To compare the quality of fundus evaluations conducted with natural and dilated pupils, 500 typical adult subjects, divided into 5 age categories, were examined using both techniques. Direct and monocular indirect ophthalmoscopes were used with the natural pupils; direct and binocular indirect scopes were used for the dilated exams. Retinal anomalies were classified on the basis of posterior pole or peripheral location and whether the anomalies would require significant action by the doctor. Of the 29 posterior pole anomalies which required action, 38% were missed during the natural pupil examination; 49% of the anomalies not requiring immediate action were also missed. These miss rates, along with the 287 anomalies found in the periphery (20 of which required immediate action), suggest that dilation should be strongly considered for all patients so as to optimize the probability of detecting fundus anomalies.
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