Documentation & drawing in Ophthalmolgy

Anterior segment finding Documentations

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

Requisite for drawing:

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

Blue colour is used to document

Brown colour is used to document

Red colour is used to document


Fundus Drawing

Fundus drawing is universally acceptable records of the retinal disease process. It is a useful reference to monitor the clinical process and also at the time of surgery.
 
Requisites for Fundus drawing:
An examination table, indirect ophthalmoscope, 20 D lens, a scleral depressor (or paper clips etc), coloured pencils (mainly red, blue, green, yellow, black and brown), eraser, pencil sharpener, fundus drawing charts and a clipboard.

Fundus drawings are drawn in fundus chart. Generally there are three concentric circles-the innermost circle represent the areas of posterior to the equator, the middle one represent area in between equator and ora serrata and the outermost circle represent area anterior to the ora serrata.It is essential to draw the ophthalmoscopic observation in proper areas corresponding to the fundus. For example a lattice between ora serrata and equator should be drawn in between the innermost and middle circles. The optic nerve head is drawn as a small circle. The radial lines numbered in roman numerical used to designate the clock hours helps us to describe the location and extent of the lesions.

Generally the bottom right hand corner of the chart is kept near the patient’s right shoulder and this is done to overcome the difficulties arising from the inverted and reversed images perceived by the observer during indirect ophthalmoscopy.

It is always better to use a lead pencil to sketch the outlines of fundus drawing, as it can be erased and redrawn.However many a times the fundus drawings are drawn in prescription pad, outpatient cards and in case sheets of files. It’s better to use a circular stencil (like small bangle, cap of a container etc.) to draw the fundus as it looks good. The ora serrata is drawn as described in fig. -- as ora serrata is smoother in temporal side (11 to 5 o’clock in right eye and 7 to 1 o’clock in left eye).In eyes with mid dilated pupil and nondilated pupil, the obstructed view of peripheral fundus is indicated by some lines instead of the usual wavy pattern of drawing ora serrata.

It is better not to use the red colour to denote attached retina in a case of diabetic retinopathy as it is mandatory to document retinal vessels, dot and blot haemorrhages, preretinal haemorrhages and microaneurysms with the help of red colour in such cases and putting them in white background makes the documentation more useful to monitor the progression of the disease.

 

Colour Coding:
Here is a big list of colour coding of retinal lesions.

CODING IN RED COLOUR:

Red– solid

Red-Cross-lined

CODING IN BLUE COLOUR:
Blue- Solid

Blue-cross-lined

Stippled\circled

Interrupted lines

CODING IN GREEN COLOUR
Green-solid

Green Stippled\dotted

CODING IN BROWN COLOUR
Brown-solid

CODING IN YELLOW COLOUR
Yellow-solid

 Yellow – stippled       Drusen   

CODING IN BLACK COLOUR
Black-solid

Remember: