SOAP Exam, Preliminary Testing & Visual Acuity

Flashcards covering optometric SOAP exam documentation, preliminary screening tests, visual acuity measurement techniques, chart types, calculations, and clinical rules.

What does the acronym SOAP stand for in optometry?

Subjective, Objective, Assessment, and Plan.

What components are included in the Subjective (S) section of a SOAP record?

• The patient's observations

• Presenting chief complaint(s) and symptoms (frequency, location, onset, association, duration, and severity)

• Ocular history

• Medical history

• Family ocular

• Medical history

• Social history

What components are included in the Objective (O) section of a SOAP record?

The clinician's observations and test results, including vision, refraction, visual acuity, muscle balance, pupils, motility, confrontation fields/gross perimetry, external eye exam, internal eye exam, and supplementary tests (such as Amsler grid, color vision, visual fields, tonometry, and Watzke-Allen).

What does the Assessment (A) section in a SOAP record represent?

• The clinician's understanding of the problem

• Severity

• Change or stability

• Summarizing the diagnosis and its status based on subjective and objective findings.

Into what three basic parts can the Assessment (A) be categorized for a comprehensive ocular exam?

1. Refractive

2. Functional (binocular/accommodative)

3. Health

How should diagnoses be prioritized in the Assessment (A) section?

The primary diagnosis is based on the chief complaint or reason for visit (though diabetes may take priority), followed by subsequent diagnoses listed in order of clinical significance (e.g., retinal hemorrhage takes precedence over myopia).

What rule governs the diagnosis terminology used in the Assessment section?

Terminology must match ICD-10 codes exactly (e.g., using 'Myopia' instead of 'near-sightedness', or 'Hyperopia' instead of 'far-sightedness').

What elements must be detailed in the Plan (P) section of a SOAP record?

• Clinician goals

• Actions

• Advice

• Chosen interventions with rationale, referrals, additional tests or procedures

• Patient education

• Return visit schedule

How must the structure of the Plan (P) section relate to the Assessment (A) section?

The Plan items must address every diagnosis and follow the exact same order as listed in the Assessment.

What are the typical return to clinic (RTC) intervals for cataracts affecting visual acuity versus a posterior vitreous detachment (PVD) with symptoms?

6 months for cataracts affecting visual acuity; 1 month for PVDs with symptoms.

What is preliminary testing in an optometric examination?

A series of 8 to 12 screening procedures (also called 'prelims' or 'entrance tests') performed directly after history taking that have a low cost-to-benefit ratio and do not depend on sophisticated equipment.

What are the main objectives of preliminary testing?

To quickly assess health, vision, and functional vision; establish a baseline database for future comparison; and direct the remainder of the examination to specific problem areas.

Why are preliminary tests considered non-diagnostic?

They are screening procedures in nature, meaning any abnormal findings require a secondary or confirmatory test for confirmation.

What is the target timeframe and measurement precision required for preliminary tests?

Preliminary testing should take less than 15 minutes, and findings are estimates recorded to reasonable rounding (e.g., recording Near Point of Convergence to the nearest centimeter).

How can improper examination room lighting affect preliminary test results?

• Dim lighting worsens visual acuity due to enlarged pupil size

• Incandescent lighting allows color-deficient patients to incorrectly pass

• Improper lighting degrades stereopsis performance;

• Excessively bright room lighting prevents the examiner from detecting pupillary responses.

What do the Latin abbreviations 'cc', 'sc', 'OD', 'OS', and 'OU' stand for in visual acuity testing?

'cc' = cum correctione (with correction);

'sc' = sine correctione (without correction);

'OD' = oculus dexter (right eye);

'OS' = oculus sinister (left eye);

'OU' = oculus uterque (both eyes).

What are the standard testing distances for measuring distance and near visual acuity?

• Distance visual acuity is measured at 20 feet ($\approx 6\,\text{m}$)

• Near visual acuity is measured at $40\,\text{cm}$ ($16\,\text{in.}$).

What visual angle rule forms the basis of the Snellen chart?

A letter subtends 5 minutes of arc at the eye at the specified test distance (e.g., a 20/20 letter subtends 5 minutes of arc at 20 feet).

In a visual acuity ratio such as 20/40, what do the numerator and denominator represent?

• Numerator represents the test distance.

• Denominator represents the distance at which a normal eye can resolve that letter size.

If a patient correctly reads a calibrated 20/40 line at a test distance of 10 feet, how should the visual acuity be recorded?

10/40

How does a 10-foot exam lane with a mirror setup achieve an effective 20-foot optical distance?

The patient views a mirror located 10 feet away that reflects a chart on the back wall 10 feet behind them, creating a total optical path length of 20 feet.

What are the key structural features and advantages of a LogMAR acuity chart?

An equal number of letters per line (usually 5), regular line and letter spacing, uniform progression in letter size, and finer grading for improved accuracy and test/retest reliability.

When testing with a LogMAR chart, when should the examiner stop the patient?

When the patient incorrectly identifies at least four out of the five letters on a single line.

Which visual acuity charts are designed for pediatric or nonverbal patients?

• HOTV Chart

• Number Charts

• Tumbling 'E' Charts

• Tumbling Hand

• Landolt 'C' Charts

• LEA Symbols

For what target patient age group is the Tumbling 'E' chart recommended?

Children aged 3 to 6 years, as well as nonverbal patients.

How is near visual acuity in 'M' units defined?

A $1.0\text{M}$ letter subtends an angle of 5 minutes of arc at a test distance of 1 meter.

What is the equivalent Snellen visual acuity for reading 1.0M print at a test distance of 40 cm?

$\frac{0.4\,\text{m}}{1.0\text{M}} = \frac{20}{x} \implies x = 50$, which corresponds to a Snellen acuity of 20/50.

What is the Snellen equivalent visual acuity for a patient who reads 2M print at a distance of 50 cm ($0.50\,\text{m}$)?

$\frac{0.50\,\text{m}}{2\text{M}} = \frac{20}{x} \implies 0.25 = \frac{20}{x} \implies x = 80$, giving a Snellen equivalent of 20/80.

When is pinhole visual acuity tested, and what does it demonstrate?

It is indicated when visual acuity is 20/40 or worse. By increasing the depth of focus, vision improves if reduced acuity is caused by refractive error

Lack of improvement (PHNI) suggests an underlying pathological condition.

What is the standard order of eye testing during visual acuity measurement?

Right eye (OD) first, left eye (OS) second, and both eyes (OU) together last.

What is the correct hierarchy of vision testing methods when visual acuity is worse than 20/400?

Counting Fingers (CF) $\rightarrow$ Hand Motion (HM) $\rightarrow$ Light Projection (LProj) / Light Perception (LP) $\rightarrow$ No Light Perception (NLP).

What criteria define legal blindness in the United States?

Inability to read any letters on the 20/100 line in the better-seeing eye with best correction, or a visual field diameter of $\le 20^\circ$ at its widest point.

How is visual acuity recorded according to the Half Line Rule?

1. If $\ge 50\%$ of letters on a line are read correctly (e.g., 3/5), record that line minus missed letters (e.g., 20/20-2).

2. If $< 50\%$ are correct (e.g., 2/5), record the previous line plus correct letters read (e.g., 20/25+2).

What is the Quarter Rule for predicting visual acuity loss in uncorrected myopia?

An uncorrected myope loses approximately 1 line of distance visual acuity per $0.25\,\text{D}$ of uncorrected refractive error.

What is the Cylinder Rule for predicting visual acuity loss in uncorrected astigmatism?

An uncorrected astigmatic patient generally loses 1 line of visual acuity per $1.00\,\text{DC}$ of astigmatism.