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Getting ‘Worked Up’ Ophthalmology Technical Essentials. Britta Hansen, OD, FAAO March 22, 2014. Who am I?. Berkeley Optometry Grew up in Minnesota Residency at San Francisco VA Work at Northwest Eye Surgeons. “Triage”. Outline. Components of technical exam History/chief concern(s)

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Presentation Transcript
who am i
Who am I?
  • Berkeley Optometry
  • Grew up in Minnesota
  • Residency at San Francisco VA
  • Work at Northwest Eye Surgeons
  • Components of technical exam
    • History/chief concern(s)
    • Phone/walk-in triage
    • Vision, refraction
    • Confrontation visual fields
    • Extraocular motility
    • Pupillary reaction
    • Intraocular pressure, angles
    • Additional testing
  • Patient examples
chief concern phone triage
Chief concern/Phone Triage
  • Base questions upon:
    • What you expect as an answer
    • What diagnoses you’re considering/past experience
    • What they’ve already told you


where to start
Where to start?
  • Let the patient [briefly] tell you what’s wrong
  • Ask new questions that make sense:
    • Pain = what scale?
    • Redness, blurry = how long? What scale?
    • Headache = tried to alleviate?
    • Any eye drops = side effects?
    • Any new medications = side effects?
    • Injury = flashing lights, floaters, bruising?
there is an art to this
There is an art to this…
  • Some patients will overstate their symptoms
  • Others will downplay their symptoms
  • Knowing the right questions, trusting your instincts and continuously re-visiting your process for triage regularly
subjective versus objective testing
Subjective versus Objective testing







  • History/Chief Concern
  • Vision?
  • Refraction?
  • Patient medical history
  • Family medical history
  • Patient ocular history
  • Family ocular history
    • Which diseases are inherited?
      • Macular degeneration
      • Glaucoma
      • Retinal detachment
      • Strabismus (eye turns)
      • Low vision disorders: ie Retinitis pigmentosa, ocular albinism
what questions help
What questions help?
  • Location
  • Severity
  • Quality
  • Duration
  • Timing
  • Context
  • Modifying factors

HPI = History of Present Illness

know your patient base
Know Your Patient Base
  • Primary eye care setting
    • More weight on refraction, contact lens fittings
    • Less weight (but still important) on chair skills
  • Tertiary care setting
    • More weight on chair skills to help with diagnosis
  • There is overlap between the settings, knowing what to do in each instance will help to have a smooth work-up
  • Components of technical exam
    • History/chief concern(s)
    • Vision, refraction
    • Confrontation visual fields
    • Extraocular motility
    • Pupillary reaction
    • Intraocular pressure, angles
  • Triaging patient examples

“Chair Skills”

visual fields
Visual fields
  • Finger Counting: all or none
  • Transilluminatorfields: all or none
  • Automated perimetry: qualify visual field defect
    • Humphrey
    • Matrix
    • FDT
  • Abnormal fields:
    • Glaucoma, other optic nerve problems
    • Retinal detachments
    • Vein and artery occlusions
    • Stroke, tumor
extraocular motility
Extraocular motility
  • Tropia: one eye turns in (eso) or out (exo)
  • Main question: do you see double?
extraocular muscles
Extraocular Muscles
  • “Double Vision:” poor blood flow to muscles around the eye, muscle trapped from free movement
extraocular muscles1
Extraocular Muscles
  • Patients with SYMPTOMATIC double vision will tell you. PUPILS can be very important in this case.
reasons for rare eye movements
Reasons for rare eye movements
  • Poorly controlled diabetes
  • Poorly controlled blood pressure
  • Graves Disease
  • Congenital
  • Entrapment from an injury
  • Anomalies of the nerves
  • Compression to the nerves or the muscles
what to look for
What to look for
  • Equal size/shape
  • Equal reaction to light
  • Similar movement when the light is in the other eye
  • Relatively the same movement when swinging back and forth
pupillary testing
Pupillary testing
  • Anisocoria- difference between pupil size
  • Horner’s- miotic (small) pupil
  • Adie’s- acute dilated pupil
  • Relative Afferent Pupillary Defect
    • If present, it can be VERY important as a component of the doctor’s exam
    • This is a RELATIVE difference between the two eyes and their brain input
things that cause an rapd
Things that cause an RAPD
  • Asymmetric glaucoma
  • Blood loss to the OPTIC NERVE in one eye
  • Retinal detachment in one eye
  • Blood loss to the RETINA in one eye
  • Compression on the optic nerve in one eye
  • NOT: Cataract
  • NOT: Amblyopia
  • NOT: Macular Degeneration or Scar
pupillary demonstration
Pupillary Demonstration
complicated pupils
Complicated Pupils
  • One pupil doesn’t work because of an iris injury
  • A patient has a new concern in the “good eye” where the “bad eye” already has a relative pupil problem
  • Monocular? Binocular?
  • Without correction? With Correction?
  • Distance? Intermediate? Near?
  • Pinhole?
  • Reduced vision
    • Glasses wrong/outdated
    • Cataract
    • Macular disease (edema, epiretinal membrane, macular degeneration)
    • Sudden loss of vision (vascular disorder, retinal detachment)
  • Change from glasses?
  • Best “corrected” visual acuity
range of concerns and diagnoses
Range of Concerns and Diagnoses
  • Glasses change: gradual
    • Can be due to Diabetic shift in blood sugar
  • Cataract: blurry vision through glasses, glare while driving at night, haloes and starbursts
  • Retinal detachment: flashing lights, shower of new floaters, dark curtain over vision, blurred vision
  • Open angle glaucoma: no symptoms until late in the disease, high pressure in this case is painless
range of concerns and diagnoses1
Range of Concerns and Diagnoses
  • Vitreous detachment: floaters in presence or absence of flashing lights, no vision loss, usually distinct floater(s)
  • Acute Angle Closure Glaucoma: Recent pupillary dilation, foggy vision
posterior vitreous detachment
Posterior Vitreous Detachment

concerns and diagnoses pink eye
Concerns and Diagnoses: PINK EYE
  • Bacterial conjunctivitis: pus-like discharge, eyes stuck shut in morning, usually children
  • Viral conjunctivitis: white/clear discharge, contact with someone else with a red eye, current or recent past upper respiratory infection, swollen, one or both eyes
  • Uveitis: sensitivity to light, redness
  • Scleritis: extreme eye pain, extreme redness
concerns and diagnoses
Concerns and Diagnoses
  • Allergic conjunctivitis: watering and itching of eyes, usually seasonal, current runny nose/cough/sneezing
concerns and diagnoses double vision
Concerns and Diagnoses: DOUBLE VISION
  • Nerve palsy: symptoms only when both eyes open, certain gazes have less double than others, may have diabetes, hypertension, Graves, or other systemic diseases
    • May have lid droop, pupillary problem as well
concerns and diagnoses1
Concerns and Diagnoses
  • Acute angle closure glaucoma: vomiting, nausea, rainbows around lights, worse in morning, can be precipitated by dilation
  • Transient ischemic attack: blacked out vision lasting seconds to less than 5 minutes, returns to normal, typically older patients with history of high cholesterol
    • ***IF symptoms coincide with unilateral weakness, trouble findings speech or trouble ambulating, send patient immediately to ER
concerns and diagnoses2
Concerns and Diagnoses
  • Foreign body: patient usually knows when it went in
  • Penetrating injury: high velocity, either patient or object, globe may be open, check immediately or send to ophthalmology if suspect
  • Endophthalmitis: extreme pain in the eye, usually after surgery or with other illness, send to ophthalmology
patient 1
Patient #1
  • 65 yo female calls with blurry vision
  • FIRST question to ask:
    • How long has the vision been blurry?
  • Qualifiers
    • How blurry is it?
    • Does anything make it better?
    • Has anything changed
  • Accompanying concerns
    • Flashing lights, floaters, diabetes
patient 1 continued
Patient #1 continued
  • Vision blurry x 1 year
  • Glasses help but not much
  • Has glare and haloes with oncoming headlights
  • Diagnosis? Likely cataract, check next available
patient 2
Patient #2
  • 5 yo male
  • Red, painful eye
  • For the last 2 days
  • Got poked with a fake candy cane, went to urgent care, was given ointment, is sensitive to light
  • Likely diagnosis? Corneal abrasion, see same day if possible
patient 3
Patient #3
  • 45 yo male
  • Blurry vision, both eyes
    • Cobweb in the right eye yesterday, left eye now very fuzzy
  • Since yesterday the left eye has been very bad
  • Hasn’t seen any Dr. since 2009
  • Diagnosis: Proliferative Diabetic Retinopathy, see same day if possible
patient 4
Patient #4
  • 65 yo female
  • Blurry vision, right eye, since yesterday
  • Proceeded by flashing lights/mild floaters
  • Now sees a curtain over vision
  • Likely diagnosis: Retinal detachment, see today
patient 5
Patient #5
  • 20 yo female
  • Red, painful left eye
  • Very sensitive to light, vision mildly blurred
  • Has systemic lupus
  • Likely diagnosis: Unilateral uveitis, see today or tomorrow
britta hansen od faao bhansen@nweyes com
Britta Hansen, OD, FAAO