DISTANCE LEARNING COURSE. Anatomy of the Patient Exam. 2008 2012, BSM Consulting All rights reserved.

DISTANCE LEARNING COURSE Anatomy of the Patient Exam 2008 2012, BSM Consulting All rights reserved.

Table of Contents OVERVIEW... 1 PRELIMINARY WORK-UP... 1 OTHER DIAGNOSTIC TESTING... 3 DIAGNOSIS... 4 TREATMENT PLAN... 5 CONCLUSION... 6 COURSE EXAMINATION... 7 2008 2012, BSM Consulting

OVERVIEW Once the check-in process has been completed, the patient is ready to begin the medical eye examination. This module will describe a basic medical eye examination, which includes the preliminary work-up, the external exam, dilation, slit lamp exam, and fundus exam. A diagnosis (or physician s medical opinion) and a treatment plan are also important components of the exam. While different practices have unique styles and requirements for the exam, the basic components are similar. Following the description of the exam components is a listing of common diagnostic testing and common diagnoses. PRELIMINARY WORK-UP The preliminary work-up is most frequently performed by ophthalmic assistants or technicians. Preliminary work-up components include: History The patient will be asked for their chief complaint, or the reason they are visiting the office. A thorough patient history is essential for the physician to make an accurate diagnosis. Obtaining the HPI (history of the present illness) includes asking such questions as: When did the problem start? How long or how often? Which eye? What is your current treatment? Included in the history are discussions of past eye problems (including previous eye or other surgical procedures performed) and a review of the patient s medical history and family medical history. The patient s current medications should be reviewed and listed in the chart, as well as any drug allergies. Most often, the patient has completed a medical history questionnaire during the check-in process, so the technician may review the information provided and ask for any necessary clarification. Visual Acuity Visual acuity is the numerical value associated with the smallest objects the patient can see on specific eye charts at a specific distance. It is the cornerstone of the medical eye exam and gives documentation of the patient s vision before any other test is performed in the office. Distance vision is usually tested using the familiar Snellen chart (Big E on the top of the chart with increasingly smaller rows of letters below), while near vision is tested by having the patient read standard paragraphs of increasingly small print at a comfortable reading distance. Measurements are usually taken both with and without glasses, one eye at a time. 20/20 is considered normal visual acuity. External Exam The external exam consists of three segments: Confrontation Visual Field (CVF): Obtains a gross measurement of the patient s peripheral vision. It is useful in the detection of damage due to a stroke, glaucoma, and some retinal detachments. ExtraOcular Motility (EOM): Measures the range of motion and the function of the six extraocular muscles. This testing helps to detect eyes that are misaligned or not working together properly. Pupil Evaluation: Evaluates pupils according to their size, shape, and reaction to light. 2008 2012, BSM Consulting 1

Lensometry (Automated or Manual) A lensometer is an instrument that is used to document the patient s current spectacle prescription. The readings identify not only the power of the lens but also the type of lens (as noted below): Single Vision Lens: Is strictly for distance or for near. Bifocal Lens: Has two different focus points, one for distance and one for near. Usually the top portion of the lens corrects distance vision while the bottom portion corrects near vision. Tri-Focal Lens: Has three different focus points one for distance, one for near, and one for intermediate distance. The intermediate lens is usually used for computer work or music. Progressive Lens: A true multi-focal lens. The distance prescription is at the top of the lens, and the power gets progressively stronger in the bottom segment. This gives the patient a wide range of focusing points. Prism: Special formatting of the optical centers of lenses to reduce double vision or imbalance in vision. The prescription of the glasses currently worn by the patient and obtained by lensometry is recorded in the chart. Refraction This portion of the examination determines the best lens correction for eyes with refractive errors. An autorefractor (a computerized instrument) estimates the refractive error of the patient by analyzing the light reflected from the eye. Using the measurements from both the autorefractor and the lensometer as a beginning point, more specific and refined measurements are made using the retinoscope and the phoropter. The final refraction is the prescription given to provide the best corrected visual acuity. Tonometry Tonometry is a measurement of intraocular pressure (IOP). The eye s ability to maintain a proper IOP allows for proper blood flow throughout the ocular structures. The aqueous (fluid) inflow and outflow determines the steady pressure within the eye. A certain pressure is necessary to give the eye its shape and stability; yet too much intraocular fluid may indicate a sight-threatening problem, such as glaucoma. Testing may be accomplished by: Applanation tonometry, which measures the force needed to flatten part of the cornea. This type of procedure requires the administration of anesthetic drop. Intraocular pressure can be measured by indenting the cornea or sclera. Since the eye has an internal pressure, any attempt to indent it will provide an equal and opposite pressure. The indentation tonometer uses this principle for measuring. Non-contact tonometry, which measures intraocular pressure by blowing a puff of compressed air at the cornea and measuring the amount of deflection produced. No anesthetic drop is needed for this procedure (indentation tonometry). Dilation Patient s eyes are dilated with the use of dilating (mydriatic) drops. These drops are most often administered by the technician and require at least 15 minutes to effect dilation. The dilation of pupils allows the physician to see more clearly the details of the back of the eye (retina). For a few hours after the eye exam, the dilation may blur a patient s vision, cause sensitivity to light, and impair near vision. For these reasons, patients who have been dilated may be given sunglasses to wear upon completion of the exam and may wish to have someone accompany them to the office to drive them home. The amount of 2008 2012, BSM Consulting 2

temporary impairment varies from person to person. Some practices provide an eye drop that reverses the effects of dilation more quickly than the natural abating process. Slit Lamp Examination This portion of the examination is most frequently performed by the physician, but portions may be done by the ophthalmic technician. The slit lamp (a biomicroscope) focuses a narrow beam of light into the eye, and through magnification and light allows the physician to examine the lids and eyelashes, the conjunctiva, the cornea, iris, lens, vitreous, and fundus. During this part of the examination, the doctor may detect such conditions as an eye infection, cataracts, damage to the cornea or retina, etc. Fundus Examination The physician examines the retina (back of the eye) to determine the appearance of the optic nerve/disc, the macula, and the periphery. Diseases identified by the appearance of the retinal structure include macular degeneration, retinal detachments, glaucoma, optic nerve disease, etc. Special instruments used to give a clearer detail of the retina include the direct and indirect ophthalmoscope and a wide variety of fundus lenses OTHER DIAGNOSTIC TESTING Previous discussions of the medical eye examination included the basic workup; however, as a result of findings from the basic workup, additional testing may be needed for the physician to make an accurate diagnosis. Listed below are additional tests that might be requested by the physician. Amsler Grid: Helps diagnose macular problems and is performed on patients with complaints of distortion, letters jumping when reading, or anyone with unexplained decrease in near vision. Patients describe the normal or abnormal appearance of gridlines on a chart. Distortions in the gridlines on the chart are recorded by the technician. Color Vision: Using a book of color vision plates or pages, this test screens for acquired and/or hereditary color visual defects. Corneal Topography: Using a computerized and digital instrument, this test maps the curvature of the cornea and is useful in diagnosing corneal diseases such as keratoconus and astigmatism. This testing is often performed for contact lens fittings and preliminary evaluations for refractive surgery such as LASIK. Binocularity (Cover Test, Worth 4 Dot): Tests binocularity (parallelism) and alignment of the eyes. Dry Eye Test: Measures the quantity of tear secretion using a special strip of paper placed under the lower lid for a specified time (often called a Schirmer test). Extended Ophthalmoscopy: Test in which the physician uses special magnification to see retinal detail. Testing includes a color drawing of the detail seen, as well as interpretation by the physician. Fluorescein Angiography: A technique for viewing the detail of the blood vessels of the retina. Fluorescein dye is injected into the patient s arm after which time-lapse photos are taken to document the appearance of the retinal blood vessels as the dye passes through. This is important in the diagnosis of retinal disorders such as diabetic retinopathy, macular edema, etc. Fundus Photography: Photographs the appearance of the optic discs, the macula, and anomalies of the retina Glare Test - Brightness Acuity Testing (B.A.T.): Determines the effects of glare on visual acuity, which is often needed to document medical necessity for cataract surgery. 2008 2012, BSM Consulting 3

Gonioscopy: A mirrored contact lens evaluation by the physician to examine the angle structures in the front portion of eye that allow for fluid outflow (primarily a screening test for glaucoma). Keratometry: Measures the curvature of a cornea. These measurements are frequently taken on patients who are being fitted for contact lenses, measured for intraocular lenses for cataract surgery, or who may have corneal problems. The results are called K readings. Nerve Fiber Analyzer (HRT, GDX): This computerized, digital instrument captures the appearance of the nerve fibers of the optic nerve. This test is useful in the diagnosis and maintenance of glaucoma. Optical Coherence Tomography (OCT): Takes transpupillary images of the retina to assist in diagnosis and treatment of retinal diseases. Pachymetry: Measures the thickness of the cornea. This is used commonly in the diagnosis of glaucoma and corneal disease. Potential Acuity Measure (PAM): Tests a patient s potential for improvement in visual acuity following cataract surgery. Stereopsis Test: Screens for normal or abnormal depth perception in both eyes. Ultrasonography (Biometry): Uses the reflection or echo of sound waves to measure the length of the eye or to detect abnormalities in the eye. Two types of tests are performed: o o A-Scan An ultrasound biometry test used to measure the length of the eye to assist in the calculation of the power of an intraocular lens to be used in cataract surgery. B-Scan An ultrasound test that provides two-dimensional reconstruction of the ocular and orbital tissues. It is also used to detect ocular tumors. Visual Field (Perimetry): Used to test and document abnormal defects in a patient s central and peripheral vision. This test is most commonly used to diagnose and monitor glaucoma and other neurological eye problems. DIAGNOSIS After completing the examination and reviewing any additional testing that has been performed, the physician makes a diagnosis of the patient s ocular condition. Descriptions of the most common ocular diagnoses follow. Age-Related Macular Degeneration (ARMD): Degeneration of the macula, resulting in loss of central and reading vision. It affects older people. Astigmatism: Irregular curvature of the cornea causing blurred vision that normally can be corrected using a cylindrical lens. Blepharitis: Infection and inflammation of the eyelid margins, usually causing scaling and crustiness of the upper and lower lid margins. Cataract: Clouding of the crystalline lens in the eye. When the cataract gets to the point that a person s declining vision interferes with their activities of daily living (i.e., they can not see to drive, to sew, to read, to see television, etc.), surgical removal of the cloudy lens may be recommended. Chalazion: Swelling in the eyelid caused by an inflammation of one of the oil producing glands in the upper and/or lower eyelid. 2008 2012, BSM Consulting 4

Conjunctivitis: Inflammation of the conjunctiva (white of the eye), often called pink eye. Corneal Abrasion: Scratched surface of the cornea. Corneal Ulcer: A potentially sight-threatening lesion on the surface of the cornea, usually caused by infection or injury. Dermatochalasis: Excessive eyelid skin that may impair a person s field of vision. Diabetic Retinopathy: A sight-threatening disease that results in the abnormal growth and leaking of retinal blood vessels due to diabetes. Dry Eye Syndrome: Dryness of the eye due to insufficient tear production causing scratchy, burning eyes. Emmetropia: Refractive condition of the eye that requires no lens correction. Floaters: Small particles or debris suspended in the vitreous, causing shadows or shapes seen by the patient. When accompanied by flashes of light and loss of vision, floaters may be symptoms of a sight-threatening problem like retinal detachment. Glaucoma: Progressive vision loss due to damage of the optic nerve, caused by higher than normal intraocular pressure. Treatment may include eye drops, laser, or surgical intervention. Hyperopia: Farsightedness. Keratitis: Inflammation of the cornea. Myopia: Nearsightedness. Presbyopia: A condition most commonly seen in people over age 40 who have lost the ability to focus at near and who need reading glasses (magnification). Pseudophakia: Diagnosis resulting from the removal of a cataract and the implantation of an intraocular lens (IOL). Pterygium: A growth of fleshy tissue on the conjunctiva that may extend onto the cornea. Ptosis: Droopy upper lid due to age, gravity, or a weak eye muscle. Retinal Detachment: Separation of the retina from the back of the eye; a potentially sightthreatening disorder. Secondary Membrane: Clouding of the membrane (lens capsule) of the lens after cataract surgery. This condition may be surgically treated with a laser. Subconjunctival Hemorrhage: Breaking of a blood vessel under the conjunctiva causing a blood red eye. TREATMENT PLAN Once the physician has reviewed the testing and made a diagnosis, a treatment plan is developed. Recommendations may include a prescription for glasses, prescription for medication, surgical intervention, referral to sub-specialists, or perhaps, no treatment. Often practices provide educational counseling and printed materials to enable patients to better understand their condition and treatment. 2008 2012, BSM Consulting 5

It is hoped the patient leaves the office feeling their concerns have been addressed and the staff and physician care about them and are competent to help them with their problem. CONCLUSION As noted earlier, different practices have unique styles and requirements for the medical eye exam; however, the basic components are similar. Having a fundamental understanding of the patient exam, common diagnostic testing, and common diagnoses will enable staff to be more effective in their interaction with patients and help ensure a positive experience and quality of care for all patients in the practice. 2008 2012, BSM Consulting 6

COURSE EXAMINATION 1. Which part of the patient examination tests for gross measurement of peripheral vision, range of motion and function of eye muscles, and evaluates the size, shape, and reaction of the pupils? a. History b. Visual Acuity c. External Exam d. Slit Lamp Examination e. Fundus Examination 2. A numerical value associated with the smallest objects a patient can see on a specific chart at a specific distance is called: a. History b. Visual Acuity c. External Exam d. Slit Lamp Examination e. Fundus Examination 3. The lids and eyelashes, the conjunctiva, the cornea, iris, lens and vitreous are evaluated during which portion of the eye exam? a. History b. Visual Acuity c. External Exam d. Slit Lamp Examination e. Fundus Examination 4. A patient will be asked for their chief complaint and symptoms of their current problem during which portion of the eye exam? a. History b. Visual Acuity c. External Exam d. Slit Lamp Examination e. Fundus Examination 5. The examination of the back of the eye is called the: a. History b. Visual Acuity c. External Exam d. Slit Lamp Examination e. Fundus Examination 6. The portion of the examination that determines the best lens correction for the patient, and may result in a prescription for glasses is called: a. Lensometry b. Refraction c. Tonometry d. Dilation 2008 2012, BSM Consulting 7

7. In order for the physician to see clearly the details of the back of the eye (retina), patients are given drops that make the pupil larger. This process is called: a. Lensometry b. Refraction c. Tonometry d. Dilation 8. The measurement documenting the patient s current spectacle prescription is called: a. Lensometry b. Refraction c. Tonometry d. Dilation 9. The measurement of intraocular pressure is called: a. Lensometry b. Refraction c. Tonometry d. Dilation Match one of the following diagnostic tests with the description of its purpose: Diagnostic Tests a. Amsler Grid b. Corneal Topography c. Dry Eye Test (Schirmers) d. Extended Ophthalmoscopy e. Fluorescein Angiography f. Gonioscopy g. Nerve Fiber Analyzer h. Pachymetry i. Potential Acuity Measure (PAM) j. Ultrasonography (biometry) k. Visual Field 10. Maps the curvature of the cornea. 11. Evaluates the angle structures in the eye that allow for fluid transfer. 12. Allows for viewing the appearance of retinal blood vessels as dye injected into the patient s arm flows through the blood vessels. 13. Tests the patient s peripheral vision. 14. Measures the quantity of tear secretion using a special paper strip. 15. Measures the thickness of the cornea. 16. Measures the length of the eye to assist in calculating the power of an intraocular lens to be used in cataract surgery. 17. Tests a patient s potential for improvement in visual acuity with cataract surgery. 18. Uses special magnification to see retinal detail and includes a color drawing of the detail and interpretation by the physician. 19. Uses a patient s description of gridlines on a chart to document distortions in near vision. 20. Captures the appearance of the fibers of the optic nerve. 2008 2012, BSM Consulting 8

Match one of the following ocular diagnoses with its description: Ocular Diagnoses a. Age-related macular degeneration (ARMD) b. Astigmatism c. Blepharitis d. Cataract e. Chalazion f. Conjunctivitis g. Diabetic Retinopathy h. Dry Eye Syndrome i. Floaters j. Glaucoma k. Hyperopia l. Myopia m. Pseudophakia n. Retinal Detachment o. Secondary Membrane 21. Inflammation of the conjunctiva, often called pink eye. 22. Progressive vision loss due to the damage of the optic nerve, causing peripheral vision loss. 23. Separation of the retina from the back of the eye. 24. Farsightedness. 25. Nearsigntedness. 26. Irregular curvature of the cornea causing blurred vision. 27. Clouding of the crystalline lens. 28. Diagnosis resulting from removal of cataract with implantation of intraocular lens. 29. Clouding of membrane of the lens after cataract surgery. 30. Inflammation of the eye lid margins. 31. Swelling in the eyelid caused by an inflammation of one of the oil producing glands. 32. Abnormal growth of retinal blood vessels due to diabetes. 33. Degeneration of the macula resulting in loss of central and reading vision. 34. Small particles or debris suspended in the vitreous causing shadows and shapes. 35. Insufficient tear production. 2008 2012, BSM Consulting 9