Routines And How To Do Them Flashcards
Ophthalmoscopy
Anterior or external eye with +10D lids lashes, etc. reduce and check fundus. Check red reflex as well. A black dot can be
Mittendorf’s dot. Reduce power as you move through media and move closer. Widest and brightest beam first. Record negative findings.
Normal variations- Tigris fundus, myopic crescent, choroidal vessels
Static retinoscope
1.Put trial frame on px and set pads.
2. ‘I am going to shine a light into your eye to see if you need glasses’
3. Px fixates on green on the duochrome to relax their accom
4. Room lights off.
5. Start with pxs RE, ret in the right hand using the right eye with the ret collar down
6. Fog LE until see against in all meridians unless presbyopes= no accom
7. Observe reflex at 90/180 and 45/135 degrees
8. Start with fastest against or slowest with meridian and correct them
9. With add positive to neutralise and against add negative
10. Lean forward (with) backwards (against) if think you’re at neutral
11. Go to 2nd meridian and it should be against and then use negative cyl to correct this
12. Check cyl axis: 45 degrees either side observe reflex, if incorrect one with one against. If incorrect then turn the cyl axis towards the with reflex.
13. Repeat on le
14. Subtract wds
15. Record VAs
Dynamic retinoscope- Notts method
(measures how much accom lag a px is, some checks how good a pxs accomodation is) Lag and lead (baso retting px at near)
Lag= not enough accom, typically accom response is less than needed as px will have some depth of focus so some is normal. Lead is using too much accom.
Notts- measures how accurately a px accommodates at a target at a distance but without lenses. We move our own wd
- ‘I am going to check your eyes focussing ability’
- Px wears their refractive correction for distance otherwise not measuring lag measuring rx)
- Target at 40cm. Ask px to fixate on it.
- If you see with movement move back till neutral. Against- move forward till neutral.
- Target at 40cm= 1/0.4 = 2.5D but if achieve neutral at 67cm= 1.5D= lag of 1.00D (seeing it after not accom enough)
Lead- accommodating too much so px sees target before. Eg at 40 they see it at 33cm. 1/0.4= 2.5D but see it at 33cm they see it at 3.00D which means they are accom too much. Lead has no pos or neg sign. Lag does opposite they see it at 2.27D when object should require an accom of 2.5
Hard as have to keep budgie stick in right place and then move forward and back.
Lag more than 1= accom insufficiency or hyperopia. Less 0= pseudomyopia or accom spasm check w cycloplegic
Monocular estimation method
- Px wears distance rx
2.‘I am going to check your eyes for focussing accuracy’ - Holding budgie stick and retinoscope at 40cm
- Ret along the horizontal meridian of RE (sweep 1 meridian
- Most of time will see with. Lenses held in front for 0.5 seconds in front of eye what gives you neutral, do this quickly to make sure not altering pxs accom state + binocular vis.
- Record power of lenses needed to achieve neutral: MEM RE: +0.50DS LE
- No WD correction needed
- Repeat on le
Mostly plus sphere= with= lag. Neg= against= lead
Pre presbyopes up to 0.75 lag is normal
1.00D + above= accom insufficiency/ hyperopia= extra plus
Less than 0 neg lens against= pseudomyopia/ accom spasm so cant relax eye, use drops to paralyse ciliary muscles to check true rx
Binocular balancing
- After static ret and monocular subjective refraction
- ‘ I want to see how well your eyes work together which requires vision in 1 of your eyes to be blurred’
- Keep all lenses in the trial frame
- Put +0.75D lens in front of le and occlude the re and check va in the le is 6/12 if not add extra plus.
- Remove occluder from re and ask px to look at smallest line they can see
- Show +0.25DS to re if clearer or same add to rx
- Keep adding until positive sphere blurs vision
- Show -0.25DS and add if clearer
- Repeat with the le with the right eye fogged in the same way
Binocular addition
Normally after binocular balancing if pxs having near sxs
1. Remove fogging lens used during BB so both eyes see clearly
2. Px fixates on the smallest line
3. Add +0.25D to both eyes
4. If clearer or same add to rx until sphere blurs acuity
5. Record binocular va
4 techniques for binocular balancing
Monocular fogging used with trial frames
Prism disassociated blur balance- used with horopter/ projected charts
Humphriss immediate contrast HIC- uses the effect of binocular summation and inhibition
Turville infinite balance TIB- cumbersome requires a septum
Amplitude of accomodation
RAF on all young px
- Keep distance rx on, lights off. Adjust by 1.5mm each eye
- ‘I am going to measure your eyes focussing power’
- Place the raf rule on pxs face
- Illuminate a raf target- small text- words
- Px reports a blur target when target moved closer= push up amp (read in dioptres) accomodation- d for dioptres
- Px reports when clear as target moved away= pull down amp
- Average the values- bin value 1-2D higher than mono
- Record as RE:8D LE:7D BE: 10D. Higher as convergence
Why do we keep distance rx on- as without it for hyperopia they’d be using some of their accom to get over that so you’d underestimate accom and myopes too powerful so would overestimate it.
Normal- cant be more than 1.50D lower than age expected value
If pxs below normal= accom insufficiency
Accomodative facility
Measures the speed of their accomodative response. Ask the px to change their accomodative response by 4D at a time. How quickly does the pxs accom system react?
Some pxs could have normal amp of accom but have sxs which could be due to problem w this. Accomodative spasm or pseudomyopia. Poor at relaxing accom.
- ‘ I am going to check how well your eyes work together’
- Keep distance rx on
- Ask px to focus on near test chart 40cm in front of them ask them to read smallest print they can see and illuminate
- Show them +2.00D lens until clear= and px clears them and count the cycles in which they see it clear. And then show them -2.00D lens until clear
- See how many cycles they clear in 30 seconds and times 2= accomodative facility
- Do this for each eye individually and for both eyes
- Record number of cycles cleared in 1 min- CPM accom facility +-2.00DS Re= 11cpm Le= 11cpm BE= 8cpm. Less now as convergence here slows us down
Max 40cm away otherwise not stimulating enough accom
For greater accuracy do it for a minute as you may overestimate accom otherwise as it generally gets poorer with time.
Flippers= lens rock
Distances to near focus= distance rock
Normal- children and adults moe than 11cpm mono and 8cpm bin but some say kids only 5cpm mono and 2.5cpm bin which is fine as well. Controversial others suggest near mallet should be used with suppression test for bin viewing
If px fails can train to improve accom facility practice
Accom lag
All done before in dynamic ret
How to determine tentative add
And clear vision theory range
Age and working distance- least error prone recommended
Amp of accom you could do it with that equation wd-1/2amp in dioptres (error prone)
Or neg and positive relative accom and binocular cross cylinder (error prone)
Range of clear vision-
Closest point= 1/ (near add+ accom)
Furthest point= 1/ near add. Alone without accom
Ocular motility
- Lights on specs off
- ‘I am going to check if your eye muscles are working together please follow my pen torch light with your eyes only and tell me if you get any pain or see double vision’
- Sit in front of px at 40cm
- Keep light in binocular field and move in 6 cardinal positions
- Can move up or down to test for A and V patterns. A= More convergent at the top, V- more convergent at the bottom.
- Normal safe
- If diplopia record if horizontal or vertical- cover each eye in turn and the under active eye sees the furthest image
Convergence NPC
- Lights on, near rx
- Line target on raf rule
- ‘I am going to test how well your eyes converge together’
- Place raf rule on pxs face and illuminate the raf target
- Px reports when target doubles as it is moved closer = break point measured inc m.
- Px reports when target single again as its moved further back= recovery back
- Record NPC: break point/ recovery point
Normal break= less than or equal to 7.5cm
Normal recovery= less than or equal to 10.5cm
If further away= convergence insufficiency
For presbyopes may blur before doubles
If one eye loses fixation= objective break point- suspect suppression
If no break eg young pxs= to the nose
Jump convergence
- Lights on near rx
- Px distance fixation is a letter on the snellen chart, 1 line above va of worst eye
- Hold pen tip at 15cm
- Ask px to switch between letter chart and near target multiple times
- Observe convergence and divergence
- Record NPC jump: good to 15cm
Considered id sxs of near work suggesting conv insufficiency= ability to alternate convergence and divergence realistic task between 2 targets. Poor jump conv more common than poor NPC. Not routinely done
Test NVA
- Lights on
- ‘We are going to see what you can read up close’
- Measure RE or the poorer eye first
- Px holds chart at normal wd
- Px reads smallest paragraph that they can see
- Repeat for LE
- Record N_ @wd
Fusional reserves
- Lights on
- ‘This test measures the range over which your eyes can keep an object single’
- Ask px to fixate letter, 1 line above VA of the worst eye
Distance P FRS- base OUT prism
1. Hold smallest base out prism in front of re
2. Px reports when letter goes double= break point measure prism
3. Reduce prism until letter single for px= recovery point
And there is blur at distance due to convergence
(Blur/break/recovery)
P FRS at near- still blur point use to convergence (blur/break/recovery)
Distance N FRS- base IN prism
1. Hold smallest base in prism in front of re (eye diverges)
2. Px reports when letter double- break point
3. Reduce prism until letter single= recovery point
BI- No blur at distance as accom relaxed
(X/break/recovery)
Near- neg fusional reserves- some accom so blur point eventhough divergence relaxes accom (blur/break/recovery)
Distance vertical FRs- R infravergence
1. Base up prism in front of re
2. Increase prism slowly
3. Measure break and recovery points (No blur as no convergence)
Break/recovery
Distance vertical FRs- R supravergence
1. Base down prism in front of RE
2. Measure break and recovery points
3. Repeat for near with near rx
NFR AND PFRS except for neg fr at near= blur/break/recovery
R infra and r supra= break/recovery
Cover test
- Lights on, D rx.
- ‘This test allows me to see how well your eye muscles work together’
- Ask px to fixate letter, 1 line above va of worst eye
Stage 1- test for tropia
4. In primary gaze position cover LE observe RE for 2-3 secs
5. If movement= tropia. Repeat by covering RE
Stage 2- test for phoria
6. Only if no tropia
7. Cover LE 2-3 secs and observe
LE as cover taken away
8. If movement= phoria
Smooth and fast means its compensated
Stage 3- alternating
9. Reveals total phoria or tropia or intermittent tropia
10. Cover le and rapidly switch to RE and observe LE response. Repeat for 10-30 seconds and repeat at near.
Ask px about phi movements- with XOP against SOP
Measuring phoria/ tropia
Prism bar. BI= exo. BO=eso
Increase prism power till no deviation
Whilst performing alternating CT or use a ruler to estimate size
Maddox rod- check for phoria or suppression in the distance
- Distance rx in the trial frame
- ‘ i am going to test how well your eye muscles work together in the distance’
- MR in front of RE with grooves H (horizontal phoria)
- Dim room switch chart on
- Ask px if they can see a spot and a red line- if no stop as suppressing
6.’ Is the line through the spot or to the left or right’ - SOP: line is to the right to spot (uncrossed) add BO for alignment
- XOP: line is to right to spot (crossed) add BI for alignment
- Repeat with grooves vertical
- L/R: line above spot- BD to LE
- R/L: line below spot- BU to LE
- Double MR test for cyclophoria so grooves vertically LE/RE
- Disassociate eyes, 3DW LE, 3BU RE
- Px rotates MRs until lines appear parallel
Maddox wing
- ‘I’m going to test how well your eye muscles work together at near’
- Near rx- near pd (30cm)
- Lights on px looks through MW eyepiece
- ‘Can you see the arrows and numbers’
- H phoria- which white number does the arrow point to (SOP- odd XOP- even)
- V phoria- which red number does the red arrow point to (R/L- odd, L/R- even)
Aligning prism (fixation disparity- decompensated phorias)
MALLET UNIT
- ‘This test will help determine if your eye muscles are causing strain in the distance’
- Mallet unit on with OXO H
- D Rx
- Ask px if 2 red strips align with the X
- Put Polaroid visor on px
- Occlude RE and the px should see the upper nonius target
- Remove occluder and px should see 2 nonius targets- if suppressing stop test
- ‘ are the strips aligned with the X’
- If misaligned add weakest prism or sphere
- Cyclo deviation- are the strips tilted
Near mallet unit
- ‘This test will help determine if your eye muscles are causing strain when reading’
- Near rx
- Ask px if they see 2 green targets
- Put Polaroid visor on
- Ask px to read some text
- Occlude re and adjust visor till px sees upper target
- Remove occluder and ask px if both targets are aligned
- Repeat with OXO vertical
Fovea suppression (small suppression scotoma)
- Near mallet unit (33cm)
- Lights on, near rx
- RE sees letters to the left
- Le sees letters to the right
- Both eyes see central area
- Check binocularly first, then occlude each eye in turn
- If px reads better monocularly= suppression.
Use of bagolini lenses to demonstrate arc - what are they
Arc is important in determining prognosis for obtaining binocular function in pxs with tropias, deep arc has poor prognosis for treatment.
Tests arc under most natural conditions. Investigating tropias.
Plano glass trial lens with fine striations on surface px asked to look at spotlight through lens
Px sees spotlight with line running through it orientated at right angles to the striations
Room lights on
Px fixates spotlight at 6m with rx for distance
Place bagolini lens in front of deviating eye with striations horizontal (eg in front of re then re sees line and spotlight)
Carry out test binocularly and explain- this test examines how your eyes work together
Have pencil and paper ready for px to draw what they can see
Ask them to look at spotlight and draw what they can see
:how many spotlights (diplopia) can you see line (suppression) does line have ago (central suppression scotoma)
Repeat test at 33cm with Rx for near
Bagolini lenses alternating tropia
Room lights on
Same method but place bagolini lenses in front of both eyes with striations at 45 and 135 degrees
Pupils
Room light on
Rx not worn
Explain this test checks your pupil reflexes to light
Please look at letter or spotlight on distance chart
Use letter if unaided vision better than 6/18 spotlight if worse than it
Measure and observe are pupils equal in size check for anisocoria measure diameter w semi circles on ruler
Are pupils round pathology surgery
Repeat with room light off but allow enough light to see pupils
Allows differential diagnosis of anisocoria
Direct and consensual light reflexes
Normal room illumination
Remind px to keep looking at letter or spotlight
Shine light in R pupil from infero temporal side at 5-10cm
Use pen torch or ophthalmoscope
Observe extent or speed of right pupil constriction (direct reflex) and left pupil= consensual
Remove light and observe it again with dilation
Repeat several times as fatigue can occur in abnormal eye
Repeat observations of both reflexes while shining light in left pupil
Swinging flashlight test
Normal or dim room illumination
Remind px keep looking at letter or spotlight
Shine a light in r pupil 2-3 seconds from inferior side at distance of 5-10cm
And then quickly shine light in left pupil for 2-3 seconds
Alternate L and R eye several times
RAPD= relative afferent pupillary defect- detected if one eye dilates rather than constricts when light shone on it
Must do swinging flash light test as would miss RAPD
Near reflex- only do this if light reflex is abnormal
Remind px to keep looking at letter or spotlight
Now look at my finger
Hold finger at about 15cm in front of px
Observe extent or speed of pupillary constriction as px changes fixation from d to n
Now look back at letter or spotlight and observe extent or speed of pupillary dilation as px changes fixation n to d
Record light near disassociation if light reflex abnormal while near reflex normal or present
