Dilation is almost always harmless in the long term, but it does come with short-term side effects, including light sensitivity, blurry vision, difficulty driving immediately after dilation, trouble focusing on close objects, and stinging when the drops are instilled. So, it is reasonable to ask if the ophthalmologist or optometrist should insist on a dilated fundus exam (DFE) as part of a comprehensive eye exam.

Besides patient discomfort and inconvenience, there are other more serious reasons not to dilate the patient (Table 1). Consequently, a comprehensive eye exam, reported with either an evaluation and management (E/M) code (992xx) or an eye code (920xx), does not mandate a DFE.¹ The changes to the E/M coding system, effective January 1, 2021, further emphasize this point because physicians need only perform and document “…a medically appropriate examination and/or evaluation”;² that is very different from the HCFA 1997 E/M guidelines for single organ specialties that stipulated “ophthalmoscopic examination through dilated pupils unless contraindicated.”³ Importantly, “not mandatory” does not mean unnecessary or not recommended. Instead, dilation is at the physician’s discretion and guided by training, experience, and evidence-based clinical practice guidelines.

The American Optometric Association’s 2015 evidence-based clinical practice guideline states that pharmacologic dilation is generally required for the thorough evaluation of ocular structures.^7,8 At the time of this writing, the AOA Evidence-Based Optometry committee was revising the optometric guidelines and had not yet published an update.⁹ Jessica Steen, OD, attending optometrist and instructor of ocular pharmacology at Nova Southeastern University’s College of Optometry, wrote, “…if in doubt, the most appropriate course of action is to dilate for all of your fundus examinations.”¹⁰

The American Academy of Ophthalmology’s Comprehensive Adult Medical Eye Evaluation Preferred Practice Pattern (2020)¹¹ states, “The comprehensive eye examination … usually includes … evaluation of structures situated posterior to the iris is best performed through a dilated pupil.” When patients present for an eye exam with comorbid systemic disease that might affect the eyes, such as diabetes mellitus, the argument for a DFE is more urgent and persuasive.¹² Likewise, known or suspected ophthalmic disease typically found in the posterior segment argues for a DFE.^13,14

Insistence on a DFE may also be motivated by malpractice litigation against ophthalmologists and optometrists that is frequently based on retinal pathology misdiagnosis due to failure to dilate.^15,16 The medicolegal issue may outweigh any other consideration. Picture yourself in a courtroom trying to complete this sentence if you missed something that could have been picked up on a DFE: “Your Honor, the reason I chose not to dilate was _______.” Anything you would put in the blank pales beside what the patient might lose. In a study that compared exams through a dilated and natural pupil, the authors found a significant number of retinal anomalies were missed, some very serious, and concluded that “…dilation should be strongly considered for all patients so as to optimize the probability of detecting fundus anomalies.”¹⁷

In our experience with clients, a few offer ultrawidefield imaging (UWFI) as a screening service prior to an eye exam and make an additional charge to the patient for a noncovered service.¹⁸ No doubt, some patients believe (erroneously) that UWFI is a substitute for a DFE. While UWFI can show most of the retina, it will not reveal lesions anterior to the equator. In a study that evaluated the sensitivity and specificity of the Optos optomap, Mackenzie et al concluded, “The optomap showed high specificity and moderate sensitivity for lesions posterior to the equator and low sensitivity for lesions anterior to the equator.”¹⁹ Binocular indirect ophthalmoscopy (BIO) remains the gold standard for ophthalmologists and optometrists.²⁰ In an aptly titled article, “The Dilation Dilemma,” Steen opined that UWFI “…is therefore recommended only as an adjunct to a dilated fundus exam that includes careful peripheral retinal examination.”¹⁰ It has been observed that BIO, particularly on an uncooperative patient, may be poorly performed and miss abnormalities or disease and that UWFI can help point the ophthalmologist or optometrist in the right direction where it identifies something suspicious. One study showed a 30% increase in retinal lesion discovery compared with traditional DFE alone.²¹ The American Academy of Ophthalmology’s Preferred Practice Pattern for Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration states, “Wide-field color photography can detect some peripheral retinal breaks but does not replace careful ophthalmoscopy and may be useful in patients not able to tolerate the exam.”¹⁴ A representative LCD on fundus photography by National Governmental Services, LLC (L33567) states, “Fundus photography is not a substitute for an annual dilated examination by a qualified professional.”¹⁴

Significantly, the definition of an eye exam does not, in any instance, include fundus photography; rather, it mentions ophthalmoscopy, which is dynamic and personally performed by the physician. Going further, extended ophthalmoscopy (92201, 92202) is not imaging.²² Therefore, UWFI should not be offered solely as a substitute for dilation. GP

Kevin J. Corcoran, COE, CPC, CPMA, FNAO, is president of Corcoran Consulting Group in San Bernardino, California.

References

1. 2021 CPT Professional Edition.
2. American Medical Association’s CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes. June 2019. Accessed January 11, 2021. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
3. Health Care Financing Administration. 1997 documentation guidelines for evaluation and management services. Accessed January 11, 2021. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/97docguidelines.pdf
4. Family Practice Notebook. Mydriatic. Accessed December 29, 2020. https://fpnotebook.com/eye/Pharm/Mydrtc.htm
5. WebMD. Who should not take AK-Dilate Drops? Accessed January 11, 2021. https://www.webmd.com/drugs/2/drug-1111/ak-dilate-ophthalmic-eye/details/list-contraindications
6. Bhan KJ, Bastawrous A, Davey KG. Funduscopy: to dilate or not? Precipitation of angle closure may not be a disservice. BMJ. 2006;332(7534):179. doi:10.1136/bmj.332.7534.179
7. AOA Evidence-based Optometry Committee. Evidence-based clinical practice guideline. Comprehensive adult eye and vision examination. American Optometric Association. 2015.
8. Attar R. All about red caps: mydriatics and cycloplegics. Accessed January 11, 2021. https://optometrysmeeting.org/documents/handouts/2019/P450.pdf
9. American Optometric Association. Clinical guidelines. Accessed January 11, 2021. https://www.aoa.org/practice/clinical-guidelines?sso=y
10. Steen J. The dilation dilemma. Rev Optom. June 15, 2016. Accessed January 11, 2021. https://www.reviewofoptometry.com/article/the-dilation-dilemma
11. Preferred Practice Patterns Committee. Comprehensive adult medical eye evaluation preferred practice pattern. 2020. Accessed January 11, 2021. https://www.aaojournal.org/article/S0161-6420(20)31026-5/pdf
12. AAO PPP Retina/Vitreous Committee, Hoskins Center for Quality Eye Care. Diabetic retinopathy PPP 2019. Accessed January 11, 2021. https://www.aao.org/preferred-practice-pattern/diabetic-retinopathy-ppp
13. AAO PPP Retina/Vitreous Committee, Hoskins Center for Quality Eye Care. Primary open-angle glaucoma PPP 2020. Accessed January 11, 2021. https://www.aao.org/preferred-practice-pattern/primary-open-angle-glaucoma-ppp
14. AAO PPP Retina/Vitreous Committee, Hoskins Center for Quality Eye Care. Posterior vitreous detachment, retinal breaks and lattice degeneration PPP 2019. Accessed January 11, 2021. https://www.aao.org/preferred-practice-pattern/posterior-vitreous-detachment-retinal-breaks-latti
15. Goddard AG, Kingston JE, Hungerford JL. Delay in diagnosis of retinoblastoma: risk factors and treatment outcome. Br J Ophthalmol. 1999;83(12):1320-1323. doi:10.1136/bjo.83.12.1320
16. Classé JG. A review of 50 malpractice claims. J Am Optom Assoc. 1989;60(9):694-706.
17. Siegel BS, Thompson AK, Yolton DP, Reinke AR, Yolton RL. A comparison of diagnostic outcomes with and without pupillary dilatation. J Am Optom Assoc. 1990;61(1):25-34.
18. Corcoran Consulting Group. FAQ. Payment for screening by optomap retinal exam (Optos). Accessed January 11, 2021. https://www.corcoranccg.com/products/faqs/optomap-screening/
19. Mackenzie PJ, Russell M, Ma PE, Isbister CM, Maberley DA. Sensitivity and specificity of the optos optomap for detecting peripheral retinal lesions. Retina. 2007;27(8):1119-1124. doi:10.1097/IAE.0b013e3180592b5c
20. America Academy of Ophthalmology. Binocular indirect ophthalmoscopy. Accessed January 11, 2021. https://eyewiki.aao.org/Binocular_Indirect_Ophthalmoscopy
21. Brown K, Sewell JM, Trempe C, Peto T, Travison TG. Comparison of image-assisted versus traditional fundus examination. Eye Brain. 2013;5:1-8. doi:10.2147/EB.S37646
22. Centers for Medicare and Medicaid Services. LCD L33567. Posterior segment imaging (extended ophthalmoscopy and fundus photography). Accessed January 11, 2021. https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33567&ver=27&articleid=56726&keyword=&keywordType=starts&areaId=s41&docType=6%2c3%2c5%2c1%2cF%2cP&contractOption=all&hcpcsOption=code&hcpcsStartCode=92250&hcpcsEndCode=92250&sortBy=relevance&bc=AAAAAAQAEAAA&