1. Disinfect gonioprism retrospectively 1. Clean via soap (surfactant) 2. Saline rinse 3. 1:10 bleach soak > 5min 4. Saline rinse > 1min 5. Air dry, disposable cloth 2. Alcohol swab gonio prior to examination 3. Prepare slit lamp 1. Disinfect (alcohol) 2. Focus eyepiece (calibration bar) 3. Set PDs 4. low mag (10x) 5. 2mm wide, 4mm high 6. beam luminance straight on 7. decrease room and beam luminance

1. Position Px 1. Lower chin rest > lower than canthus 2. Instill NaFl 3. Assess cornea on down/up gaze 1. note abrasions 2. Otherwise NAD

1. Anesthetic drop 1. Advise not to rub eyes for 30 minutes 2. Fill 2/3 lens with coupling solution "poly-gel" 1. "This solution removes bubbles, it might run down your cheek" 3. Position gonio 1. Thumb-shaped mirror at 12' 2. Held between thumb and index 4. "look down please" 1. Pull superior lid w/left thumb 5. "Look up please" 1. Retract lower lid w/right middle finger 6. Position gonio on lower lid 7. "Look straight ahead please" 1. Pivot prism until lens in contact with globe 2. Bubble formation requires reset 8. release lids while holding lens in place 2. pressure on cornea slightly (avoid visible wrinkles)

- Instruct Purpose of exam - Hand hygiene - Instruct throughout exam - Set up slit lamp width/height/intensity/mag - Determine BVS over-refraction - VA each eye also beforehand - assess/narrate centration and coverage of CL - assess/narrate movement of CL - Push up test - Assess/narrate rotation of CL - Explain how to correct for lens rotation - Record CL prescription in standard terminology - BC - TD - BVP (-ve cyl form) - State if the CL is good fit - note next trial soft CL to consider - Name, BC, TD, BVP

- comfortable - Centered (no difference between quadrants) - 0.2-0.5 mm on blink - Full coverage on all gazes - regular edge alignment w/conj. - stable vision

OSCE 2 Flashcards by Dyllan Nye

Gonio OSCE procedure:

Instruct purpose and obtain consent
Hand hygiene and equipment disinfection
Slit lamp set-up
- beam width/height
- Light intensity
- Magnification
Check corneal integrity
Instill anesthetic drop
- Time, name, conc, dosage
Safely inset gonio
Clear view of 4 angles
Describe structures
remove gonio safely
check corneal integrity
record findings in correct orientation

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Gonio Px Explanation:

This test will assess the hidden angle on the front of your eye
I’ll need to place a contact lens on you
I’ll drop an anesthetic in your eye to numb your cornea
- Are you pregnant, breast-feeding, or allergic to anything
- Do not rub your eyes for 30 minutes to avoid scratches
Do you consent to this test being performed

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Gonio preparation:

Disinfect gonioprism retrospectively
1. Clean via soap (surfactant)
2. Saline rinse
3. 1:10 bleach soak > 5min
4. Saline rinse > 1min
5. Air dry, disposable cloth
Alcohol swab gonio prior to examination
Prepare slit lamp
1. Disinfect (alcohol)
2. Focus eyepiece (calibration bar)
3. Set PDs
4. low mag (10x)
5. 2mm wide, 4mm high
6. beam luminance straight on
7. decrease room and beam luminance

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Gonio corneal check:

Position Px
1. Lower chin rest > lower than canthus
Instill NaFl
Assess cornea on down/up gaze
1. note abrasions
2. Otherwise NAD

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Gonio insertion:

Anesthetic drop
1. Advise not to rub eyes for 30 minutes
Fill 2/3 lens with coupling solution “poly-gel”
1. “This solution removes bubbles, it might run down your cheek”
Position gonio
1. Thumb-shaped mirror at 12’
2. Held between thumb and index
“look down please”
1. Pull superior lid w/left thumb
“Look up please”
1. Retract lower lid w/right middle finger
Position gonio on lower lid
“Look straight ahead please”
1. Pivot prism until lens in contact with globe
2. Bubble formation requires reset
release lids while holding lens in place
1. pressure on cornea slightly (avoid visible wrinkles)

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Gonio assessment procedure:

Vertical parallelepiped 2/4mm
1. lower brightness reduces pupillary action
Sweep pupil > iris
1. Note elevations/abnormalities
Sweep angle; note seen structures
1. Schwalbe’s line
2. Trabecular meshwork
  1. Ant. is clear
  2. Pos. is pigmented
3. Scleral spur
4. Ciliary body band
5. Iris processes
Tilt lens towards thumb mirror to see more
Rotate lens 90’
1. both hands to spin lens
2. Rotate illumination perpendicular to mirror
Repeat assessment for all 4 angles
Remove lens
1. Rock lens back and forth
Examine corneal integrity

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Gonio recording:

In each X quadrant
- Record most posterior structure
- CBB
- SS
- TM
- SL
- Record NAD/other abnormalities
- Record pigmentation of TM 0-4(dark)
- normally 2

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CL fitting procedure:

BVS over-refraction
1. Push/Pull method
2. +1 blur check
Coverage
1. 1mm beam at limbus
2. CL should extend 1mm over limbus
Centration
1. 1mm beam at 4 quadrants
2. CL should have same coverage
Movement on primary
1. direct focal illumination, wide beam
2. “please perform a natural blink”
3. measure motion from inferior CL
Movement on up-gaze
1. “look up 30’ then blink”
2. Measure motion from inferior CL
Lens lag on lateral gaze
1. measure coverage on temporal side
2. ‘look nasally’
3. measure change in coverage
4. Measure coverage on nasal side
5. “Look temporally”
6. Measure change in coverage
Movement on push-up
1. push on inf. lid and release
2. note resistance to motion and speed of recovery
3. Grade 0-100% tightness
Rotation
1. note in degrees anti-/clockwise from inferior position
Surface and edge quality
1. Diffuse focal illumination, wide beam
2. assess alignment of lens with peripheral cornea
3. note crimping of conj. BVs or edge standoff
4. otherwise NAD

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Corneal wedge structures Ant > Pos

Schwalbe’s line
1. Anterior opaque line
2. point where the 2 reflections meet
3. Junction between posterior cornea (decemet’s) and trabeculum
4. Can’t be visualized usually
Trabecular meshwork
1. Ant. is pale (next to Schwalbe’s line)
2. Pos. is u/pigmented (heavy w/pigmentary dispersion syndrome)
3. Schlemm’s canal in TM can only be seen if filled with blood
Scleral spur
1. Narrow dense shiny band
2. pos. to TM, most ant. part of sclera
3. Visibility indicates open angle (wont close)
4. consistant across different eye colours
Ciliary body band
1. Brown/Grey/Pink band
2. narrower in hyperopic eyes /Vice versa
3. Iris processes may partially cover
Iris processes

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Van Herick assessment:

Illumination straight on
observation 60’ from illumination
Narrow beam at edge of limbus
Note ratio of Shadow:Beam
- Grade 4 “Wide” 1:1
- Grade 3 “Open” 0.5:1
- Grade 2 “Narrow” 0.25:1
- Grade 1 “Closed” <0.25:1

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OSCE CL rubric:

Instruct Purpose of exam
Hand hygiene
Instruct throughout exam
Set up slit lamp width/height/intensity/mag
Determine BVS over-refraction
- VA each eye also beforehand
assess/narrate centration and coverage of CL
assess/narrate movement of CL
- Push up test
Assess/narrate rotation of CL
- Explain how to correct for lens rotation
Record CL prescription in standard terminology
- BC
- TD
- BVP (-ve cyl form)
State if the CL is good fit
- note next trial soft CL to consider
- Name, BC, TD, BVP

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Ideally fitting CL:

comfortable
Centered (no difference between quadrants)
0.2-0.5 mm on blink
Full coverage on all gazes
regular edge alignment w/conj.
stable vision

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Assessment of loose fitting lens:

Uncomfortable
VA worsens post-blink
Poor centration: displaced inferiorly
Edge alignment: bucklink/folding
Motion on blink: >0.5mm
Push-up: easy motion w/erratic recovery

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CL orderings:

Tighter lens:
Easyvision Umere Toric
BC 8.6
TD 14.3
BVP as Px script
Looser lens:
EasyVision Linarial Toric
BC 8.6
TD 14.5
BVP as Px script

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Assessment of tight fitting lens:

Comfortable
VA improves on blink
Full coverage: little sag
Edge alignment: limbal nipping > hyperemia
Motion on blink: none
Push-up: resistant motion w/slow recovery

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Colour vision rubric:

instruct purpose of test
appropriate procedures to protect integrity of test
HRR test:
1. Set up plates correctly
2. correct illumination, observation distance
3. Clear instructions
4. Recording correct notation
L’Anthony’s Desaturated D-15:
1. Set up test correctly
2. correct illumination, observation disance
3. Clear instructions
4. Plot results correctly w/correct notation
Correctly interperate results of test provided

HRR test principles:

24 plates showing 1 or 2 symbols
Px to name shape and location
4 initial demo plates
- seen by all observers
- one with nothing
6 screening plates
- 4 protan-deutan CVDs
- 2 tritan CVDs
14 plates grade severity
- 10 deutan
- 4 tritan

HRR interpretation:

Probable CVD 2 errors on screening plates
Definite CVD 3 or more errors on screening
Severity:
- Mild: errors on first 5 classification plate
- Moderate: errors on next 3 classification
- Strong: Errors on last two classification

HRR explanation:

I am going to show you some coloured symbols
without touching them, how many are there, what they are, and where they are

HRR administration

75cm from Px
- Show 4 demo plates while explaining
- show screening plates while recording
- If plates 5-6 are not checked: BY color defect
- show plates 21-24
- If any plates 7-10 are not checked: RG colour defect
- Show plates 11-20
- If plates are not checked in either category show all the plates

L’Anthony’s Desaturated D-15 administration:

15 caps in colour sequence
Illumination of > 270Lux
- Approx. daylight
View from 50 cm
2 minute timer (Roughly)
caps randomised
Px to arrange caps based on similarity to pilot cap

L’Anthony’s Desaturated D-15 interpretation:

Minor errors: reversal of adjacent caps
Major errors: distant caps placed adjacent
Faliure requires 2 major errors

BIO OSCE rubric:

Instruct purpose, Px orders, obtain consent
Adjust BIO for optimal viewing
Maintain appropriate lens vertex distance in all gazes
Maintain appropriate lens tile in all quadrants
Maintain level/position while scanning
Troubleshoot poor view
Systematic view of peripheral, mid-periphery, central retina
Obtain stable/clear view in all regions
Comprehensively scan the retina in all regions
1. view anatomical landmarks
2. Vortex veins
3. Short/Long ciliary nerves
Record retinal lesion described by examiner on recording sheet

BIO explanation:

This test will examine the health of the inside of your eye using a light from my head-band and a lens
do you consent to this test
I’ll lower and recline your chair and position you as if you were at the dentist
Please look at the ceiling (straight ahead)
Let me know if the light is too bright
Blink as you need, just try to keep your eyes wide
Change your gaze, i’ll hold your eyelid when you look down
1. up-right
2. up
3. up-left
4. left
5. down-left
6. down
7. down-right
8. right
Change your gaze
1. Up
2. Left
3. Down
4. Right
Please look at my ear
- the ear in-line with the eye not being observed

BIO set up:

- Wash hands - Eye pieces perpendicular to eyes - Directed at arms length thumb - Adjust PDs to center thumb - Adjust tilt to situate light in upper VF - Adjust illumination to medium intensity - Largest spot size - Dim room lights - Lower Px - Hold lens between thumb/index - middle finger can hold/pivot sup. lid - Direct light on pupil - BIO at arms length from Px - Introduce lens 4cm from eye - external eye is seen - center pupil in lens - observe red reflex - move lens away from px until red reflex fills lens

BIO scanning procedure:

While Px looking in gaze - Full lens focus shows mid-periphery - Direct beam towards gaze and tilt lens in opposite direction - partial view of peripheral fundus - sweep and change Px gaze Mid periphery requires gaze in 4 quadrants - full lens focus should show most of mid periphery Posterior pole - Sweep in snake motion to observe structures

BIO troubleshooting:

Losing view: - move lens towards eye until pupil is noted > centre pupil and pull back Reflections on lens: - tile lens slightly

BIO recording sheet description:

- Outer circle is posterior edge of ciliary processes - Middle circle is ora serrata - Inner circle in equator

BIO standard recording:

Record flipped and inverted - BV - Long ciliary nerves - thin band at 3' and 9' - Short ciliary nerves (hard to note) - Thin ovals crossing equator at 1'/5'/7'/11' - Vortex veins - Pineapple shape - Ora seratta - Traced middle circle - leave some holes like a tent

BIO abnormality recording:

Retinal pigmentation: Black dots Laser photocoagulation scars: Black crosses - CWS Lattice degeneration: Black stitching inside black oval Retinal detachment: blue border with shading over detached area White without pressure: blue circle Macula edema: yellow patch Hard exudate: yellow dots

Recording position and size of lesion on retina

As # of disc diameters in a given direction (temporal) from ON And as # disc diameters in size Also record time and drops used

BIO narration:

2. ONH 1. Disc margins distinct 2. Average size 3. No PPA 4. NRR uniform, ISNT obeyed 5. CDR 0.4H, 0.4V 6. No abnormalities 3. Clear NFL 1. ILM sheen noted 4. BV normal 1. AV ratio of vessels near disc 2:3 5. Posterior pole NAD 6. Macula NAD Narrate anything of note as DD size and distance from OD