HANDS-ON PRACTICAL LAB

M. Patrick COLEMAN, ABOC, COT

RECOGNITION & THANKS TO:

Dr. Robert JANOT, OD

Survey to determine what we teach Soliciting (and getting!) equipment we need Most support I’ve EVER rec’d for a paraoptometric

program! Amy Goudeaux (CPOT), Shonna Daigle (CPO), & Anne

Schlicher

Volunteered to help teach & run “learning stations” High stress & No pay! Be nice to them. THANK

THEM! Dr. James D. Sandefur, OD

Spectacle frames for us to use/abuse!

RECOGNITION & THANKS TO: Chris North & Bayou Ophthalmic Instruments,

Inc. e-mail: bayouchris@msn.com

5601 Jensen Street New Orleans, LA 70123 Phone: (504) 734-9399 www.bayouophthalmic.com Provided:

SLIT LAMPS with tables & stools PUPILLOMETERS

RECOGNITION & THANKS TO: Carol Aphonse & Mid-Gulf Instruments http://midgulfinstruments.com/ 158 Kingspoint Boulevard, Slidell, LA,

70461 (800) 359-2089 or (985) 649-6336 E-mail: mgi@bellsouth.net Supplied: Three (3) Topcon LM-80 LENSOMETERS

RECOGNITION & THANKS TO: Enhanced Medical Services 1202 Hanley Industrial Ct, Brentwood, MO,

63144 Phone: (888) 781-4458 E-mail: contact@emseye.com Provided: Two (2) LENSOMETERS

INTRODUCTION & OVERVIEW The OBJECTIVE for the next 3 hours will be to review: SLIT LAMP (basic operation, checking angles, CL

assessments)

LENSOMETER (manual)

SPECTACLE FRAME ADJUSTMENTS

COVER TESTING / EXTRAOCULAR MOTILITY (EOMs)

PUPILLARY ASSESSMENTS

PD MEASUREMENT (PD ruler vs. Pupillometer)

CASE HISTORY (& HPIs)

SLIT LAMP Basic operation Checking angles CL assessments

SLIT LAMP (cont.)

BASIC OPERATION:

• Lots of PARTS!

• Best to “show” you & have you “do” it!

SLIT LAMP (cont.) GRADING ANGLES:

• Set beam @ 60 degrees; fine slit; aim at iris close to limbus so light goes through cornea.

• The ratio of the thickness of the cornea to the amount of ‘dark space’ between the back of the cornea & the iris is evaluated.

• Wide gap? Good! Open (3 or 4)

• Narrow (or no?!) gap? BAD! Narrow (1 or 0)

SLIT LAMP (cont.) GRADING ANGLES:

SLIT LAMP (cont.) GRADING ANGLES:

SLIT LAMP (cont.) ACA = Anterior Chamber Angle

ACD = Anterior Chamber Depth

Pic A =

NARROW ANGLE (lens pushing iris

forward)

Pic B =

OPEN ANGLE (lens removed &

IOL in eye)

SLIT LAMP (cont.) Evaluating CLs (soft)

• Does it center on cornea well? (or ride high, low, temporal, or nasal; does edge rub or ride on limbus?)

• Does it move? (want 0.5mm to 1mm of movement when pt blinks; no move = bad!)

• Toric SCL? Where are the ‘hash’ marks? Some have one hash, some have two hashes, some have three hashes, and one lens has a series of ‘dots’ on each side of the lens. Arggghh! Need to know lens type to know where ‘marks’ should be…

SLIT LAMP (cont.) Evaluating CLs (soft)

• Toric SCL? Where are the ‘hash’ marks? DEPENDS ON THE LENS!

• One hash? (want it at 6 o’clock)

• Two hashes? (want them @ 3 o’clock & 9 o’clock or 12 & 6 o’clock! Depends on the lens!)

• Three hashes? (want middle hash at 6 o’clock)

• And then there is the lens with four DOTS on each side of the lens (180 degrees apart) – want them at 3 o’clock and 9 o’clock

SLIT LAMP (cont.) Evaluating Toric SCLs

SLIT LAMP (cont.) Evaluating Toric SCLs

SLIT LAMP (cont.) Evaluating Toric SCLs

LENSOMETRY (manual) • Parts (Power Wheel, Lens Table, Axis Wheel, etc.)

• SPHERE, CYL, AXIS & ADD – figuring it all out!

• The key concepts?

• DIRECTION TRAVELED

&

•DISTANCE TRAVELED

( ) (cont.)

1. Focus the EYEPIECE for you! (CCW ‘til stops; then CW ‘til clear image!)

2. Check “calibration” of machine (focus SPH/CYL lines without a lens in machine; PWR WHEEL should read “O” (zero)

3. Put glasses in lensometer 1. Temples AWAY from you 2. Both lenses touching the LENS TABLE 3. Start with RIGHT LENS (OD)

4. Put PWR WHEEL at +9.00 5. Start rotating in the “minus direction”; when something starts to come

into focus, manipulate AXIS WHEEL and PWR WHEEL to bring the SPHERE LINES into focus FIRST

6. Write down number from PWR WHEEL as SPHERE power (black is

PLUS + and red is MINUS -) 7. Write down number from AXIS WHEEL as the AXIS of the Rx (NOTE: If the SPHERE & CYLINDER LINES came into focus together, at

the same time, you have a SPHERICAL lens & are done. Yea! They )

LENSOMETRY (manual) (cont.)

SPHERE lines out of focus;

Use the AXIS WHEEL & PWR WHEEL to make them

crisp, sharp, & perfect

When SPHERE lines & CYLINDER lines come into focus @ the same

time? You have a SPHERICAL LENS!

( ) (cont.)

SPHERE LINES

(skinny; close together)

CYLINDER LINES (fat; far apart)

LENSOMETRY (manual) (cont.) 8. Continue by rotating the PWR WHEEL in the

MINUS direction until you see the CYLINDER LINES come into focus

9. Now it is “math” time. Your CYLINDER POWER is how far you traveled from your SPHERE PWR to your CYLINDER PWR. Your CYLINDER “SIGN” is based on the direction traveled (in this case, you were going in the MINUS direction, so your CYL will be a minus power.)

10. Let’s say the SPHERE lines came into focus @ BLACK 3.00 (+3.00). Your CYLINDER lines came into focus @ BLACK 2.00. You traveled in the MINUS direction & you went one (1) diopter.

Your CYLINDER POWER will be -1.00

LENSOMETRY (manual) (cont.) What s the RX?

LENSOMETRY (manual) (cont.) BIFOCAL “ADD” Power? Put PWR WHEEL back on your DIST SPHERE

POWER number Slide lens up so you are measuring thru the NEAR

SEGMENT Rotate the PWR WHEEL in the plus (+) direction (ADD

PWR is always PLUS!) until the SPHERE lines come into focus. (Do NOT touch the AXIS WHEEL!!!)

Now it is “math time” – Direction & Distance TRAVELED?

EXAMPLE: Distant SPHERE LINES were in focus at red 3.00 Near SPHERE LINES came into focus at red 1.00 You traveled in the PLUS DIRECTION and… you went two (2) diopters: ADD PWR is: +2.00!

LENSOMETRY (manual) (cont.) What’s the RX?

SPECTACLE FRAME ADJUSTMENTS

FOUR POINT BALANCE – It’s where you BEGIN, not where you END UP!

Check alignment of Frame Front first! (if twisted EVERYTHING ELSE is messed up…)

Temples next Move in the direction of the problem! BRACING IS KEY Desire: 5 to 7 degrees PANTOSCOPIC tilt

Nose Pads? Spread apart to lower glasses Move closer together to raise glasses

SPECTACLE FRAME ADJUSTMENTS (cont.)

Start with 4 point ‘balance’ Now put on Patient Adjust specs to fit THAT PERSON When you are done, probably WON’T have 4

point balance! That’s okay. Do they fit the patient? GOOD!

SPECTACLE FRAME ADJUSTMENTS (cont.)

Move TEMPLE in direction of the problem R. lens sits HIGHER than L. lens?

Move the R temple UP! (or L temple DOWN) L. lens is CLOSER to eye than R. lens?

Move L temple IN more, closer to head! (or R temple OUT more) ------------------------------------------------------------------------ Move NOSE PADS to adjust height on face

Moving nose pads CLOSER TOGETHER (toward each other) will RAISE the glasses on Pt’s face

Moving nose pads FARTHER APART (away from each other) will LOWER the glasses on Pt’s face

NOTE: Doing this affects SEG HT position! Be AWARE.

PERFORM SKILLS!

COVER TESTING & EOMs

Two different tests here: COVER TESTING tells you if the patient is

ORTHO Heterophoric Heterotropic TWO PARTS to the TEST! “ALTERNATING” &

“COVER/UNCOVER”

Ocular Motility (EOMs) tell you if the six extraocular muscles are:

NORMAL UNDERACTIVE OVERACTIVE

COVER TESTING (cont.) COVER TESTING has ‘two’ parts: 1) ALTERNATING test 2) COVER/UNCOVER test 3) Do them in this order! (Please?) 4) Done at DISTANCE then NEAR 5) Pt wears the “correct” Rx for test distance --------------------- ALTERNATING tells you DIRECTION of DEVIATION

(if any) ESO, EXO, HYPER/HYPO No movement? Pt is ORTHO! Yea! (Don’t have to do

COVER/UNCOVER test )

COVER TESTING (cont.) COVER/UNCOVER test Only done if MOVEMENT during the ALTERNATING

test! Observe LEFT EYE as you COVER RIGHT EYE

Did it move? (Yes = TROPIA; No = PHORIA) Repeat for other side… Observe RIGHT EYE as you COVER LEFT EYE

Did it move? (Yes = TROPIA; No = PHORIA) ---------------------------------------------------------------------- UNCOVER only matters if you saw MOVEMENT when

you COVERED! (i.e., had a TROPIA) Do you see movement AGAIN when you UNCOVER?

UNILATERAL TROPIA! No movement when you UNCOVER?

ALTERNATING TROPIA!

COVER TESTING (cont.)

WHAT DOES THIS CHILD HAVE?

COVER TESTING (cont.)

• PHORIAS are a “latent”, or hidden condition

• Can’t just “see” a PHORIA

• Can only detect it with testing

• TROPIAS are a “manifest”, or obvious condition

• Sometimes you can just look at a person & see TROPIA!

• If not easily “seen”, it is easily detected when tested

OCULAR MOTILITY (EOMs) Muscle-H Test Checks “ocular motility” controlled by six (6)

EOMs attached to each eye When you are “done” you will have checked

all 12 muscles! (EOMs for both eyes) Patient follows your penlight 14” to 16” away is ‘best’ Move light in a “H” pattern, pulling the eyes in

the 6 “CARDINAL” positions Observe the eyes

Do they track together? Do they go the “same amount” in the “same direction”? This is also considered ‘checking pursuit’ movement

OCULAR MOTILITY (EOMs) (cont.)

Six (6) ExtraOcular Muscles (EOMs) for each eye: Four (4) RECTUS muscles

Pull the eye the direction they “say”; EASY! Superior RECTUS (SR) pulls eye superiorly (up) Inferior RECTUS (IR) pulls eye inferiorly (down) Lateral RECTUS (LR) pulls eye laterally

(temporally) Medial RECTUS (MR) pulls eye medially (nasally)

------------------------------------------------------- Two (2) OBLIQUE muscles

Obliques are “unique”; work the OPPOSITE of name! Superior OBLIQUE (SO) pulls eye inferiorly (&

across nose) Inferior OBLIQUE (IO) pulls eye superiorly (&

OCULAR MOTILITY (EOMs) (cont.)

RECTUS MUSCLES

OBLIQUE MUSCLES

OCULAR MOTILITY (EOMs) (cont.)

(cont.)

PUPILLARY ASSESSMENT Follow the PERRLA format & you’ll do great! PER = Pupils EQUAL & ROUND? RL = Pupils REACT TO LIGHT?

Direct Consensual

A = Accommodate? (i.e., pupils get SMALLER when focusing on a NEAR object)

But what about MARCUS GUNN (MG)? Also called APD for “afferent pupillary defect”

(APD) or… The “Swinging Flashlight Test”

PUPILLARY ASSESSMENT (cont.) Check for “equal & round” FIRST! (put the penlight down!) Perform direct & consensual response to light (“reacts to

light”) DIRECT – shine in OD & observe OD; repeat for OS INDIRECT – shine in OD but observe OS; repeat for other

side Evaluate “accommodative” response (pupils constrict @

near) Hold a pen tip 6” in front of Pt’s eyes (yes, that’s close!) Have the patient look at the 20/200 “E” Then have Pt look @ the pen tip; PUPILS should

CONSTRICT when attempting to focus on the near object! That’s all that matters. (Don’t care if blurry or double!)

At this point, you’ve covered P E R R L A ! Not done… Check for an Afferent Pupillary Defect (APD), also called the

“Marcus Gunn” (MG) test, or the Swinging Flashlight test

PUPILLARY ASSESSMENT (cont.)

WHAT DO YOU THINK ABOUT THESE PUPILS?

PUPILLARY ASSESSMENT (cont.)

PUPILLARY ASSESSMENT (cont.)

PUPILLARY ASSESSMENT (cont.)

PUPILLARY ASSESSMENT (cont.)

PD MEASUREMENT PD or Pupillary Distance (often referred to as IPD, for “inter-pupillary distance) is CRITICAL for an optical department to know & do correctly!

GOAL is for the Optical Centers (OCs) of glasses ordered to MATCH the Patient’s PD

Two ways to measure PD: PD Ruler (millimeter ruler)

Gives you a BINOCULAR measurement (GOOD!)

Pupillometer Gives you a BINOCULAR ‘total’ and a

MONOCULAR measurement for each eye (BETTER!)

PD MEASUREMENT (cont.) In THEORY, you are measuring from the

center of one pupil to the center of the other, as shown in the picture…

PD MEASUREMENT (cont.) In REALITY, you will measure from OD

temporal limbus to the OS nasal limbus! Why? Much easier to SEE & MEASURE!

(meaning “more accurate”)

PD MEASUREMENT (cont.) Instruct Pt “Look at my LEFT eye” (it will be the

ONLY eye you have open!) Line up the ZERO mark with Pt’s R. Lateral

Limbus

PD MEASUREMENT (cont.) With Pt still looking at your LEFT eye (the only one

you have open), you look over at the Pt’s LEFT eye & get the NEAR PD reading from their Left Nasal Limbus

In this case, their NEAR PD would be 62mm

PD MEASUREMENT (cont.) Now have the Pt look at your RIGHT EYE (you will

close your LEFT eye and OPEN your RIGHT EYE.) You will look at the Pt’s LEFT eye (again) & get the

DIST PD reading from their Left Nasal Limbus

In this case, their DISTANT PD would be 65mm

PD MEASUREMENT (cont.) PUPILLOMETER Can set to measure

DIST or NEAR Pt looks @ object in

unit Optician slides tabs to

put “lines” through Pt’s pupils

Read-out shows you the PD!

EASY…LOVE IT!

PERFORM SKILLS!

CASE HISTORY & HPI Evaluation & Management (E/M) Codes: All levels have same four basic history-taking

components in common: Chief Complaint (CC) History of Present Illness (HPI) Review of Systems (ROS) and Past, Family and/or Social History (PFSH)

CASE HISTORY & HPI: Chief Complaint (CC) CHIEF COMPLAINT dictates the exam process!

(Reimbursement intimately linked to the chief complaint.)

CC: should detail primary reason(s) patient scheduled an examination

At times, should be in the patient's own words (put in “QUOTES” to show it is verbatim from Pt)

The chief complaint also suggests what tests you'll need to perform (saves time; impresses the doctor; gets Pt care they need & deserve)

CASE HISTORY & HPI (Chief Complaint, cont.)

"I'm just here for checkup" or, "I want new glasses" These two responses would disqualify

reimbursement by some payers (e.g. Medicare) How OLD is Pt? What is PRIMARY insurance?

Pts returning for eval of chronic conditions such as Glaucoma or AMD can be reason enough for visit (even in absence of specific pt complaint)

If pt complains of blurred or decreased VA, get a specific “lifestyle” issue it is negatively impacting!

CASE HISTORY & HPI (HPI) History of Present Illness (HPI) Try to elicit @ least four HPI bullets (or status of

three or more chronic or inactive conditions) Signs & symptoms (decreased VA, pain, tearing,

discharge, redness, FB sensation, etc.) Context (while driving, after take pills, when CLs

in) Duration (date of onset; duration of problem) Location (R. eye, L. eye, lid, behind eye, etc.) Quality (blurry, double vision, etc.) Modifying Factors (Art tears help, bright light

aggravates, blinking makes it better, etc.) Severity (degree of pain or loss of sight)

Timing (a m p m upon waking at end of day

CASE HISTORY & HPI (HPI, cont.) Example of an HPI:

Mrs. Braxton gives this CC (HPI), w/your help! “My right eye is red” “It began 3 days ago” “It doesn’t hurt” “Lids stick together in the morning last two

days” “Art Tears soothe it, but redness remains”

You did GREAT! You got more than FOUR of the HPI elements & info the doc can use to help Pt

CASE HISTORY & HPI (ROS & PFSH) Review of Systems (ROS) Most time-consuming! Most offices use pre-printed forms that can be filled out

by patients online or at home before exam. Go here for lots more info on this!

http://emuniversity.com/ReviewofSystems.html A review of 10 or more systems will qualify any E/M

code Past, Family and/or Social History (PFSH)

Past History of Pt (illnesses, injuries, surgeries, other treatments)

Family History (most interested in diseases which may be hereditary and/or place the patient at risk)

Social History (review of past & current activities like smoking drinking drugs)