Eye Examination Structure Notes

Purpose of Optometric Examination

• Provide prescription (Rx).

• Detect ocular disease.

• Detect systemic disease.

• Identify binocular vision (BV) anomalies.

• Measure functional performance, including legal aspects.

• Assess suitability for specific activities like driving, flying, and certain occupations.

The Most Important Thing to Offer Patients

• Advice: Providing informed recommendations based on examination findings.

Types of Advice Given

• Obtaining optical correction: Glasses, contact lenses, etc.

• Visual hygiene: Recommendations for lighting, lid scrubs, etc.

• Seeking further opinions: Referral to other healthcare professionals like OTs, GPs, ophthalmologists, or specialist optometrists.

• Lifestyle changes: Modifying behaviour, such as pursuing or avoiding specific careers or giving up driving.

Components of the Optometric Examination

• The individual components of the optometric examination provide the necessary information for giving advice.

Information Needed to Provide Advice

• Information from the patient about their problem (from case history).

• Clinical exam results.

• Knowledge from journals and textbooks (evidence-based medicine).

Types of Eye Examinations

• Database approach (routine exam).

• Systems-based approach (map for thinking about how information in an eye exam fits together)

• Problem-based approach

• Combination approach.

Data Base Approach

• A standardized set of clinical tests performed during each exam.

• Aims to collect a "complete" set of information to address most patient problems.

• Commonly used in student consults, especially when starting out.

• Also used in research where a standard battery of information is required from each patient.

Advantages of Data Base Approach for Students

• Provides practice in performing techniques (technical competence).

• Allows students to work with less supervision.

• Facilitates the development of clinical competence: understanding test meanings, synthesizing information, and using tests to solve patient problems.

Disadvantages of Data-Base Approach

• Inefficient: Collecting information that is not relevant or useful for solving patient problems.

• Inflexible: May require additional tests, leading to extended consultation times or the need for patient to return.

• Wastes patient and practitioner time and resources.

Systems Examination

• Focuses on assessing different "systems" rather than individual tests.

• Different classifications of systems exist:

  • Visual system (Sensory system).

  • Binocular system (Motor system).

  • Refractive system.

  • Ocular health.

Visual “system” Components

• Case History

• Visual Acuity (VA)

• Colour Vision

• Visual Fields

• Contrast Sensitivity

• Disability Glare

• Stereopsis

Binocular System Components

• Case History

• Cover Test

• Motility

• Convergence tests

• Accommodation tests

• Suppression tests

• Pupil responses

• Stereopsis

Refractive System Components

• Case history

• Visual acuity

• Retinoscopy

• Autorefraction

• Subjective refraction

• Near add determination

• Keratometry

• Aberrometry

• Topography

Ocular Health Components

• Case history

• Visual Acuity

• Biomicroscopy

• Fundoscopy

• Tonometry

• Gonioscopy

• Pupil Responses

• Topography

• Optical coherence tomography (OCT)

Systems Approach

• It is a way of thinking about information, not a rigid protocol, and can be used with both database and problem-oriented approaches.

• It involves assessing systems rather than individual tests.

Problem Oriented Approach

• Based on the systems approach.

• Involves performing routine tests necessary for a competent, legal eye exam.

• Includes additional tests based on signs and symptoms.

• It is a tailored consultation.

Importance of Case History

• Critical in conjunction with routine tests:

  • Gives tentative diagnoses.

  • Tentative diagnoses guide choice of tests.

  • Test results guide choice of other tests (including further case history).

  • Cycle repeats until enough information gathered to assist problem solving.

• cycle part is very important!! => for exam

Questions to Ask

• Do I understand what the tests I am doing are measuring?

• Will they provide significant decision-making information?

• Am I using the minimum amount of procedures for maximum information?

Problems with Problem-Oriented Approach

• Centred on case-history, which can be difficult or impossible (e.g., neonates, dementia).

• Patients may not disclose all symptoms:

  • They believe symptoms (e.g., HA) are not associated with eyes.

  • They believe symptoms are normal for age.

  • They believe symptoms will make them appear stupid (e.g., spots before eyes, Charles Bonnet syndrome).

  • They believe the practitioner will ask if the symptom is important.

• Good history-taking skills/rapport are important.

• Complexity: Requires a skilled practitioner, a good knowledge base, and significant experience in primary eye care.

Combination Approach

• Involves a database approach for initial consultations and then a problem-based approach for subsequent consults.

• problem: patients don’t return for second exam.

The Routine Exam

• Procedures done on every patient.

• Efficiency: Doing things enough makes it a fluid sequence, saving time and brain power.

• Efficacy: Doing tests likely to yield information on the most likely problems patients have.

Why a Routine Exam?

• Legal standpoint (duty of care):

  • You must undertake procedures considered standard for the profession.

  • Failure to do so, resulting in an adverse outcome, could lead to civil litigation.

  • Specified by medical insurers or law.

Recording

• Essential that all test results are recorded (including case history):

  • Useful for the practitioner to review at the end of the consult for decision-making.

  • Useful for future consultations.

  • Legal issues: If not recorded, it may be assumed the test was not done.

Recording Tips

• Write it once (don’t do a rough version).

• Inefficient use of time and potential legal issues with rewriting.

• If you make a mistake, cross it out with a single stroke and write the alteration next to it.

• Don’t use white-out or blotting out.

• Use a pen and try not to swap pens during the consult.

At QUT

• You must record your findings; don’t expect your supervisor to do it.

• If you haven’t recorded your findings, we will assume you did not do the test.

  • (Write down your retinoscopy results before you do subjective refraction.)

Styles of Record Keeping

• Data base style record.

• Problem oriented record.

Data Based Style Record

• Because tests are the same for each patient, forms may look similar from patient to patient, sometimes done on pre-printed pages.

• Space for recording results of each test (including case history).

• Space for recording advice and management.

• Easy to find information on proformas.

Problem Oriented Approach Record: SOAP

• Subjective (case history).

• Objective (test results).

• Assessment (diagnosis where possible).

• Plan (management)

Recording Advice and Plan

• Legally important to document diagnoses, treatment advice, and referrals (also useful in case of later complaints).

• Ensures clinician reviews case history and discusses patient complaints.

• Ensures clinician deals with significant findings.

• Good summary for future consults (without having to read the whole record).

Diagnosis/Problem-Plan List

1. List problems in a column: most important to least important. In the next column, outline actions to be taken.

2. Diagnose where possible. Don’t list individual symptoms and signs that lead to the diagnosis.

3. If no diagnosis is made for some Sx (symptoms) or signs, include them in the list (may still be actions one can take or prompts further investigation).

In Plan

• Treatment.

• Further procedures.

• Referral.

• COUNSELLING

Example Problem Plan

• Style is very useful for students.

Management Checklist

• Useful for beginners (and others).

1. What was the patient’s presenting complaint? Have you dealt with it?

2. Will prescribing glasses/changing glasses make a significant difference for this patient? (new Rx, near/distances/Progressives, Sunglasses, photochromatics, occupational Rx.)

3. Have my tests discovered something that requires further management (e.g., disease/BV, Contact lenses)?

   • If so, am I the person to manage the problem?

   • If a referral is required, when should it be done?

4. Have my tests discovered something that requires further testing/review (e.g., glaucoma suspect)?

   • if so, am I the person to follow the problem?

5. When do I need to see this patient again?