Clinic: Troubleshooting deck [Ongoing]

Question 1

Unexpected poor vision with phoropter (cf glasses). Provide 2 alternative solutions

Answer 1

Could be mask related fogging of the lens (phoropter lens fogs very easily). Also the phoropter doesn’t simulate free space.

Potential solutions:
Switch to trial frames (ideal)
Get patient to pull mask down below nose (phoropter)

Question 2

Trial frame has only 3 slots for lenses in a high rx patient as the back slot is not working. (3)

Answer 2

Get a new trial frame
Use trial frame in drawer
Consider just taking lenses out to put new ones in (bit finicky, but could be worse)

Question 3

Where should you place the cyl in a trial frame?

Answer 3

In the front, so you can spin the axis with JCC (remember to use the JCC lens)

(also remember: handle of JCC is the cyl axis for trial frame)

Question 4

When should you place a patient’s current prescription into trial frames?

Answer 4

Best to do this before the consult has begun. For speed.

Question 5

What should you do before calling for your patient?

Answer 5

Prepare the workspace (with equipment ready to go)
Read the history and previous consults
Obtain the patient’s dispensing sheet from the front so you can hand it back to them filled out after the consult

Question 6

OCT stereo photo in MEC not taking a photo when you press the button?

Answer 6

On the bottom left of the touch screen there is a button saying which eye is being examined. Press the eye that matches with the eye you are looking at

Question 7

OCT in MEC can’t find patient file?

Answer 7

Make sure you brought the dispensing sheet with you to search via patient ID. If no file, register a new patient.

Question 8

Where in sunix should you place BV testing?

Answer 8

“Just place it in the pupils section, that’s the best section” - Christine Nguyen

There’s technically a separate tab you can open for this but nobody looks at it so pupils section it is. Don’t put anywhere else (e.g. bottom right which is associated with end of consultations)

Question 9

Very minor pupillary reflex response to light in a PRP patient

Answer 9

Because of the PRP they have less retina therefore less afferent signal to the retina resulting in less light response. It’s just a feature of the PRP mainly.

Check for asymmetry though in patients with bilateral PRP, because that could indicate a problem. But only say its asymmetrical when sure of it because these things can be hard to tell.

Question 10

What prescription should you provide a presbyopic patient performing Visual Fields for near?

Answer 10

SPE: Spherical Equivalent [SPE = sph + 1/2 cyl]

Could theoretically get away with just sphere too I believe.

Question 11

What should you do first with a patient’s current specs before any refraction? (4)

Answer 11

Ask what specs are for (eg D, N)
Ask what kind of specs (if not already known)
Ask how vision is doing in specs

PHYSICALLY CHECK AND LOOK AT SPECS TO SEE IF SINGLES/BFs/PALs.

Also do vertometry on specs if previously not gotten from the clinic you are at/Rx unknown.

Question 12

What is the estimate for near add based on age? Should you always adhere to this?

Answer 12

50yo is +1.50. Add an extra +0.50 for every 5 years.

But there is large patient variability. It’s best to judge near add based on estimated progression from prior add. And check if patient comfortable with it.

Question 13

When should you trust your RET?

Answer 13

ALWAYS. Don’t second guess self! Use my eyes and see reflex and check for reversal, working down from more positive to less to get max plus.

Question 14

What effect will cyclo have on RET?

Answer 14

Can draw out extra plus by stopping accommodation.

So look for extra plus!!

Question 15

When taking a measurement of some kind, what should I use? (1)

Answer 15

My EYES.

Question 16

Should you get patient to read a line every time you put in a lens?

Answer 16

No! Of course not. Just is it better or worse.

Only really ask to read if they say minus is better I guess and your close to best VA you’d expect for the patient. And if blur check.

Question 17

What should you look for when doing RET?

Answer 17

Reversals

Question 18

Should I tell patient: “this is up to you”? When making a mx recommendation

Answer 18

Not really, it muddies the waters when making a recommendation, suggesting there are equally valid options when there are not.

Question 19

What is a good method for checking VA post retinoscopy?

Answer 19

Blur by adding +0.50 or +0.75 or so and work way down. This ensures we didn’t over minus. And can act as a kind of blur check. — Leo.

Question 20

When should you ask a patient about driving?

Answer 20

If their habitual distance VA is 6/15 or worse

Question 21

How can you speed up trial frame retinoscopy?

Answer 21

+/- 0.50 flippers and +/-1.00 flippers can tell you a great amount

Question 22

When performing retinoscopy, from which direction should you approach?

Answer 22

Always start with more plus then necessary to ensure we don’t over minus, i.e make sure you see a definite with movement then go down to neutral.

Key point is to check for reversals (i.e with and against) then aim for the side of neutral that has more plus.

Question 23

When asking a patient if a lens is better, what’s a simple easy to understand way of asking?

Answer 23

Is this better view 1 or view 2?

Question 24

How can I instruct PD more quickly?

Answer 24

“look in to my open eye, now look into my other eye” - while moving ophthalmoscope to side of other eye

Question 25

Patient’s eyes not looking through phoropter properly (4)

Answer 25

Check bubble, ensure it’s on diverging lever, ensure PD is correct.

If all else fails, can switch to trial frame (or even just do trial frame first).

Question 26

What tool does NRC/PRC require?

Answer 26

Prism bar and prentice card diamond. Check for blur, break, recovery.

Question 27

What tool does vergence facility require?

Answer 27

Prentice diamond and prism flipper.

Question 28

What is an amazing way to perform gonio?

Answer 28

Look through the slit lamp eyepiece as you place the gonio (CTI style). Don’t need to hold lids, but get patient to look up to get eyelashes out of the way then look straight.

This method is less awkward, more comfortable for the patient, and is much easier to achieve greater centration and stability, especially since you’re already in the correct position seating wise and won’t have to awkwardly move back behind SL while keeping centration.

Question 29

What should you not miss in examining a contact lens wearer (especially hydrogel wearers)?

Answer 29

Corneal neovasc.