Lab 1 - Case History & Refractive Status (2021) Lab Manual PDF

Lab 1 Case History and Assessing Refractive Status This lab session will cover the following procedures and concepts: Gross Observation Equipment needed: Diagnostic kit Diagnostic Indicators...

Lab 1 Case History and Assessing Refractive Status This lab session will cover the following procedures and concepts: Gross Observation Equipment needed: Diagnostic kit Diagnostic Indicators Lens racks Cosmetic Indicators Occluder/Patch Case History Trial lens kit Assessing Refractive Status Prism bars Cover test paddle Retinoscopy Accommodative near Mohindra Near Retinoscopy fixation target Pinhole Visual Acuity 1 Gross Observation Diagnosis of the patient begins from the moment you meet the What gross observations would you record for these patients? patient. As you greet the patient in the reception area, walk them to the exam room and take a case history, observe the patient’s gait, head/body posture, and eye movements. Monitor for diagnostic and cosmetic indicators. Diagnostic Indicators Cosmetic Indicators ! ! Head Circumference Epicanthal folds Head Position: tilt, turn, chin lift Width of bridge of nose or depression Body Stature Width of face ! Mobility Interpupillary distance Asymmetries in lid, pupil, orbit ! 2  ! ! ! ! ! ! ! 3 2 Case History BACKGROUND Probe the areas in the case history in order to: Help to establish the diagnosis Develop the prognosis Prepare the examiner for the patient/parent conference. FOLDARS DRFLOPS EMR Establish the goals of the patient/parent. Frequency Duration Quality: Describe complaint (dull, sharp) Decide on appropriate referrals Location: Where is the problem lo- Onset Relief cated? Chief Complaint Duration: How long has it been go- Why is the patient here? What’s patient/parent’s main Location Frequency ing on? concern? Duration Location Timing: How often it occurs? Cosmesis? Diplopia? Asthenopia? Failed screening? Second opinion? Aggravating Onset Severity: Scale from 1-10? Factors Symptoms 1. Is patient aware of eye turn? What direction is the eye turn? Modifying Factors: What helps to im- Relief Pain prove? 2. Is patient experiencing double vision? In what direction are the diplopic images? Is it monocular or binocular true diplopia? Severity Severity Context: Affecting when? 3. When is the eye turn/diplopia present? Once in a while or all the time? Does the eye turn/diplopia seem associated with a particular Associated signs: What else occurs time of day? Is it associated with a specific viewing distance or w/ CC? direction? 4. Is there anything they are able to do to eliminate either the symptom(s) or eye turn/diplopia? (e.g. by turning or tilting head?) 4 Onset (Time and Type) 1. When was it first noticed? Age? By whom? Patient Medical History 2. How did it start? Suddenly? Gradually? After an injury? After an illness? 1. General health status? 3. Has the eye turn or symptoms changed over time? Either in severity 2. Past childhood illnesses? Hospitalizations? (size of eye turn) or frequency (time the eye turn is present)? Does 3. Prenatal, Perinatal, Postnatal? patient feel it has gotten better or worse? Maternal health and nutrition? Patient Eye History Exposure to teratogenic substances? 1. Dates of previous evaluations and/or treatment(s)? Gestation? 2. What was done? Labor and delivery? Complications? Glasses Birth weight? 1. Compliance with suggested wearing schedule? APGAR score (Score of 1-10 taken at 1 and 5 minutes after birth) 2. Success of glasses improving VA or eye turn? Occlusion (Patching) A: Appearance (Skin color/complexion) 1. Eye patched? P: Pulse (Heart rate) 2. Type of patching? G: Grimace (Reflex irritability) 3. Hours per day of patching? A: Activity (Muscle tone) 4. Compliance with patching schedule? R: Respiration (Breathing) 5. Success of patching? 4. Other diagnosis and treatments? 6. Other passive or active therapy given with patching? Vision Therapy Psycho-educational? 1. Goals and length of program? Audiological, Speech and Language? 2. Compliance with recommendations? Occupational or Physical therapy? 3. Success of program: both short/long term results? Neurological? Surgery 1. Which eye(s), muscle(s) were operated on? 2. Success of surgery: both short/long term results? 5 Developmental History Medications 1. Motor? What is medication for? Name of med? Dosage? How long Age the child first crawled, rolled, walked? have they been on the med? 2. Language? Age the child speaks - one word, two words, and simple Allergies sentences? 1. Allergies to medications? 2. Environmental allergens? Foods? Academic History 1. Grade level matches age? What grades left behind? Special classes and/or tutoring? 2. How is the child doing in school? Trouble or excellence in specific subjects? Family Eye/Medical History 1. Any specific eye/medical problems? Any eye turns or lazy eye? 2. Any history of binocular vision or learning related problems? Goals of Patient/Parent What do they want to see as a result of this evaluation/ treatment? Better cosmesis/ function? Other Pertinent History Occupation, vocational, academic visual needs? 6 3 Assessing Refractive Status Retinoscopy (static or cycloplegic) BACKGROUND MATERIALS Retinoscopy for patients with strabismic deviations, can be done Retinoscope by having the patient view a projected target, cartoon, or video in Lens Racks order to keep the patient’s attention. To best scope on axis using the phoropter, strabismic patients need to have prism held in front of the fixating eye by the amount of deviation. Horizontal deviations: Exotropia – use BI prism before the eye that is fixating the Esotropia – use BO prism before the eye that is fixating the distance target. distance target (for example the red/green E) Example: 30 LXT, use 30BI over the RE while scoping the LE. Example: 30 RET, use 30BO over the LE while scoping the RE. 7  Vertical deviations: Hyper/Hypotropia - use neutralizing prism before the fixating eye. Example: 15 RHT, use 15 BU before the fixating eye, while scoping the RE, then 15 BD before the RE so it can fixate the Clinical Pearls distance target while scoping LE. For XT’s with deviations > 15 PD, it’s better to perform out of phoropter and move yourself with your retinoscope to be aligned with the turned eye (therefore aligning Purkinje images) along with using your lens racks. For patients who are young or special needs, it may be best to perform retinoscopy out of the phoropter and scope with your lens racks. 8 Movie 1.1 How to perform retinoscopy with the phoropter on a patient with strabismus. Patient has around a 20 prism of a left esotropia. 9 Near Retinoscopy (Mohindra) RECORDING BACKGROUND 1. Record the GROSS findings on the optical cross. This method may be useful for estimating refractive errors, 2. Transpose the gross findings of the optical cross to sphero- especially with young strabismic children. cylinder form. Near point testing conditions. 3. Calculate the net findings by adding –1.25 algebraically to the Monocular testing conditions. sphere power only. This technique is NOT appropriate under cycloplegic conditions. Example: MATERIALS Retinoscope Patch Lens Racks PROCEDURE 1. NO PHOROPTER 2. Turn off ALL room lights and close door so that retinoscope light is the only source of light in the room. 3. Sit directly in front of the patient at ~ 50cm. OCCLUDE ONE EYE with patch. 4. Direct patient to look at the retinoscope light. 5. Using lens bars, neutralize the primary meridians of the un- occluded eye. 6. Repeat for other eye. 10  Clinical Pearls Perform Near Retinoscopy on your partner If patient has reduced acuity through best correction, perform pinhole visual acuity. If there is an improvement, rule out corneal distortion, ocular media abnormalities, or uncorrected refractive OD OS anomalies. Don’t confuse Mohindra with MEM (MEM tests your accommo- dation) Don’t forget to turn off all the lights. Even if its a non-verbal child, your retinoscope light will become the interesting target to look at with all the room lights off. Some ways to attract the young patient to look at your light are by calling their name, making sounds (like animal or clicking sounds) or singing songs. Gross: OD: ___________________________ 1.25 is subtracted from the sphere gross value for adults be- cause it takes into account an assumption of 0.75D for tonic OS: ___________________________ accommodation (with some proximal accommodation as well) in a working distance of 2D (50cm). (Owens et al 1980) Net: Modify based on age (tonic accommodation can increase by OD: __________________________ younger ages) and can be affected by the type of refractive error OS: __________________________ (Saunders and Westall). Subtract the following to the sphere only children under 2 years: 0.75D children over 2 years of age: 1.00D 11 Movie 1.2 Mohindra Retinoscopy Caption 12