Sir,

We read with interest the article by Natkunarajah et al.1 We agree that indirect ophthalmoscopy with indentation remains the gold standard for the detection of retinal breaks.

It is not clear if the initial examination by trainees was performed on slit lamp biomicroscope or with a binocular indirect ophthalmoscope? It would be easy to pick up relatively ‘non-peripheral’ tears on slit-lamp biomicroscopy. The authors acknowledge that the high pick-up rate by the consultant using the slit-lamp biomicroscopy could be attributable to the fact that he/she was aware of the presence of a retinal tear. A better alternative would be to examine all patients with symptomatic PVD with slit-lamp biomicroscopy. These patients should then be re-examined by the same observer with an indirect ophthalmoscopy to see whether any more tears can be detected. This would avoid the examination bias mentioned in the article and may be a truer reflection of the sensitivity of slit-lamp biomicroscopy in the detection of peripheral retinal tears.

We are concerned that in majority of consulting offices, no flat couches are available to lie the patient down for examination with binocular ophthalmoscope and indentation. There is a tendency to examine the patients with a 90 D lens and less incentive to perform indirect ophthalmoscopy that might involve taking the patient to another room. The Royal College Higher Specialist Training curriculum only requires assistance in vitreoretinal procedures and none to be performed. With fewer opportunities to perform scleral buckling surgery, trainees are less likely to gain experience in indirect ophthalmoscopy and indentation. In most units, rigorous preoperative evaluation using the binocular indirect ophthalmoscope and detailed retinal drawing has given way to intraoperative search for retinal breaks. With this trend, newly trained consultants are likely to be less proficient in indirect ophthalmoscopy and as an extension, less likely to pass on this valuable skill to their juniors.