If you've wanted to dilate a narrow angle patient but have had concerns that you might precipitate an angle closure attack, Michael Silverman, O.D., of Coral Spring, Fla., suggests you consider a sector dilation. This will enlarge the pupil in only one meridian, allowing a retinal exam while minimizing the risk of angle closure.
Dr. Silverman suggests you try this approach:
Before you sector dilate, perform gonioscopy to properly grade the angles. You might be surprised to find out that angles graded as very narrow with the Von-Herick technique are open and reveal visible trabecular meshwork when you view them with a gonioscopy lens. This allows a relatively safe dilation, assuming that the iris doesn't have too much of a convex approach to the trabecular meshwork.
To perform sector dilation, first instill a drop of proparacaine (Alcaine, Ophthetic) into each eye. Take a new cotton-tipped applicator and soak it with a couple of drops of tropicamide (Tropicacyl) and 2 1/2% phenylephrine. You can use 10% phenylephrine, but Dr. Silverman says this doesn't work as well.
Shake off the excess from the cotton tip and touch it for only 1 to 2 seconds to the inferior limbus while having the patient look up. If your cotton tip is too wet, or you hold the cotton tip on the limbus for too long or press too hard, the entire pupil will dilate. It's better to touch the limbus for a second and then do it again in 15 minutes, rather than holding it too long the first time.
If you've done the procedure properly, you'll soon observe a vertically elongated pupil that will permit you a decent view of the retinal fundi without closing off the angles.
Of course, if a patient has an extreme narrow angle, you should consider prophylactic therapy. Explain this to the patient and warn him of the symptoms of an angle closure attack and medications he should avoid. These include anything that can dilate the pupils, such as overthe-counter cold medicine.
Copyright Boucher Communications, Inc. Oct 1998
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