I Cannot Get My Patient To 20/20

Question 1

Step 1: Modify refraction technique.

Answer 1

• be confident
• try +/-0.50D and modify question you are asking
• encourage pt to guess
• move on!

Question 2

Step 2: Use pinhole
Which one would you use for an elderly patient?

What does pinhole acuity tell you?

Clinical pearls

Answer 2

• pinhole tells you if you got the pt’s BVA; if not, your refraction is wrong; refractive vs organic problem
• irregular corneas w/ irregular astigmatism where you can get 20/20 pinhole acuity but not 20/20 refraction -> these pts will have scissoring w/ ret and distorted mires on keratometry
• ret to eval clarity and regularity of ocular media — just as important as subjective refraction

Question 3

Limitations of pinhole test

Answer 3

• poor fine motor skills (old people)
• moderate cataracts
• can only “correct” ~3D of RE - ***important to keep in mind when checking pinhole on APHAKE - use +10.00D lens to compensate + PH

Question 4

Step 3: If NIPH

What do you do?

Answer 4

quick SLE — front to back:

• corneal defects? (Mild/Moderate SPK, central SPK, corneal scars)
• lens defects? (Opacities in visual axis; ***Mild NS alone DOES NOT cause significant decr in VA)
• retinal defects? — Do your best to obtain undilated view of nerve and macula. Look for signs of DR involving macula (exudates, hemes) in diabetics who have never had an eye exam.

*** DO NOT PUT ANY DROP IN EYE UNTIL YOU SPEAK TO YOUR PRECEPTOR!

Question 5

Step 4: Obtain RE info from other sources.

What are these sources?

Answer 5

• Autorefractor
• Have attending check your ret

***Note distorted mires during AR (irregular astig)

Question 6

Step 5: Present all of this info to attending.

You can always bring the pt back for another refraction. True or false?

Answer 6

True - Checking the fundus (req dilation) for anything that may require prompt referral is the PRIORITY!

Question 7

Golden rule of good optometric care

Answer 7

If the pt cannot see 20/20, your job is to DIAGNOSE the cause or INITIATE the necessary steps to diagnose the cause.

Question 8

Helpful tests for assessing the posterior visual pathway

Answer 8

• pupil testing
• HRR color vision OD, OS
• VF
• electrodiagnostic testing: VEP, ERG
• blood testing, imaging (not as readily available)

Question 9

Things to AVOID

Answer 9

• Do not blame decreased vision on mild cataracts not affecting visual axis.
• Do not diagnose amblyopia when there is no amblyogenic factor.
• Do not forget to ask pertinent history.
• Do not forget to document pertinent negatives.
• Do not forget to state that you intend to f/u if cause remains unknown.
• Do not be afraid to refer pt out when you are out of ideas.

Question 10

Pt w/ 20/20 acuity but keeps complaining that it is blurry…
What’s going on?

Answer 10

Look for other causes of mild decreased vision: Start w/ the common causes.

- Signs of dry eye or unstable tear film:
— excessive blinking
— reduced tear meniscus
— corneal staining
— oily tear film

• small, not so opaque central media opacity: lens vacuole or floater in macula
• ** DO NOT EVER BLAME DECREASED VA SOLELY ON NS if you are able to see the macula clearly w/ good lighting and careful focus.
• If no common cause found, do VF/OCT.