Review of Retinal
Mapping
Tiffenie Harris, OD
Clinical Assistant Professor
Clinical Assessment
Fall 2005
Review of BIO Technique

Sitting vs. Supine
– Sitting allows folds within the RD or break to open
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Smooth and efficient
– Systematically examine the quadrants out to the periphery
– “Sweeping” views of retina
– Posterior pole last
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Patient head position
– Stand/sit directly opposite meridian of interest
– Turn the patient’s head toward the examiner/ have the patient
look toward the meridian of interest
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Illumination
– Light fundus vs. dark
– Periphery vs. central
Review of Anatomical
Landmarks
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Horizontal meridian
– Long posterior ciliary nerves at 3 & 9 o’clock
represent the anatomical horizontal
meridians
– divides the retina into superior/inferior
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Vertical meridian
– Short ciliary nerves seen between 10 and 2
as well as 4 and 6 o’clock represent the
anatomical vertical meridians
– Divides the retina into nasal/temporal
Long Posterior Ciliary Nerve

Retinal photo of
patient looking
left with OD
Review of anatomical
landmarks

Anterior/Posterior retina is divided by
the Equator
– Vortex ampulla are located just
posterior(approx 3mm)and there are usually 4
to 6 vortex veins
– located in the 1, 5, 7, 11 o’clock meridians

Ora Serrata
– The junction between the retina and ciliary
body
– Nasal ora appears “serrated” and the temperal
does not

Posterior pole
– Macula and optic nerve along with the sup/inf
vessel arcades
Ora Serrata
Nasal or

Temperal
retina?
Extended Ophthalmoscopy
CPT 92225

Documentation requirements
– A detailed sketch must be included in the
medical record with sufficient labeling along
with an interpretation that affects the plan of
treatment
– The sketch should be a minimum size of 3-4" in
diameter
– All items noted must be identified
– Drawings in 4-6 standard colors are preferred

92225-Extended ophthalmoscopy is one
of the most heaviest audited codes by
medicare
Limitations

Considered not medically necessary if
– there is insufficient drawing
– the medical record does not document the
interpretation
– it replaces a routine ophthalmoscopy.
– when other testing such as fundus photography
gives the same information
– It is not enough to link the procedure code to a
correct, payable ICD-9-CM code
– The diagnosis or clinical signs/symptoms must
be present for the procedure to be paid.
Conventional Color Scheme
for Retinal Mapping
-Red:
Light red: attached retina
Dark red: retinal arteries, preretinal or intraretinal
hemorrhages
-Light blue: Retinal Detachment
-Dark blue: Retinal veins, margins of retinal breaks,
lattice is outlined in blue with inside crosslined
--Black: chorioretinal pigmentation
-Yellow: intraretinal or subretinal exudates
-Brown: nevi, melanomas, choriodal detachment
-Green: vitreous or lens opacities Opacities in media,
vitreous hemorrhage
Example #1
28 yo 8D myopic female
Cc: floaters/flashes x 3-4 days, no hx of
injury
DVA: 20/20 OD, 20/20 OS
PERRLA, EOM: snf,
Slex: C/C- clr, L/L –clr AC: C&Q, VH-Gd4
Example #1

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What additional tests/examination can
you perform?
What do you expect to find?
Why are her acuities good?
Would you expect her to have an APD?
Example #1


CVF: FTFC – OS, superior defect noted OD, -APD
+Shaffer’s sign
– The presence of pigment granules in the anterior vitreous
(Berger's space) AKA "tobacco dust,"
– Very significant clues to a retinal break or detachment. Hamilton
and Taylor found that 98% of patients in their clinical review
with this sign had retinal detachments and 60% had flat retinal
holes
– Failure to check for this sign on a symptomatic patient could be
considered gross negligence
– Red blood cells, secondary to a vitreous hemorrhage, may be
difficult to differentiate from the pigment granules. However,
with a red free filter (green) the red blood cells will disappear
The pigment granules will not absorb the red-free light and will
still be seen.
Example-view w/20D lens
Example #1-OD looking
down and right
-What do you see?
-Where do you draw
your findings?
ok

VR consultants
Example #2-view with 20D
Example #2-OS looking up
and left

Where do you draw
your findings?
Example #3
Example #3-OD looking up
and right

Where do you draw
your findings?
Sketch What You See
Assignment
Due: October 5th
Clinical Assessment
Fall 2005
Instructions

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Use stencils if available
Record locations by clock hour when appropriate
Include anatomical landmarks to reference location
Use labels with arrows when appropriate
Approximate size of lesion (range is allowed) use
optic disc as gauge (e.g., 2DD in size)
Note topographical characteristics when appropriate
(e.g., elevations, escavations, etc.)
Each item is worth 10 points of credit and partial
credit will be given, 100 total points possible
Case #1
Case #1
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This is a 20D view
of the posterior
pole
Which eye is this?
Provide a list of
differentials for this
retinal finding (at
least 5)
Case #2
This small circle is
an artifact
Case #2

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This is a retinal photo
of a patient looking up
and to the left with
the right eye
What is this retinal
finding?
Provide a differential
list for this retinal
finding (list at least 3
conditions)
Case #3
Case #3
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This is a 20D view of OS
looking up and to the
right
What is this retinal
finding?
What symptoms do you
expect this patient to
experience?
Case #4
Case #4


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Describe what you
see in this retinal
photo as you would
record it in a
patient’s record
Provide a list of
differentials for
this fundus finding
What is your best
answer and why?
Case #5
Case #5


This is a retinal
photo of OD looking
up
Provide a list of
differentials for
this retinal finding
(at least 5)
Bonus: What is this
retinal finding?
Case #6
Case #6

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This is a 20D view
of OD looking down
to the left
What is this retinal
finding?
What are the risks
associated with this
finding?
Case #7
The white
spots are artifacts
on the photo
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Case #7
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Describe what you see
in this retinal photo as
you would document it
in a patient’s record
What is the retinal
finding?
Provide a list of
differentials (at least 3)
BONUS: What tests
should be performed
on this patient?
Case #8
Case #8
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This is a 20D view
of OD looking down
Provide a
differential list for
this retinal finding
(at least 3)
What is your
answer and why?
Case #9
Case #9

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This is a retinal photo of
OD looking right and
slightly down
Provide a list of
differentials for this
retinal finding(at least 3)
What symptoms might this
patient experience?
Case #10
Case #10
What is this fundus
finding seen in this
retinal photo?
 This diabetic patient has
what stage of diabetic
retinopathy?
NOTE: be as specific as
possible

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Give at least ONE
differential
Extra Credit Case 
Extra Credit Case
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What is this retinal
condition?
Why does the retina
appear this way? Be
as specific as possible

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What is the expected
visual acuity?
Is there any underlying
systemic conditions
associated with this
retinal finding?