Clinical Optometry Practice PDF

-To determine what specific test/procedure to perform CASE HISTORY TAKING / PATIENT HISTORY during the examination (can be improved with experience in further...

-To determine what specific test/procedure to perform CASE HISTORY TAKING / PATIENT HISTORY during the examination (can be improved with experience in further practice) The Optometric Examination -To generate reasonable differential diagnosis Constitutes of 5 parts: -To discuss patient education about visual function, 1. CASE HISTORY (patient history) ocular & general health 2. PRELIMINARY EXAMINATION -To create good patient-doctor relationship 3. OCULAR HEALTH EXAMINATION 4. REFRACTIVE EXAMINATION 5. BINOCULAR VISION EXAMINATION FORMAT PRIMARY EYE CARE EXAMINATION / 1. Case History OPTOMETRIC EXAMINATION - Optometrist’s main/chief tool are his/her EARS. -DATABASE FORMAT - We can be able to make a tentative diagnosis of (Typical primary eye care examination) patient’s problem - It can be thought as an INVESTIGATION from gathering -SYSTEMS APPROACH data's (Systems examination style) - Makes whole examination not boring & serves as data- collection procedure -PROBLEM-FOCUSED FORMAT (Problem-oriented approach) CASE HISTORY TAKING -COMBINATION APPROACH It is the most important procedure in entire examination --- - crucial details about px complaints & overviews its potential causes of symptoms. 1. DATABASE FORMAT (Typical primary eye care examination) Conducted usually at the beginning of examination - Using essentially the same set of clinical procedures in - helps determine diagnosis from the history alone. every examination - Large ‘complete’ database of information is collected Clinician and patient becomes acquainted ensuring patient’s problems - px becomes compliant w/ clinician’s advice. can be addressed using the information provided. Clinician presents him/herself to show care and DATABASE FORMAT empathy to patients w/ regards to their (TYPICAL PRIMARY CARE EXAMINATION) visual concern 3 COMPONENTS / PARTS - gives clinician an opportunity to explain w/ regards to 1. INTERVIEW visual problems & other concern Includes: -Chief complaint It will lead to a definitive diagnosis and management -Visual Task & demands (visual needs of px’s daily life: plan driving/commuting/surveying) -Visual efficiency (question about his vision & visual function) (in cases of px non-voluntary complaint) CASE HISTORY TAKING (OBJECTIVES) CHIEF COMPLAINT -To analyze the reason of px visit A.) Asking open-ended questions: -To gather relevant information: “How may I help you today?” Px’s chief complaint “How are your eyes bothering you?” Visual function “Are you having problems with your sight or eyes?” Ocular & systemic health “Is there any particular reason for your visit?” Lifestyle “What made you decide to have your eyes checked? “What is your chief complaint?  CHIEF COMPLAINT (HEADACHE / BLURRED VISION / VISUAL TASK & DEMANDS (The task with Vision & level DIPLOPIA) of visual effort) B.) Elaboration of chief complaint “What kind of work do you do?” (filling-in the holes in what the px has already told you) “What are your hobbies?” (F.O.L.D.A.R.Q) “Do you drive?” (F)requency: (eg… twice a day / once a week / “How long do you use computer/gadgets?” seldomly) “How often does HA occur?” VISUAL EFFICIENCY (The ability to see clearly) “How often do you get blurred vision?” “Can you see clearly & comfortably both far & close “How often you get double vision?” up?” “How is your distance vision?’ (O)nset: (eg… last month / last year / a week ago / few “Any problems reading from the whiteboard?’ days ago) “Is everything clear on the TV?’ “when did the HA start?” “Any problems with reading?” “how long have you had blurred vision?” “Can you see the computer screen clearly?” “when did you first get double vision?” 2. QUESTIONAIRE (Written or directly spoken by (L)ocation: (eg… frontal / temporal / occipital / parietal the Px) / browridge / one-sided) Includes: “In which part of the head is the HA located?” -Ocular history “is the blurred vision in both eyes or just one?” -Corrective Lenses history “Is the double vision in all directions of gaze or just -Medical history one?” -Family ocular & Medical health history -Common eye problem (D)uration: (intermittent / longer period / constant) “how long does the HA/BV/DV last?” OCULAR HISTORY (if you are unsure if px wears (A)ssociated Sx: (nausea / feeling of dryness / redness / spectacles) dizziness) “When was your last eye exam?” “What other symptoms do you experience with this “By whom?” problem?” “What was the outcome of that examination?” “Are there any other symptoms associated with the “Have you ever worn glasses?” problem?” CORRECTIVE LENSES HISTORY (if px w/ Rx, specs (R)elief: (sleep / drinking cup of coffee / medication) should be checked) “What seems to make your symptoms go away?” “how long have you been wearing glasses? For Dist, “Does anything make the double vision go away?” near, or Both?” “Does anything make the blurred vision go away?” “can you clearly and comfortably with them?” (possibly a family member’s spectacles for example) “When was your last glasses changed?” “do you wear your specs. All the time? (Q)uality / Type: (throbbing / pulsating / sharp / dull) “how many pairs of glasses you have? “How would you rate the severity of your symptom?” “how old were you when you first wore spectacles?” (throbbing/pulsating/radiating/stabbing/ “do you wear contact lenses?” dull/sharp) “Is the blur constant or intermittent?, Did the blurred MEDICAL HISTORY (question of present & past health vision start suddenly or gradually? If issues or illness) sudden vision loss, ask Was the vision loss partial or “have you ever had any medical attention to your eyes? total?” Any surgery, injuries, or serious infections?” “Is the double vision one-on-top-of the-other or side-by- “have you ever used medication with your eyes? side? “have you ever been told that you have cataracts,glaucoma,or any eye disease? “How is your general health? “when was your last physical examination? By whom?” “have you ever been told that you have diabetes, highblood pressure, thyroid disease, 2. SYSTEMS APPROACH heart disease, or any infectious disease?, are they (Systems examination style) controlled?” - Assessment of visual function system, the refractive “are you taking any medications? system and binocular systems and an ocular health “do you have allergies?, if yes what are your symptoms assessment. & how are they treated? - Much more flexible as it does not demand a certain collection of tests is used. FAMILY OCULAR HISTORY (concern towards sight- threatening condition known to be inherited: glaucoma 3. PROBLEM-FOCUSED FORMAT / cataracts / strabismus / amblyopia) (Problem-oriented approach) “‘Has anybody in your family had any eye problem or - Examination is based on reported problem/s. disease?” - Clinician gathers a list of tentative diagnoses. Disadvantage: FAMILY MEDICAL HEALTH HISTORY (concern towards - dependent on patient’s symptoms health-threatening condition known to be inherited: - complexity (hypertension / diabetes / thyroid diseases) - knowledge of test/s are required to perform & gather “‘Has anybody in your family had any medical problem? huge variety of DDx “any diabetes or high blood pressure in the family? COMMON EYE PROBLEM (some of the common 4. COMBINATION APPROACH disturbance of vision) - To gain a complete database of information during an “Have you ever experienced any of the following: initial examination of a patient, and then use a problem- - flashes of light oriented approach during subsequent examinations. - floaters - halos around lights - double vision COMPONENTS / CONTENTS - frequent or severe headaches CASE HISTORY SCRIPTS - eye pain - redness -Demographic Information & patient profile - tearing * name, address, age, gender, race, tel.#, occu/educ, - or sandy/gritty sensation in your eye? birthplace, religion, marital status, religion/ethnicity 3. SUMMARY / RECAP -General overview of the patient Includes: * peculiarity, symmetry, posture, gait, speech -Brief summary by the clinician’s words -Opportunity to add-on concerns -Chief complaint (CC) * tentative process of differential diagnosis / eye SUMMARY / RECAP redness/itching/tearing/nausea “Is there anything else about your eyes, your general health, or your family’s eyes or -Secondary Complaint health that would you life to tell me more about? “the reason for your visit today is.. And you have -History of present illness concerns about..? -Ocular history (OH) * previous ocular treatment, manifestation of disorder -Medical history * manifestation of systemic disorder (commonly Diabetes, Hypertension, Thyroid Disease) -Medication information complaint? * Intake & adverse effect of systemic medication -Family ocular & Medical health history (FOH / FMH) THE CHIEF COMPLAINT * correlation with patient’s current visual or systemic Majority of Px complaints can be considered in terms condition (diabetes,myopia, amblyopia, glaucoma) of the ff. categories: - Blurred vision -Social/personal history & occupational visual - Eyestrain task/demands - Headaches * lifestyle function of the patient, hobbies, interest, - External eye symptoms habits (tobacco/alcohol) - Disturbance of vision - Double vision - Deviating eye - Protruding eye - Unequal pupil size - Reading or learning problems Classification of symptoms I - BLURRED VISION (THE CHIEF COMPLAINT) -Consider the many conditions that could be responsible of Blurred Vision -Consider follow-up question for sufficient information to create Diff. Diagnosis. BLURRED VISION (CLASSIFICATION OF SYMPTOMS o BV at Far = uncorrected myopia o BV at near = presbyopia / hyperopia o BV after prolonged close work For non-presbyopic = uncorrected Hyperopia / uncorrected Astigmatism / poor facility of accommodation o BV occurring in reduced illumination (night driving) = night myopia / rod degeneration (RP) Most likely: retinitis pigmentosa- abnormalities of the photoreceptors (rods and cones) or the retinal pigment epithelium (RPE) of the retina lead to progressive visual loss. Ex. Nyctalopia o BV occurring in bright daylight THE CHIEF COMPLAINT = cataracts / lens opacities The last major item in patient history taking o BV occurring in unilateral / one eye = amblyopia (uncorrected error / high astigmatism / Part where the patient tells the doctor why he/she strabismus) needed the particular examination o BV accompanied by a change in refraction in the direction of more myopia or less hyperopia It should be recorded in the patient’s Own Words to prevent misinterpretation. = nuclear sclerosis, increased blood sugar (change vision from one type of eor to another) if px is hyperopic, if elevated sugar, lens changes and Begins this part of history with Open-ended questions reverse grade. ‘how are your eyes bothering you?’ ‘what made you o BV accompanied by a change in refraction in the decide to have your eyes examined?’ ‘what is your chief direction of less myopia or more hyperopia  = serous detachment of the retina (unilateral), because change of nearwork task) ex. screentime increased decreased blood sugar (bilateral) (retinal detachment) due to new work. Decreased sugar level: hypoglycemia. Onset time: usually occurs morning after prolonged use prior to that day Intensity: Mild-moderate II- EYESTRAIN (THE CHIEF COMPLAINT) Character: Dull o Termed as any complaint involving a feeling of Location: mostly located @ brow region (also known as fatigue, discomfort, or pain localized in or about the supercilliaryridge) / area around behind the eye eyes. Muscular tension (HA) - result of prolonged use of eye o Also known as "Asthenopia" excessively, HA located in the nape of neck and/or occipital o mostly referred as "Headache" located near the region. eyes. o Is thought to occur as a result of the prolonged use of the eyes. OCULAR H/as (CLASSIFICATION OF SYMPTOMS) 2. Ocular Headache involving the eyes EYESTRAIN (CLASSIFICATION OF SYMPTOMS) o Myopia HA related to uncorrected refractive error = uncorrected myopia tend to squint in an effort to see - Will not incapacitate the Px clearly causing strain o Hyperopia Myopia = uncorrected hyperopia with excessive use of Cause of onset: in relation w/ ASTHENOPIA (eyestrain). accommodation (myopia usually doesn’t give headache) but with o They have the weakest eye because accomodative power astigmatism, they have HA when doesn't use glasses. is kulang. Onset time: None o We need to magnify vision to correct Intensity: Medium o Astigmatism Character: Dull = uncorrected astigmatism no amount of Frequency: None accommodation can bring point of focus in the retina Location: None causing strain or fatigue. o Binocular vision anomalies = accommodative ratio Hyperopia is high and/or low: Cause of onset: Uncorrected Hyperope Conv. Excess/Insuff Onset time: Afternoon Divergence Excess/Insuff Intensity: Medium Character: Dull Basic eso/exo Frequency: Constant Vertical phoria Location: Brow region / frontal area / temporal area / Anisometropia- asymmetric refraction between the superciliary ridge (between eyebrow) two eyes. This condition is defined by a difference of 1 or more diopter in spherical equivalent Astigmatism Aniseikonia- diff size Cause of onset: Uncorrected Astigmatism Strabismus Onset time: Afternoon Intensity: Medium III - HEADACHES Character: Dull (THE CHIEF COMPLAINT) Frequency: Constant o Pain in the cranium, nape of the neck, and forehead, Location: frontal / occipital area / Unilateral Eye pain= in having numerous causes. hugher asrtigmatism. o Patient usually diagnosed as being due to visual Associate Sx (symptoms): Nausea problem. Differential Dx: Between Astigmatism & Glaucoma o Headache history includes important questions: (F,I,C,C,D,O,L) Glaucoma FREQUENCY (how often HA occurs) Location: Unilateral Eyepain / Occipital area INTENSITY (painscale assessment) (1-10 intensity) Intensity: moderate-severe CHARACTER (dull/sharp/stabbing Associate Sx: Eyepain / redness / seeing Halos when look @ sensation/pulsating/throbbing/radiating bulb. CAUSE OF ONSET (what usually triggers HA) Test to rule out: Ophthalmoscopy / Amsler's Grid / DURATION (how long does it usually last) confrontations ONSET TIME (time of the day) LOCATION (frontal/temporal/occipital/parietal/one- 3. Non-Ocular Headache (mostly vascular in nature / Referred sided/superciliary ridge to as headaches occurring on the basis of age) Frequency: Mostly Intermittent EYESTRAIN H/as (CLASSIFICATION OF SYMPTOMS) Intensity: mostly severe Cause of onset: Vascular in nature (Inc. BP / Low. BP / 1. Due to Eyestrain (A.k.a Eye Hangover) Hypertertension/ Hypoglycemia (low sugar) Character: Throbbing / sharp Cause of onset: prolonged use of eyes / change in px's visual Onset time: Mostly Morning requirement. (complain headache due to eyestrain, coud be  Migraine HA (young adults) CLUSTER H.A Hypertension HA (middle-aged) - A.K.A histamine cephalgia Temporal Arteritis HA (older/geriatric patients) - severe, boring, unilateral headache occurring in Muscular Contraction HA temporal region accompanied w/ unilateral lacrimation Cluster HA & nasal congestion. Nasal Sinusitis HA - ‘Cluster’ refers to H.A occurs daily one or more in short period of time. NON-OCULAR H/as (CLASSIFICATION OF SYMPTOMS) - mostly occurs during night time and are more apt to MIGRAINE H.A (young adults) occur when lying down. Cause: Constriction of branches of internal carotid artery NASAL SINUSITIS H.A supplying the visual cortex - occurs on patient with acute nasal sinusitis HA caused by dilation and then congestion of branches of ext. carotid artery meningeal artery - pain is mostly located frontal region 2 types: - other symptom include low-grade fever, temporary 1. Classic migraine - consists of visual aura, unilateral loss of sense of smell throbbing headache, and feeling of nausea Frequency: Mostly Intermittent Intensity: severe Cause of onset: Vascular in nature IV - EXTERNAL EYE SYMPTOMS 1/2 Character: Throbbing / sharp (THE CHIEF COMPLAINT) Onset time: Mostly Morning Location: Unilateral portion of head In many cases are manifestation of eyestrain Associate Sx: Nausea / Visual Aura / Photophobia (sensitive (collection of symptoms/asthenopia) to light) / loss of vision (peripheral) / Can be relieved by correction of patient’s refractive tunnel vision / seeing bright colors error/bino. vision anomaly or due Predominant Symptom: Visual Aura (significant factor, more challenging) = loss of vision / experiencing tunnel vision / to pathological processes Positive visual phenomenon (px. see cresent shape or zigzag Complaints: lines) Itching / burning sensation of eye Pain or foreign body sensation Light sensitivity 2. Common migraine - nausea is the predominant symptom, Excessive tearing and visual aura does not appear. A feeling of dryness Frequency: Mostly Intermittent Intensity: severe Cause of onset: Vascular in nature Pathological processes Character: Throbbing / sharp Conjunctivitis (allergic, vernal, bacterial) Onset time: Mostly Morning Blepharitis (inflammatory process of lid margin, small Location: Unilateral portion of head (one side) Associate Sx: Nausea / Photophobia scale dandruff like) Relief: Sleep Allergic conjunctivitis (association w/ allergic rhinitis ‘hayfever’) HYPERTENSION H.A (middle-aged) Bacterial conjunctivitis (inflammatory process in Severe, occurring in the morning, and usually present on awakening and disappearing at some time during conjunctiva due to bacte.) the day Ectropion/entropion (outward/inward positions of lids) Trichiasis (inward position of eyelashes) TEMPORAL ARTERITS H.A (elderly) A.K A cranial arlerilis ano diant cell arlerius V - DRY EYE Cause of onset: Chronic inflammation of the cranial arteries. (THE CHIEF COMPLAINT) Associate Sx: headache / a feeling of malaise / loss of appetite / scalp tenderness / claudication of the jaw while DRYNESS OF THE EYE/S chewing - due to certain tearfilm anomalies. MUSCULAR CONTRACTION H.A / A.K.A TENSTION H.A a. aqueous deficient Considered most common type of headache which is vascular b. mucin deficient in nature Cause of onset: prolonged use of eye@ work/school d. lid-surfacing abnormalities Onset time: late in the afternoon or toward end of work period. Location: Frontal / occipital area - more serious cause due to degeneration & dystrophies Associate Sx: Muscle neck stiffness affecting anterior portion of the Cornea: Fuch’s dystrophy Seeing “spots” – shadows due to presence of vitreous floater due to liquefaction of vitreous A. Aqueous Deficient (A.K.A Keratoconjunctivitis Sicca) - tends to occur in Myopes & Older people Cause: - fine vitreous opacities cast shadow onto the retina - partial or absolute defiency in aqueous tear production - enhanced when looking at sky or unstructured Prevalence: background - Older women - Px describes as ‘spot’ strings’ cobweb’ appearance of Signs: bacteria under a microscope’ - excessive debris in tear film - more serious cases: - poor tear production of tears (Schirmer’s test) Retinal hemorrhage (seeing red spots) Symptoms: Pars planitis (floating spots due to inflammatory cells in - sandy/gritty sensation retroretinal space) - burning sensation - sensitive to light Light flashes Management: - complaint of light streaks lasting on fraction of seconds - Artificial tears - due to vitreous detachments B. Mucin Deficient Temporary loss of vision Cause: - migraine scotoma: caused by classic migraine w/ visual - reduced in goblet cell population due to Avitaminosis aura following “sick HA” A. - multiple sclerosis: temporary loss of vision Signs: - temporal arteritis: mostly elderly due to closure of - low precorneal tear-film breakup time (less than 10 central artery in retina seconds) (eg… Tear Breakup Test) “curtain” coming down - test should be done several times - suspected with retinal detachment & is subject for - if breakup occurs repeatedly in same area = epithelial emergency referral. defect Symptoms: Seeing “Halos” - feeling of dryness - presence of rainbow halos around the lights Management: - classic symptom of Angle-Closure Glaucoma - Artificial tears (mucomimetics) Seeing “red spots” C. Lid-surfacing Abnormalities - caused by hemorrhage within retina or vitreous Cause: - common cause: Diabetic Retinopathy / Hypertensive - lids not completely close when blinking (corneal retinopathy resurfacing) - paralysis on CN7 (facial nerve) Distortion of Objects - other cause: Pinguecula – prevent lids resurfacing the Patient complaint that an object seem to be distorted limbal area 1. Metamorphopsia: vision dysfunction that causes - hard contact lens disrupts lid resurfacing objects specifically straight lines to appear Signs: warped, distorted or bent. - Dryness in the lower portion of cornea 2. Accommodative micropsia: refers to minification of Symptoms: retinal image due to excessive accommodation (optical - feeling of dryness factors such as minus lens) Management: 3.Age-Related Macular Degeneration: macular disease - Artificial tears w/c px reports some lines when used with Amsler’s Grid, on graph or chart may appear wiggly, wavy or VI - DISTURBANCE OF VISION absent. (THE CHIEF COMPLAINT) Disturbances that may be reported in case history includes: VII - DOUBLE VISION (THE CHIEF COMPLAINT) Most possible cause of diplopia: Binocular vision X - UNEQUAL PUPIL SIZE anomaly / uncorrected refractive (THE CHIEF COMPLAINT) error / monocular diplopia. Essential anisorocia – condition in which one pupil is Diplopia due to Bino. Vision Problem noticeably larger than the other. - Phorias Most common cause: - Long standing Strabismus Adie’s Tonic Pupil – pupil of one eye constricts very slowly in response to Monocular Diplopia light - classic cause of this Keratoconus - however it response/constricts to near stimulus - Px may complain of poor vision within their glasses - occur mainly in young women inspite of reasonably goo visual - lesion of ciliary ganglion acuity XI - READING OR LEARNING PROBLEMS VIII - DEVIATING EYE (THE CHIEF COMPLAINT) (THE CHIEF COMPLAINT) Common among parents who bring their child to Most common complain made by a parent regarding a optometrist complaining about the child child is not progressing well in school. Typically parent complain eye’s turn inward Reading requires “Seeing” = most parents would seek Epicanthus – relative common cause of child’s inward help from optometrists when a reading problem turns of the eyes presents itself - condition where one/both inner canthus are covered -Rule out possible refractive or binocular anomaly may with folds of skin play part in child’s learning: Clinician assures that the child is not crossed-eye & should go away about the age of 6. Refractive Anomalies - uncorrected hyperopia = requires excess amount of IX - PROTRUDING EYE accommodation / more likely to have reading/learning (THE CHIEF COMPLAINT) problems - uncorrected myopia = require little effort to Another common complain made by a parent accommodation regarding a child One of the child’s eye appear to be larger than the Phorias other. - binocular vision anomalies Causes: - hyperopic child w/ esophoria @ near = lower reading - Congenital / infantile glaucoma (appears to be larger score eye) - Microphthalmos (smaller eye making normal eye looks XI - READING OR LEARNING PROBLEMS larger) (THE CHIEF COMPLAINT) - Exophthalmos (protruding eye as a result commonly from orbital cellulitis, Color vision anomalies for adults commonly from thyroid diseases) - affecting 8% males rather than the 0.5% of females - Congenital ptosis (one eye appears to be partly closed - Big four most common color vision anomaly: or squinting) - Protanopia & Protanomaly - Horner Syndrome (one eye appears to be partly closed - Deutranopia & Deutranomaly or squinting) - Enophthalmos (post. Displacement of the globe of eye - Color coding used in progressive teaching program within orbit) (classroom teacher may not be aware that some children are at a disadvantage) - includes variety of difficulty in color-related task in kindergarten Color vision screenings - should be included in the examination of all young patients - particularly for those children with reading problem MOST COMMON ERRORS Not fully investigating the patient’s chief complaint. Not recording all information obtained from the patient. PROCEDURE: Failing to identify a drug name and dosage or identify 1. Make sure that the room lights are on before the possible side effects. patient enters the examination room. Recording personal abbreviations that will not be universally understood. 2. Observe the patient’s appearance: Observe their Not following through the case history in an organised stature, walking ability and overall physical manner. appearance. Pay particular attention to any head tilt or Forgetting that the case history taking can continue obvious abnormalities of the face, eyelids and eyes throughout the examination. that will require further investigation, such as facial Taking the confidential case history in public (e.g. asymmetry, lid lesions, ptosis, epiphora, entropion, waiting room). ectropion, a red eye or strabismus. Assuming the same information is still current from the previous case history. 3. You should sit about 1 m from the patient at eye Repeating questions. level. Try to avoid long silences while writing notes and Leaving a record card on view to the public, such as on attempt to develop the ability to write down answers the reception desk. as the patient is talking, while retaining intermittent eye contact. Try to avoid long periods without making eye contact with the patient. 4. Chief Complaint (CC) or Reason For Visit (RFV): Determine the chief complaint by asking a very general open-ended question such as ‘Do you have any problems with your vision or your eyes?’ or ‘Is there any particular reason for your visit, Ms Smith?’ With some patients, you may get a good description of the problem with little prompting. However, you are unlikely to obtain all the information you require and so will have to ask some questions to ‘fill in the holes’ in what the patient has already told you. The order of the type of questions you would generally ask is given below, to provide a reasonable acronym LOFTSEA for students, rather than a logical sequence. Examples of questions to ask are provided for symptoms of blurred distance vision, headaches and diplopia.