probably seen it correctly(you think you have seen it all but moment you come to draw it you find that you don’t remember where the break was it at 1 o’clock or 3 o’clock position and so on). Only when there is need to document your observation skills will vastly improve. To allay your fears its not time consuming and once you start doing it for every patient it gets seamlessly integrated into your system and hardly obstructing the flow of your busy clinical session.
- This section deals with methodical documentation of ophthalmology findings using standard colour coding
Requisite for drawing:
- Mainly 6 coloured pencils- black, blue, brown, red, green, orange (alternately you can keep pen with four coloured refills and brown and orange pencils)
- Eraser –to allow modifications of drawing
- Some stencils – Like for drawing circle you can use a circular object
Cornea & Anterior Segment:
Generally corneal pathologies are documented as frontal view and in cross sectional view.
Following colour coding is generally used to document the findings of anterior segment
Black colour is used to document
- Limbus
- Scars
- Degenerations
- Foreign bodies
- Sutures
- Contact lens
- Band keratopathy
Blue colour is used to document
- Oedema,
- Small circles for epithelial oedema
- Wavy lines to document folds in Descemet’s membrane
Brown colour is used to document
- Pigmentation-iron or melanin
- Pupil and iris
Red colour is used to document
- Blood vessels (see figures)
- Rose Bengal staining
- Haemorrhages
Orange colour is used to document (in many centres,yellow colour is used instead of orange)
- Hypopyon
- Keratic precipitates
Green colour is used to document
- Fluorescein staining of cornea
- Punctuate epithelial keratopathy (dots)
- Filaments (small lines)
- Epithelial defects
- Lens and vitreous haze (see later)
Alternatively many clinicians uses a monochromatic system of lines for documentation of corneal diseases. Few examples are shown in below (Adapted from Bron AJ.Br J Ophthalmol1973; 57:629–34.)
Next: Documentation of Disc, ...Coming soon
