Ocular Diagnostics Midterm Working Review

What is Heterophoria?

A misalignment of the visual axes in the absence of an adequate stimulus to fusion

What is Vergence?

Simultaneous movements of both eyes in opposite directions – goal is to maintain single binocular vision.

What is Von Graefe Phorias?

Subjective assessment of binocular deviations in the absence of fusion.

What is Vergence Ranges?

Subjective assessment of the eyes’ ability to perform fusional vergence movements.

What is Relative Accommodation?

Subjective assessment of the ability to decrease and increase accommodation while maintaining single vision.

What is Fused Cross Cylinder?

Subjective assessment of the accuracy of accommodation (non-presbyopes) and to find a tentative add (presbyopes).

Your Results are Distance 3 BI, what is its interpretation?

3 XP

Your results are Near 3 BU OS, what is its interpretation?

3 H’P OD

What kind of fusional vergence are you testing?

Base-in: Divergence

Base-out: Convergence

Base-down: SUPRAvergence

Base-up: INFRAvergence

What are the Direct and Indirect tests of each relative accommodation for NRA?

Direct: Relaxes accommodation

Indirect: Convergence

What are the Direct and Indirect tests of each relative accommodation for PRA?

Direct: Stimulates accommodation

Indirect: Divergence

How do you record this scenario?

Relative Accommodation: You started at +2.75 DS.  The patient reports sustained blur at +0.25 DS.  Record this test and findings.

PRA -2.50 D

Record this test and the findings for this scenario.

FCC: You start at the patient’s manifest refraction of +0.75 DS.  The patient reports that the lines appear equal at PL DS. 

-0.75 D (lead)

Record this finding in this scenario.

FCC: The patient’s manifest refraction is +0.75.  You add 4 clicks of plus into the phoropter over the manifest.  The patient reports that the lines appear equal at +0.50.

-0.25 D (lead)

Record this test and findings:

FCC: You start at the patient’s manifest refraction of +0.75 DS.  The patient reports that the lines appear equal at +1.25 DS

+0.50 D (lag)

What are these parts?

What are these parts?

What are these parts?

Identify lens, iris, and crystalline lens

What are these parts?

How does the Zeiss Slit Lamp differ from a Haag Streit?

Illumination:

Zeiss comes from below

Haag Streit comes from above

How does the Greenough type slit lamp differ from the Galilean type?

Greenough has two mags, flipper level to change mag

Galilean has 3-5 steps on the side, (what we have)

What is the general application of direct diffuse illumination on slit lamp examination?

General gross scanning

An overview of various tissues

What is the appropriate beam and brightness (low/med/high)?

Van Herick

Optic section, High brightness

What is the appropriate beam and brightness (low/med/high)?

Corneal scan

Wide parallelepiped beam, Medium brightness

What is the appropriate beam and brightness (low/med/high)?

Corneal opacification

Optic section, Med-high brightness

What is the angle of the illumination arm for this tissue?

Lids

30 degrees

What is the angle of the illumination arm for this tissue?

Cornea

30-45 degrees

What is the angle of the illumination arm for this tissue?

Anterior chamber

30-45 degrees

What is the angle of the illumination arm for this tissue?

Transillumination of the iris

0 degrees

What is the angle of the illumination arm for this tissue?

Van Herick

60 degrees

What are the reasons for everting the upper lids?

Giant papillary conjunctivitis

Irritation and seasonal allergies

Removal of potentially lost contact lens

A foreign body location/removal

Evaluating the apex of internal or external hordelum

Evaluating the internal apex of chalazions

Determine the TENTATIVE add for this scenario:

Your new patient is 48 years old and has high hyperopia.

+1.75

Look at the chart from class/textbook

Determine the TENTATIVE add for this scenario:

You adjust your patient in the phoropter with the +1.00 D over their distance refraction and begin the FCC test.

With the first presentation, the patient reports that the lines are equal.

+1.00

Endpoint of FCC is the tentative add

Determine the TENTATIVE add for this scenario:

Using the push up method, you find that a patient can keep a target clear until it is 50 cm away (OD & OS). The patient prefers to work at 33.33 cm.

+2.00

Explanation: patient can use half of AA comfortably. AA=1/0.5m=2 D. AA/2=1.00 D. Patient’s preferred WD = 1/(0.3333 m)=3 D. Tentative add is what brings AA/2 up to the WD (with plus): 1.00 D+x=3 D,x=2 D

Determine the TENTATIVE add for this scenario:

After the distance refraction procedure, a patient’s near VA is 20/50 OU as measured with a traditional Snellen chart.

+1.00

Explanation: think Egger’s chart. 20/50 is 4 lines worse than 20/20, estimation is 0.25 D for each line of reduced VA. This is +1.00.

What is the REFINED add for this scenario?

A patient has the following results:

NRA = +2.50

PRA = -2.00

Tentative Add: +0.75

+1.00

Explanation: Refined Add=(NRA+PRA)/2+Tentative Add

=(+2.50+-2.00)/2+0.75=+1.00

Determine the REFINED add for this scenario?

A patient has the following results:

Tentative Add: +1.25, NVA 20/25 OU

You add another click of plus, and the patient reports clearer vision (NVA 20/20 OU).

You add another click of plus, and the patient reports clearer vision.

You add one more click of plus, and the patient reports no change.

1.75

Explanation: Leave the add at the least plus position that allowed maximum vision and was subjectively better to the patient.

What is the range of clear vision for this scenario?

The patient reports that their near vision is clear at 30 cm at the near extreme, and 45 cm at the far extreme. This is near extreme is not close enough for where the patient usually prefers to hold their reading material.

-What is the dioptric depth of field for this patient?

-What adjustment should you make to the refined add?

Dioptric depth of field is between 2.22 D and 3.33 D.

Adjust the add by adding +0.25 of plus to shift the range of clear vision closer to the patient.

Document normal for:

Adnexa

WNL or Normal OD, OS

Document normal for:

Lids

(-) crusting/flaking OD, OS

Document normal for:

Conjunctiva

(-) injection, (-) papillae, (-) follicles OD, OS

Document normal for:

Cornea

Clear OD, OS

Document normal for:

Anterior Chamber

Deep and quiet OD, OS

Document normal for:

Van Herick

OD 4×4, OS 4×4

Document normal for:

Iris

Brown, flat OD, OS

Document normal for:

Lens

Clear OD, OS

How do you describe this adnexa?

Asymmetric, Proptosis OS

Describe these ABNORMAL findings (Assume OD)

(+) RUL lesion – tender upon touch OD

(+) RUL edema, hyperemia OD

Describe these ABNORMAL findings (Assume OD)

(+) flaking RUL

Describe these ABNORMAL findings (Assume OD)

(+) fleshy-elevated, triangular growth nasal encroaching onto cornea OD

What does NaFl stain?

Missing epithelial cells of the conjunctival and/or cornea

What does LG stain?

Dead or devitalized or epithelial cells of the conjunctival and/or cornea

What does RB stain?

Dead or devitalized epithelial cells of the conjunctival and/or cornea

What are the clinical applications of NaFl, any disadvantages?

Evaluation of ocular surface integrity

Goldmann applanation tonometry

Evaluation of the tear film (TBUT)

Evaluation of penetrating injury (Seidel’s sign)

Evaluation for patency of the lacrimal system (Jones Test)

Gas permeable contact lens fitting evaluations

Fluorescein angiography

What are the clinical applications of LG, any disadvantages?

Evaluation of ocular surface integrity (bulbar conjunctiva) but can be used to evaluate the cornea too

Dry eyes, Herpes Keratitis

What are the clinical applications of RB, any disadvantages?

Evaluation of ocular surface integrity (bulbar conjunctiva) but can be used to evaluate the cornea too

Herpes keratitis, dry eyes

What is the best vital dye(s) for Tear Film Assessment?

Sodium fluorescein (NaFl)

What is the best vital dye(s) for Gas permeable fits?

Sodium fluorescein (NaFl)

What is the best vital dye(s) for Open globe?

Sodium fluorescein (NaFl)

What is the best vital dye(s) for Herpetic keratitis (dendritic)?

Lissamine green (LG)/Rose Bengal (RB) >> Sodium Fluorescein (NaFl)

What is the best vital dye(s) for Dry eyes?

Lissamine green (LG)/Rose Bengal (RB) >> Sodium Fluorescein (NaFl)

What is the light source/filter for NaFl?

Cobalt filter with Wratten filter

What is the light source/filter for LG?

White light

What is the light source/filter for RB?

White light

What is your Assessment and Plan for this?

1. Esotropia OD, Ed pt on condition. Refer to BV specialist.

What is your Assessment and Plan for this?

1. Exophoria, Ed pt on condition and associated symptoms. Monitor 12 months or sooner if symptomatic

What is your Assessment and Plan for this?

1. Exophoria, Ed pt on condition and associated symptoms. Monitor 12 months or sooner if symptomatic

What is your Assessment and Plan for this?

1. Esophoria, Ed pt on condition and associated symptoms. Monitor 12 months or sooner if symptomatic