Ocular Diagnostics Midterm

Case History purpose

establish a caring relationship with patient
-gather information about patient's chief complaint, visual function, ocular and systemic health, risk factors, and lifestyle
-begin process of differential diagnosis and patient education

what is the most important procedure of the examination?

obtaining a thorough case history

Case history components

1. Introduction
2. Chief Complaint/History of present illness
3. Past medical History and Review of Systems
4. Family History
5. Summary

when does the clinician begin diagnostic thought process?

by asking appropriate questions during case history

Chief complaint

the main reason for the patient's visit
-use open ended questions

History of preset illness (HPI)

elaborate on CC
use FOLDARQ

Background information

Ocular history, medical history, medications, family medical history, family ocular history, social history and review of systems

questions for patients who smoke

-for how long?
-how many per day?
can be used to determine whether the patient is a heavy or light smoker

commonly missed items (during case history)

-inquire about any other complaints, in addition to chief complaint
-compliance with current medication
-any other medications

4 components of history

1. Chief Complaint
2. History of Present Illness
3. Review of Systems
4. Past, Family, and Social History

several reasons for visit

list them in order of importance

case history and coding

-level of history that is involved in an office visit is one of the three criteria that determine which E&M code can be billed

finding history level

1. determine the type of HPI, ROS, and PFSH
2. Circle the appropriate HPI, ROS, and PFSH
3. Criterion that is farthest to left determine level of history

positives marked on ROS

must be accompanied by a statement of treatment plan; otherwise, they won't necessarily count
-If patient states they have asthma, you might document that she controls it with an inhaler

PFSH elements

1. Past history, which focuses on prior major illness, operations, current medications, and allergies
2. Family history should document members of the family who have disease that may be hereditary
3. Social history focuses on smoking, drinking, and drug uses, as well as employment or job duties

when does patient communication occur?

-Before
--scheduling, appointment reminders, history forms
-During
--case history, elements of the exam, pt education
-After
--post-exam education, referrals, follow-up appointment scheduling

Verbal communication

face to face, telephone, video

nonverbal communication

facial expression, body language, hand movements

written communication

email, report, chat

listening communication

active act of absorbing verbal communication
-required for effective communication

visual communication

imagery through platforms, videos, memes

patient greeting

Part of patient interaction- make eye contact, introduce yourself, speak clearly, verify patient identity

understanding patient's emotions

anxiety
-towards "1 or 2" and puff of air test
Fear
-vison loss, mental health problems, vision symptoms "floaters", and loss of independence
Financial considerations

patient education

discuss in layman's terms, check for understanding and provide additional educational resources

delivering bad news

make eye contact, be frank but understanding and empathetic, provide resources

exam flow

1. case history
2. eye health
3. refractive status
4. functional vision
5. assessment/plan/Rx/PT. ED

Eye health

-general medical observation (observe pt as a whole)
-Ocular health assessment
-Ancillary testing

Refractive Status

-Obtained by performing manifest refraction (goal is 20/20)
-Refractive errors are corrected with refractive corrections
-Some patients are not correctable to 20/20

functional vision

-assessment of the patient's accommodative system and vergence system
-an assessment of how well the eyes work together

endpoint of functional vision

clear, comfortable, binocular vision for all visual tasks

assessment and plan

the conclusion to the clinical examination
Assessment refers to the pertinent diagnoses made.
Plans refer to the decisions made for each diagnosis.

differences in exam types

depends on the reason for the visit
-Vison or medical
-comprehensive or wellness

Confrontation Visual Fields

Assessment of peripheral vision
-conducted 60-80cm in front of the patient at eye level
-patient does not wear SRx
-monocular
-bright illumination
-examiner closes eye opposite to pt

finger counting

examiner presents 1, 2, or 4 fingers approximately 20 to 30 degrees from fixation
-ensure hand is perpendicular to the patients visual axis
-be sure to present fingers halfway between examiner and patient
-do not present finger on horizontal midline

advantages of CVF

simplicity, flexibility, requires no specialized instrumentation (can be performed in any setting)

disadvantages of CVF

-can not determine the exact size of field loss (qualitative not quantitative)
-lack of standardization
-not sensitive enough to detect subtle defects

recording CVF

full to finger count
-shading in restricted areas on field
ex. OD: no defects (or full) OS: superior nasal restricted field

Amsler grid test

test to assess central vision and to assist in the diagnosis of age-related macular degeneration
-monocular
-ask pt if any squares within the grid are missing or blurred or if the lines are appear wavy or distorted
-record findings on recording sheet; patient can draw what they see

visual acuity purpose

measure the clarity of vision or the ability of the visual system to resolve detail

numerator of VA

test distance
-typically 20ft or 6 meters

a patient's VA depends on

the accuracy of the retinal focus, the integrity of the eye's neural elements, and the interpretive faculty of the brain

denominator of VA

distance at which the smallest discernable letter subtends 5 minutes of arc
-also stated: distance at which a person with 20/20 acuity would discern the same letter

when should VA be done?

the first procedure following the case history

setting up VA

-pt wears habitual correction for the distance being tested
-acuity chart shown with multiple lines
-room illumination should maximize contract on the VA chart used
-occluder to cover eye

what should the examiner observe when performing VA?

always the patient
-make sure they have eye covered properly
-not squinting

when should the examiner stop the pt during VA?

when more than half the letter son a line have been missed

what should happen when the pt can not see the largest letter on the chart?

have the pt walk toward chart until they can just make out the largest letter
-not the distance

tests for dVA (after walk-up testing)

-finger counting
-hand motion
-light projection
-light perception
-no light perception

near VA

-provide high illumination on near point card
-card at appropriate distance for which it is calibrated
16 in (40 cm) for reduced Snellen Acuity Card

types of near VA charts

-reduced snellen
-logMAR
-Tumbling E
-Reduced LEA symbols
-Cards with words or paragraphs
-Samples of newsprint, playing cards, the Bible, or musical staff notation

recording nVA

can be recorded in Snellen notation, logMAR, N units (used by printers), decimal notation or M units

what notation should be avoided for recording nVA?

Jaeger notation
-since the difference between the sizes of letters on different lines is not consistent

M units

used for assessing near visual acuity in low-vision patients and increasingly used for primary car patients
20/20 is recorded as 0.4/.4M
20/50 is 0.4/1.0M

cc

with correction

sc

without correction

cCL

visual acuity take through contact lenses

recording VA

record the Snellen fraction or print size for smallest (lowest) line in which more than half the letter were correctly identified
-record quality of pt's response

LogMAR chart

the incremental size of letter is determined according to the base 10 logarithm of the critical detail in minute of arc of the letters

LogMAR charts should be used when

a precise, quantitative assessment of VA is needed
-VA in logMAR should be used in all research studies where VA is a dependent variable

logMAR scoring

circle each letter correct and put a X through incorrect letters
-proceed until pt incorrectly identifies at least 4 of 5 letters

logMAR formula

multiply number of letter read correctly by 0.02 and subtract this product from 0.10 more than the LogMAR of the first line read
ex. pt began reading at 0.10
logMAR VA= 0.20 - (0.02 x # of letters correctly read)

expected findings for logMAR

VA of 0.0 or better (-0.01) is considered normal
-the difference between the two eyes should be no greater than 0.16

pinhole VA purpose

to determine if a decrease in vision is correctable by lenses
-taken when the VA is worse than 20/30 at both distance and near through habitual or induced correction

anterior

toward the front

posterior

toward the back

superior

toward top of the head

inferior

away from the head

nasal

toward the nose

temporal

toward the temple

inner

toward the center

outer

away from the center

fick's axes

all eye movements can be described as rotation about one or more axes, around a center of rotation
-x-axis (horizontal/transverse)
-y-axis (sagittal
-z-axis (vertical)

x-axis rotation

elevation and depression

y-axis rotation

extorsion and intorsion

z-axis rotation

adduction and abduction

vergences

moving against each other
-convergence
-divergence

versions

moving with each other
-right gaze (dextroversion)
-left gaze (levoversion)
-up gaze (supraversion)
-down gaze (infraversion)

extraocular muscles

-striated muscles
-6 per eye
-each is innervated by a cranial nerve
-each has a least one action
-most have multiple actions

lateral rectus

primary: abduction
secondary: none
Cranial Nerve 6

Medical Rectus

primary: adduction
secondary: none
Cranial Nerve 3

Superior Rectus

primary: elevation
secondary: adduction and intorsion
Cranial Nerve 3

Inferior Rectus

primary: depression
secondary: adduction and extorsion
Cranial Nerve 3

Superior Oblique

primary: intorsion
secondary: depression abduction
Cranial Nerve 4

Inferior oblique

primary: extorsion
secondary: elevation and abduction
Cranial Nerve 3

how many cranial nerves relate to the eye?

6

extraocular motilities

access the ability to perform conjugate eye movements

EOM instructions

follow the light with your eyes without moving your head. Tell me if you ever see two lights instead of one or if you feel any pain or discomfort

EOM procedure

-glasses off and transilluminator
start with light on primary gaze, move to 6 other positions in an H pattern
Observe smoothness, accuracy, fullness, and extent of movements

EOM recording

Normal:
FROM (full range of motion)
SAFE (smooth, accurate, full, extensive)
USA (unrestricted, smooth, accurate)
reported for each eye

abnormal:
describe the abnormality
and which eye
-diplopia upper right gaze
-pain OD on left gaze
-50% restriction on downgaze OD

Near point convergence

subjective and objective assessment of the ability to converge

NPC setup

habitual near correction, target 1-2 lines larger than best corrected VA of worse-seeing eye, near lamp on target

NPC instructions

follow the target and keep it clear and single. Let me know if the target ever splits into two

NPC procedure

move the target toward the patient and observe their eyes
move the target away from the patient and observe their eyes.

break

distance at which the patient reports diplopia or at which you observe one eye lose fixation

recovery

distance at which the deviated eye regains fixations or at which the patient reports regaining single vision

recording NPC

record correction, break/recovery distances and eye that deviated (leave blank if diplopia)
normal:
NPC (cc) 4cm/7cm OS out
NPC (sc) 5cm/7cm diplopic response
NPC TTN

Abnormal NPC

break/recovery worse than 5cm/7cm

Saccades

quick eye movements from one fixation point to another

pursuits

smooth eye movements that involve following or tracking a moving target

purpose of saccade and pursuits

assess the quality of refixation and smooth eye movements