Problem-Oriented Optometric Records PDF

The Patient Hister seh ee vA vn ve J, a 7. eee Cy Leo bt m0, Mi PROBLEM-ORIENTED OPTOMETRIC...

The Patient Hister seh ee vA vn ve J, a 7. eee Cy Leo bt m0, Mi PROBLEM-ORIENTED OPTOMETRIC Additional procedures that may be suggested by the RECORDS patient’s history or symptoms include visual field examina- The systern of record keeping used in this text is based on tion, strabismus. dgnois,(so) development tests, and a the problem-oriented medical record system developed by low fisiox) examination. Laurence Weed (1968, 1969). Weed’s system had its begin- nings in teaching hospitals and clinics. The Complete Problem List Although record systems used for ambulatory patients The complete problem list is a sheet kept in the front of the must differ in some respects from those used for hospital patient’s record (e.g., on the left side of a manila folder) ers patients, the majority of Weed’s concepts can be applied having a numbered and titled list that includes every directly to optometric practice. The problem-oriented problem the patient has or has_had, The list is constantly medical record system consists of four basic components: changed with time, as old Groblems) are solved and new 1. The defined database problems are identified. Weed-defiried a problem as “any- oy Saale 2, The complete problem list thing that requires management or diagnostic workup; this 3. Initial treatment plans includes social and demographic problems.” He illustrated ) buss a) 4. Progress notes the importance of sdcial and psychological problems by commenting that “the management of a patient’s heart The Defined Database failure often has more to do with his living conditions than As described by Weed, the defined database includes the it has to do with a urinary tract infection.” The problem 4. “Patient profile, chiet Ceo eee review of list, according to Weed, should include all of the patient’s systems, physical examination, and laboratory reports. The problems—-not only the ones that can be solved by the adjective defined indicates that the database is limited to student or practitioner who makes the list. those items-that are deemed appropriate for an initial 5-Although an optometric patient's problem list would medical examination: with the ever-increasing number of -~emphasize problems relating to the visual system, problems diagnostic procedures now available, a complete database of a more general nature should be included when indicated would never end. by the patient’s history or by the optometrist’s findings. Par-? For optometry, the defined database should include a ticular care should be taken to include problems that tend problem-oriented history, together with all of the tests of 39 Dave Oca or yisual effects, cluding-hypertension, eye health, refraction, and binoctilar vision that are appro- farterioscler issidiabetes, heart diseate, migs#ine and other priate for the patient’s age group. The database-would tend headache problems, multiple eros and many others. to vary from one practitioner to another but typically would For each problem, the list includes a space for the date when inclitd@ the following procedures§ the problem is entered on the list and a space for the date The history. Patient profile, ocular history, and health when the problem is resolved. At subsequent visits the prac- history; family ocular and health history; and. chief titioner refers to the problem list, entering new problems coniplaint and secondary complaints Wy when indicated and noting when existing problems have The pr imindry examination. Uncorrected and corrected been resolved. visual acuity, visual field screening tests, cover test and other ocular motility tests, tests of pupil function, Initial Treatment Plans tonometry, sphygmomanometry, and external Each initial treatment plan is numbered and titled on the examination basis of the problem (in the complete problem list) that The ocular health examination. Slit-lamp examination and the plan addresses. For each of the patient’s problems, fundus examination under dilation and other tests as the initial plan should consist of the following three | indicated parts: The refractive examination. Keratometry, retinoscopy, 1. More information concerning diagnostic workup and | subjective refraction, and corrected visual acuity management, including things ruled out, specific plans, The binocular vision examination. Lateral and vertical - for each diagnostic possibility, and parameters to be phosias, fusional vergences‘and fixation disparities at followed in management of the disease 6m and 40jcm, gradient phoria test, binocular cross- 2. Therapy, including not only drugs and other cylinder test, amplitude of accommodation, and therapeutic procedures but also precise statements of relative accommodation tests ‘ goals, end points, and contingency plans cet 0 99  NS 100 PRIMARY CARE OPTOMETRY a 3. Education of both the patient and family concerning tive and binocular vision examination results, along with a the problem the initial problem list, initial treatment plans, and lens pre- Oe For the optometric patient, some problems will be in scription, are recorded on the inside right (side 3) and on OS the province of the optometrist, but others will have to the back (side 4) of the folder. be resolved by practitioners in other disciplines. For those OY problems requiring the services of another health care prac- The Problem List. This is recorded on the inside left (side titioner, the initial treatment plan should indicate the type 2) of the folder. This is a permanent list: at subsequent visits, OY of practitioner to be consulted. as new problems are identified and as existing problems are OLY resolved, this information is recorded. Progress Notes OY As with the initial treatment plans, each progress note is Progress Visit. It is convenient to have a variety of NY OY concerned with a single problem and is numbered and progress visit forms available for use in contact lens fitting, titled accordingly. Each note is written in narrative form vision therapy, low vision patient care, and other areas of and should include four components: optometric care. In addition, an unstructured progress visit Symptomatic form, for narrative recording, is often desirable. Nee Objective Assessment Subsequent Database. A two-sided subsequent database Plan form is designed for use at annual or biannual optometric Not surprisingly, this portion of the record system is known examinations. It contains the same information as is as the SOAP system. included on the form for the original database, but it is The progress notes are the final step in a feedback loop, printed on paper rather than on the cardboard manila often resulting in the formulation of additional plans folder. that will be evaluated at additional progress visits. When a patient is being transferred from one practitioner to Special Purpose Forms. Special purpose forms may be another, the final progress notes should emphasize the required, depending on the practitioner, for diagnostic assessment of unresolved problems. procedures such as strabismus diagnosis, dilated fundus When applied to optometric practice, progress notes can examination, vision development examination, and so exist only when the practitioner sees a patient on more than forth. Whereas the original database form and the complete ONS one occasion in relation to a particular problem or prob- problem list form are printed on the manila folder, all other lems. When ophthalmic lenses are prescribed, the results forms are printed on paper and are bound by staples or are often so predictable that no follow-up visit is required. metal clasps to the inside right (side 3) of the manila folder. Ne In such cases, the practitioner tacitly assumes that the As new forms are sequentially placed on top of the older lenses have solved the patient’s problem if he or she does forms, it becomes a simple matter to review the patient’s NN not hear from the patient within several weeks. However, previous optometric care by thumbing through the pre- for those patients whom the optometrist schedules for vious records. (Examples of these forms are given in progress evaluation visits, the use of progress notes for each Appendix A.) we of the patients’ problems will form the final step in the feed- back loop. DEMOGRAPHIC INFORMATION AND. - Progress notes are of particular value to the optometrist PATIENT PROFILE -57tc, ele 2419 surge when contact lenses are fitted. Because contact lenses tend Demographic information (name, address, telephone to cause problems of their own, the careful recording of number, occupation, and so on) may be obtained by an aide progress notes for each progress evaluation visit can give or directly from the patient. When the latter procedure is direction to the procedures performed at these visits and used, the patient is given a form, usually on a clipboard, to to the advice and instructions given to the patient. This fill out in the practitioner's reception room, #——"~ also applies to patients undergoing vision therapy and low Such a form can also include a checklist for additional vision rehabilitation. Rather than generate a separate set of history items, including complaints, ocular history, health _ progress notes for each problem, as Weed recommends, it history, and medications taken. An example of a form used may be preferable to use a less structured format. for this purpose is illustrated in Appendix A. The use of such a form does not absolve the optometrist of the responsibil- Record Forms for the Problem-Oriented ity of taking a history, but it can simplify the history taking System by allowing him or her to concentrate on problem areas. The following system of record form, based on Weed’s Weed suggested that a new component be added to the Problem-Oriented System, is recommended for application demographic portion of the history—the patient profile— to optometric practice. However, some modifications of this pointing out that the practitioner can often be more effec- system will be required for those practices making use of tive in providing patient care if he or.she has knowledge computerized record keeping. ~ of the patient’s home life, family life, and any problems Ou 9 +€ncountered in_daily life. In the database form recom- The Original Database. This is a manila folder, which inended by @urs) (1972), the patient profile includes the becomes the patient’s permanent record and into which are following itenis: birthplace, occupation, education, marital bound, by staples or metal clasps, all subsequent record status, religion, home situation, hobbies and special inter- - forms. The demographic and ‘patient profile information | ests, average day, habits (tobacco, -alcohol, and so forth),- and the results of the preliminary examination are recorded “behavior during assésSthent, ability to communicate and on the outer cover (side 1) of the manila folder; the refrac- “ ‘understand, and other comments. The database described Ne __Chapter 6 The Patient History 101 by Hurst is for use with hospital patients. His patient profile, pressure, heart disease, Kidney disease, diabetes, or any which may be more detailed than optometrists may think other chronic disease. Cee ws, necessary, is taken by a member of the hospital’s nursing service. ” "Ss Family Ocular and Health History JIT be est 27 bigjaw Questions concérhing family ocular and health history Occupation and Visual Requirements should be directed mainly toward those sight-threatening Knowledge of the patient’s occupatio andn visual require- conditions that are known to b inherited, includifig glau-ceimte, ments, both on and off the job, is of obvious importance ‘i i. coma, hypertensiom and diabetes. annem \The use of an informa- to the optometrist. For the older patient, readin and tion form-filled“Out by the patiént in the reception room is working distances, as well as illumindtton levels, are of par- particularly helpful in providing the practitioner with ticular importance. For patients of any age, knowledge of details concerning the patient’s health status and family relative amounts of time spent at near-vision as compared ocular and health history, as these are items that otherwise with distance-vision Qursuits is often helpful. For example, may make the practitioner’s history taking rather tedious many patients who claim to have no symptoms of eyestrain and time consuming. Jr accompanying reading may be found to engage in little or no reading. Knowledge of a patient’s occupation and visual MM THE CHIEF COMPLAINT ; CC. OHIO habits may also be helpful in determining the need for sun- As a matter of convenience, the chief complaint is discussed glasses or other protective lenses or in advising the patient here as the last major item in the patient history. However,. whether or not to consider wearing contact i lenses.. many practitioners would take up the chief complaint as MB ocULAR HISTORY #3 the item_after profile information) obtaining the demographic or patient others would place it just after ques- If the patient comes in wearing glasses or contact lenses, tioning the nt on his or her ocular history. the practitioner should determine when the glasses or The prachvgger usually begins this part of the history contact lenses were prescribed and how’ olten (or, in the with an open-trided question such as “How are your eyes case of contact lenses, how many hours per day) they are bothering you?” or “What made you decide to have your worny It may also be important to know when glasses or eyes examined?” or, more directly, “What is your chief com- we contact lenses were first prescribed and whether or not the plaint?” The patient’s chief complaint, ae as any sec- patient’s eyes have been examined since the present lenses ope complaints, should be recorded in were prescribed. The patient should also be questioned on e patient’s own 0 rds to prevent misinterpretation. For example, a patient’s WY any history of.eye injury, disease, or operation, and appro- complaint of blurred distance vision should not be recorded _ priate details should be recorded, as “myopia.” The patient’s 6 it) spectacle lenses or contact lenses When the patient has responded by stating his or her should be neutralizedand the results recorded on the record chief complaint, the practitioner should ask follow-up ques- form. For spectacles, the lenses should be spotted and the tions to more clearly define the nature of the complaint and distance between lens centers should be recorded, as should identify any secondary complaints. The record form should the presence of any vertical prism power. In addition, the provide sufficient space to record the patient’s complaints Jens material (glass or plastic, tint if present) and the type and other problems in narrative form. Although and size of the bifocal segment, if any, should be recorded. checklists may be appropriate for forms completed by For contact lenses, the base curve, power, diameter, foptic patients, they are not satisfactory for use by the practitioner. (Zone width feenter thickness) tint, lens mater (if ial known), The great majority of patient complaints can be considered any other identifiable variables should be recorded. in terms of the following categories: blurred visién, eye- It is extremely helpful if an assistant or an optometric strain, headaches, external eye Symptoms, disturbances technician is available to determine the parameters of spec- of vision, double vision’ deviating eye, protruding eye, tacle lenses or contact lenses. Indeed, if a practitioner has unequal pupil size, and reading or learning problems. only one employee, the first procedures the employee should be taught to do (other than to act as receptionist Complaint of Blurred Vision ” and office manager) should be to neutralize and determineIn interpreting a patient’s complaint of blurred vision, the. the other specifications of glasses and contact lenses.. -practitioner should consider the many conditions that curren EC 4 polo Ci could be responsible. In most cases the patient will provide, WB WEALTH HISTORY © a without the sneed for.cobxiKg, sufficient information to The patient should be questioned concerning the present perniit’4 *éMtative-haghosis. For example, a child’s com- state of his or her health and the nature of any current plaint of blurred distance vision suggests uncorrected recent illness. Information concerning medication? cut-”. 5 : : :. 2, myopia as the cause, whereas a middle-aged adult’s com- rently taken should include the name of each medication plaint of blurred near vision suggests presbyopia. If the (some patients carry their medications with them) and the patient's initial statement fails to provide sufficiently condition for which it is taken. The practitioner should be detailed information, follow-up questions are necessarye aware that many patients do not consider over-thé-coufter The nature of the patient’s complaint often suggests preparations (aspirin, antihistamines, sleeping pills, diet rather obvious follow-up questions. In any case, the practi- pills, and so forth) as medications. The time of the tioner should keep the following possibilities in mind: most recent medical and dental examinations should be 1. Blurred vision that occurs after prolonged close work, obtained. Ce Se for a patient not of presbyopic age, may be due to © The practitioner should also:question the patient about ‘ uncarrected hyperopia, uncorrected astigmatism, or the presence (either currently or in the past) of high blood poor facility of accommodation.  toOSQ > pets Syl Ty? cae cetiaiks piynen PRIMARY CARE OPTOMETRY NY 102 SY 2. Blurred vision occurring primarily in reduced hyperopia or hyperopic astigmatism, in which distance illumination (as in night driving) may be due to night vision can be improved by accommodating, there is little lt myopia or a receptor degeneration, such as retinitis that an uncorrected myope can dp to improve distance pigmentosa. acuity. Although the myope can Squfftt ff°an effort to see 3. Blurred vision occurring mainly in bright daylight may more, clearly and may feel that his or her eyes are under a be due to nuclear or posterior subcapsular lens strain when doing so, the fact that vision is blurred is so opacities. Ly Cuye Oa obvious that most uncorrected myopes are likely to relegate 4, Blurred vision involving a transient loss or obscuring any feeling of eyestrain to a secondary role. Oe Oa of vision in an older adult Could be due to temporal arteritis or to carotid artery StéTasivé disease, and could Hyperopia. In his textbook On the Anomalies of Accommo- therefore lead to closure of the central artery of the dation and Refraction of the Eye, Donders, (1864; reprinted ~ —— 1972) used the word asthenopia alm6st exclusively to hee A retina. Lia \ Os 5. Blurred vision involving a transient loss of vision could ignate the visual fatigue and other symptoms arising be due to one of a number of conditions, including from uncorrected hyperopia. In Donders’s time (the 19th So-w temporal arteritis, the migraine syndrome, or multiple century), most oculists failed to understand that cgnvex_. a. sclerosis. lenses could be used for young people for distance vision; G possible cause of unilateral acuity loss is functional most thought they were indicated solély for presbyopia. OO ic amblyopia. yore However, in the absence of additional Donders described asthenopia in the following manner: festirig or unless there is a definite _historyo The eye has a perfectly normal appearance, its movernents strabismus, anisometropia, oigh stigmas a are undisturbed, the power of vision is usually acute—and functional amblyopia should n weEassuMed to be the nevertheless in reading, writing and other close work, espe- Owe cause.. we cially in artificial light, or in a gloomy place, the objects, In many cases, the practitioner’s impression of the cause after a short time, become indistinct and confused, and a of the reduced vision must await the results of the refrac- SN feeling of fatigue comes on in, and especially above the tive examination. The following possibilities should then be eyes, necessitating a suspension of work. (p. 259) ENON considered: ols 1. In an adult, blurred vision that accompanies a change, Donders sai Ayayas generally agreed that asthenopia in refraction in the'direction of more myopia or less was due to the éxcéssive use of accommodation and that hyperopia may occur as a result of nuclear sclerosis of because asthenopia didng -affect everyone, 1e, writers believed ‘~ the lens or of increased blood sugar. Nuclear sclerosis that people who were a fitered with it Hada peculiar pré- Ne tends to cause a unilateral change in refraction, disposition. Donders questioned the idea of a predisposi- whereas increased blood sugar causes a bilateral tion and concluded that hyperopia was the condition \Y change. responsible for asthenopia. C)lveies 2. In an older patient, blurred vision that is not due to a Many of Donders’s contemporaries considered change in refraction is most likely due to lens opacities asthenopia to be a form of €mblyopiay Rather than pre- or to age-related macular degeneration, = scribing convex lenses of adequate power, they prescribed A complaint of blurred vision that is confirmed by a weak convex lenses or no lenses at all. Children suffering finding of reduced visual acuity but/s not due to a change from asthenopia were advised to give up their schooling, in refraction may often warranf” additional testing. A and adults were encouraged to give up their sedentary occu- number of diagnostic procedures are available that are pations and become horsecart drivers or immigrate to Aus- designed for the purpose of determining whether the tralia. Donders wrote that it was a great satisfaction to be reduced visual acuity is the result of a retinal, optic nerve, able to say that asthenopia no longer needed to be an or lenticular problem. ey inconvenience to anyone because it could so easily be cured -—® Tests included in this category are the Amsler chart test, by prescribing convex lenses. He also noted that opticians slit-lamp examination with the Hruby lens,photostiéss the understood asthenopia and knew that some people required test, the swinging flashlight test, the light-brightness com- convex lenses for distance vision. _ parison test, color vision testing, the color saturation test, If a patient has [latent hyperopia, the first attempts at the neutral density filter test; arid acuity testing with pupil- refraction by means of routiné fogging procedures may lary constriction. Procedures for conducting and interpret- indicate only a small amount of hyperopia (say, 0.25 or ing these tests are given in Chapter 8. , 0.50 D). If the patient is a child or a young adult who has complained of headaches, “tired eyes” or other symptoms Complaint of Eyestrain of eyestrain accompanying reading or other close work, a The term eyestrain is use ‘here to describe any cgmplaint cycloplegic refraction should be done. Although specific involving a feeling of fatigue, discSmfort, or paift localized refraction procedures designed to fully relax accommoda- in or about the eyes or thought to be associated with the tion may bring out the latent component of the hyperopia, use of the eyese The term asthenopia is often used as a it is generally agreed that a cycloplegic refraction is, by far, synonym for eyestrain. The term headache is often used by the most effective method of detecting latent hyperopia. patients,to describe what is discussed here as-eyestrain, par- ticularly when the ache is localized near the eyes or is Astigmatism. In uncorrected astigmatism, no amount of ‘thought to occur as a result of the use of the eyes. accommodation can bring about a point focus on the retina. for a point object. However, in hyperopic astigmatism, one Myopia.. Complaints of eyestrain or visual fatigue are not or both focal lines are located behind the retina, and accom- likely to occur’in myopia. As compared with uncorrected modation can plate the circle of least confusion on or near ee  Chapter 6 The Patient History 103 the retina. This will have the effect of improving visual on negative fusional vergence. If the patientis not hyper- acuity at the expense of a feeling of eyestrain or fatigue. opic, or if correction of the hyperopia does not fully correct Simple or compound myopic astigmatism, in which one the esophoria at near, additional plus lens power may be or both focal Teste located in front of the retina, is prese(l ed for near work baly)eithe in the form of reading similar to myopia in that accommodation is not effective glasses’or bifokal' lenses. in clearing up distance vision. Therefore, symptoms of Divergence insufficiency. The patientwho has divergence asthenopia would not be expected to occur. However, for insufficiency, being esophoric at(both ‘distance and near, near vision, accommodation may, in some cases, place the may suffer symptoms of asthenopia; including headaches, circle of least confusion closer to the retina and, therefore, for distance vision as well as for near vision. The treatment may be accompanied bya feeling of eyestrain. for this condition involves the full correctian,of any hyper- aL (Cerwy opia, with possibly the prescription of(base-out prism power Binocular Vision Anomalies; Anomalies of binocular for constant wear. : vision are often accompanied by symptoms of eyestrain. ' Divergence excess. The...divergence excess patient, The extent of these symptoms, or the absence of symptoms, —_ having a high exophoria at ldistance| may not suffer symp- will ‘guide the practitioner in the management of the _ toms of eyestrain but may have occasional diplopia for dis- problem: ‘he majority of people who have a phoria __ tance vision tasks such as driving an automobile or viewing probleffi afe rélatively orthophoric at distance, but because television. Some patients are unaware that anything is of a relatively high or low AC/A ratio—the ratio between wrong until they are told that one eye occasionally turns accommodative convergence and accommodation—they — outward. Because divergence excess is due to an abnormally are esophoric (high AC/A ratio) or exophoric (low AC/A ratio) “high AC/A ratio, the use of minus lens power at distance at near. OG Se , wee (overcorrecting myopia or undercorrecting hyperopia) is These two conditions are referred t respectively as con- _ often successful in reducing the exophoria. If the exopho- vergence excess and convergence Thsufficiency. In the less __ ria is also present at near, the use of base-in prism power , », common situations, in which the patient is found to have should be considered: ?0'“4 significant phoria at distance, the condition may or may Basic exophoria. A patient who has a_ significant not be. accompanied by an unusually high or low AC/A exophoria at both distance and near may complain of occa- ratio. If a patient is found to have a high esophoria at dis- _ sional diplopia; at either distance or near (or both) and tance, with or without a similarly high esophoria at near, _ fatigue after prolonged reading. An effective form of man- the condition is referred to as divergence insufficiency. If a agement in many cases of basic exophoria is the prescrip- high exophoria exists at distance, usually with a somewhat __ tion of base-in risms—which reduce the need for positive | lower exophoria at near, the condition is called divergence _ fusional vergénce—for constant wear. we \ excess. Basic esophoria. This condition, in which the patient is -. The conditions just described—convergence insuffi- esophoric at both distance and near, is much like diver- ) ciency, convergence excess, divergence insufficiency, and _ gence insufficiency (already described), except that basic»: * ; divergence excess—are Often referred to as binoculgr visjon, « esophoria implies a higher esophoria at near than in:: J) syndromes. Two’ additional conditions that are occasionally ” divergence insufficiency. Symptoms of basic esophoria are’. } ) po iy encountered _are basic exophoria, in which there is a signifi- © headaches and eyestrain for both distance and near visual -; or cant amount of exophoria at both distance and near, and tasks; an effective form of management.is the prescription ) ‘SP basic esophoria, in which there is a significant amount of of baserout prisms)—which reduce the détnand on negative esophoria at both distance and near. fusional vergencé—for constant wear, ~~~ - J Convergence insufficiency. \The patient with t Paay dom. Other binocular vision problems that should be consid- } insufficiency, having high exophoria ; at near, may gom-.. ered as possible causes of asthenopia are vertical phoria, ani- plain of fatigue or even diplopia following prolonge close yey) pretropia, aniseikonia, and strabismus. \ work This is because constant use must be made of positive Hi Vertical phoria. The presence of a vertical phoria, par- fusional vergence. The most effective treatment for conver- ticularly if combined with inadequate vertical fusional gence insufficiency usually involves visual training to build _ reserves, may be responsible for headaches, diplopia, and ) up the Positive fusional vergence reserve.’ Many patients other symptoms of eyestrain. Although visual training for with“apparent convergence insufficiency have what more _ the purpose of increasing the vertical fusional reserve range ) properly is called “false convergence insufficiency.” The:. may be attempted, the majority of vertical phorias tespond-, * problem is that in close-work, the visual system does not 5c Only to the prescribing of vertical prism. ~ ) ¢“4espond fully to the stivulus to accommodation, and a lag— Anisometropia. pincer cted anisometropia, even of )& of accommodation exists. For these patients, additional © moderate amount ay eluce eyestrain by virtue of the training to build up the facility of accommodation has been fact that it is impossible for the accommodative mechanism found helpful. + =ay- Tar to maintain clear images on both retinas at the same time. Convergence excess. The patient having the syndrome of - On the other hand, large amounts of anisometropia (i.e., convergence excess typically complains of. headaches and 2.00D or more) séldom cause symptoms, as no effort is ‘other signs of asthenopia accompanying elose work) The made to maintain single binocular vision. asthenopia is due to the fact that the patient must con- Aniseikonia.. A difference in the sizes or shapes of the stantly use negative fusional vergence for close work; it may. retinal images for the two eyes, aniseikonia is usually the be particularly severe if the patient has uncorrected hyper- result of magnification differences brought about by cor- opia in addition to the convergence excess. Fortunately, cor- rective lenses and tends‘to cause symptoms of eyestrain and Tecting the hyperopia with plus lenses has the effect of headache, as well gi Blrceptual distortions such as the reducing the esophoria at near, thus reducing the demand tilting or curving of vertical objects. eee  104 PRIMARY CARE OPTOMETRY as) ne svt ninmeneuunce Stfabismus. Also known as tropia, or squint, strabismus that the headaches occur in conjunction with the use of the may occur as a functional or a paralytic condition. Func- eyes, the main problem will not be matching up symptoms tional strabismus is an adaptation to a preexisting refractive to findings but detérmining whether or not the correction or binocular vision problem, and if it is a successful adap- of the patient’s refractive or binocular vision problem will tation, symptoms of eyestrain seldom occur. Paralytic stra- also solve the headache problem. bismus that occurs early in life seldom causes symptoms of eyestrain; but strabismus that occurs during adult life, as a To Prescribe or Not to Prescribe? One of the most diffi- result of paralysis of an ocular muscle or nerve, may cause cult decisions an optometrist has to make is deciding severe asthenopia as a consequence of constant, intractable whether or not to prescribe lenses for a patient who has a diplopia. previously uncorrected refractive error when the patient's. Functional strabismus is said to be concomitant, meaning only complaint is headaches. For some patients, the cor- that the angle of deviation is the same for all directions of rection of as little as 0.50 D of hyperopia or hyperopic astig- gaze, whereas paralytic strabismus is usually incomitant. matism will solve an eyestrain or headache problem. On the~~ - :.other hand, because the peak of the refractive error distri Headaches db, shoe * bution curve for unselected subjects is in the neighborhood 7. Headaches can have numerous causes. However, when a of 0.50 D-6f hyperopia, it should be understood that not person having a headache as a major complaint visits an everyone who has 0.50 D of hyperopia should necessarily_ optometrist, he or she usually has diagnosed the headache wear correcting lenses. ‘ae oes as being due to a visual problem. In many S, PBS the Malcolm Cholerton, a New Zealand optometrist, inves- of a headache problem can be determine el on. the tigated the placebo effect of spectacle lenses by prescribing basis of history. In other cases, well-chosen diagnostic pro- planio lenses for a number of patients who complained of cedures (many of which are included in a routine opto- eyestrain but had little or no refractive e1f0 _Iyf_miany cases, metric examination) are a necessity. In Headache: Diagnosis his patients found that the plano lenses telfvéd their eye- and Treatment, the otolaryngologist Ryan (1954) listed 26 strain for a matter of weeks or months, but the symptoms points to be included in a thorough headache history. The eventually returned. —~ most important of these are the following: Among the factors that should be taken into considera-. Patient’s description of the headache tion when the optometrist is deciding whether to prescribe ODUOANAUAHWNH eH lenses for a patient who complains of an eyestrain or N-. Family history. Headache’s first occurrence headache problem are the following:. Onset time (time of day) 1. The practitioner should make every effort to Naess a. Frequency ee establish whether the patient’s symptoms occur in. Intensity —"“* relation to the use of the eyes. For example, if the. Character cute patient is a student or an office worker, the. Duration - practitioner should find out if the problem occurs. Cause of onset during weekends or other times when the patient is. Location not doing close’ work. Even if the answer is no, the’ = patient’s refractive error is not necessarily the cause Headaches Due to Eyestrain. An important and obvious of the problem. Factors such as inadequate NON characteristic of eyestrain headaches is that they generally iNumination, glare, and poor ventilation should be accompany prolonged use of the eyes. However, Drews considered. ““~ — (1954) suggested that an eyestrain headache can occur the 2. The patient's binocular vision status should not be Ne morning after prolonged use of the eyes. He calls this an ignored. High phorias at near (particularly esophoria) Caii béa Source Of eyestrain or headache, Ne “eye hangover” headache. Most patients visiting an optometrist because of eye- even if there is no significant refractive error. strain headaches will have experienced the headache 3. The patient’s age, occupation, visual habits, and problem for amatter of weeks or months, but not for years. other factors should be Considered. For éxample, an The pain is not soSévere that the patient is driven to find accountant is more apt to require a correction for. a the cause within a few days, but.it, is usually persistent low refractive error than is a farmer or an outdoor enough so that the patient “evetitially pasts around to worker who spends little time at close work. lookit ittto the problem. Often the origi the problem 4. If medical and dental evaluations have found no maybé“tfaced to a change in jobs or other change in the cause for a patient’s headache problem, prescribing patient’s Visual requirements. Eyestrain headaches tend to glasses to correct the refractive error may well be the —- be of medium intensity, and dull in character (as opposed least expensive—and gertdinly the least invasive—C* b to sharp, bysping, or boring), “and they tend to Weocated method of coming to’gfips’with the problem, If 1 _? brow inthe bro region or in the area around or behindMhe eyes. glasses solve the problem, they may obviatéan 2” If prolonged use of the eyes gives rise to excessive muscular extended diagnostic workup, which could include tension, the pain may be located in the back of the neck or procedures such as angiograms, in the gccipital region. :., €lectroencephalograms, and CAT scans.. _—. Some authors have attempted to relate headache loca-. _5. “Loaner” lenses, consisting of low-power spheres, tion and severity to specific reftactive and binocular vision low-power cylinders, or low-power prisms, often, -_ » anomalies. However, these discussions are usually not well prove. to be of great assistance in deciding whether. ---” documented by clinical data and are of limited practical to prescribe for low refractive errors. After a trial of importance. Once the practitioner has established the fact ’ 3 or 4 weeks; a decision often can be made whether  2 Chapter 6 The Patient History 105 to prescribe permanent lenses. The possibility of a and occurs in 20% of the adult population, half of whom placebo effect, however, should be kept in mind. have pypertensixg heart disease. Smith (tape no. 47) has charaeterized h nsion headaches as_ bein, Nonocular Headaches swe, occurring-tasly UP ecko usually being Many patients who have headaches that they believe are present on awakening and disappearing at some time due to eyestrain will be found to have headaches due to _ during the day. other causes (Smith, tape no. 47), A large proportion of He reported that many patients find that they can make headaches are vascular in nature. Smith has pointed out that the headaches go away by drinking a cup of black coffee vascular headaches tend to occur on the basis of age: immediately on arising, and that so atients even go to migraine headaches tend to occur in young adults; hyperter- the extentiof keepirig a hot plate anf Dotiof coffee on a sion headaches tend to occur in the middle-aged; and bedsidé table. Large-scale clinical trials have indicated that headaches due to temporal arteritis tend {o-ocBy, in older mortality resulting;from hypertension can be significantly. patients. Other types of headaches ee optometrist should reduced by early treatment. ° be aware of are muscular contraction headaches, cluster headaches, nasal sinusitis headaches, and headaches due to Yee) UGH) Gba pp Témporal Aiteritis Headche. Also known as giant trigeminal neuralgia. — cell arteritis and cranial arteritis, temporal arteritis is an _.. 7 Cw J inflammat ion of the 4émporal_branch of the internal Migraine Headache. The classic migraine syndrome con- carotid artery, whictt“éappités“the central artery of the sists of a prodromal visual aura, followed by a unilateral, retina. Henkind and Chambers (1979) described temporal throbbing headache accompanied by a feeling of nausea. OD arteritis as: : The visual aura has been variously described as a The most frequently misdiagnosed extraocular cause of OY “scintillating scotoma”; a “fortification scotoma,” which expands as an ever-enlarging fortification; or “heat waves.” preventable visual loss, having an exceedingly high inci- a Many migraine sufferers refer to migraine headaches as dence of ocular involvement. ‘ *}- “sick headaches” and find that they can abort the headache, OG The pathological process is a Ke inflammation of once the visual aura occurs, by going to bed or by drinking the cranial arteries (particularly the ‘temporal. prteries), i we a cup of black coffee. which giant cells are found in the inflammStory exudate”? The visual aura is confined to one side of the visual field Most temporal arteritis sufferers are older people, beyond wee and is due to the constriction of the branches of the inter- the age of 55 or 60 years. : ;. @) nal carotid artery supplying the visual cortex. The headache Symptoms of temporal arteritis includesheadachéin the is caused first by dilation and then by congestion of the epee) region, a etna feeling oFinalaise and loss NS branches of the external carotid artery and the meningeal OoF Sbbptitey scalp tenderness (noted particularly when arteries; the nausea is due to stimulation of the vagus nerve(..) in'g thé“hair), and claudication of the jaw while Troost (1978) has described what he callsa Chewing. By interfering with the blood supply to the vessels common NS migraine. This is a headache in which nausea is the pre- ~ supplying the optic nerve, temporal arteritis often leads to dominant symptom and the prodromal visual aura does not a condition known as..ischemic-optie neuro athy:’ This is Ne appear. likely to cause a trafistet IR CPatiOon, known as amauro- Migraine headaches must be diagnosed entirely on the Ve sis fugax, and may lead to occlusion of the central artery of basis of history and symptoms, because there are no posi- the retina. tive physical or pear nogical ipsings, the fact that Because the consequences“of temporal arteritis are so \m: migraine headachesstend to be erited. may help in the severe, optometrists should eae ck whenever G} oe ye ‘differential diagfOS Treatment of migraine includes des bot! both an older patieny complains ofadebitlifating heddache and ‘G+ prophylactic (preventive) and symptométit “medications” 1) ) 77 One of the most common forms of symptomatic treatment transient loss &c vision. Diagnosis of temporal arteritis is(j},.s Day involves: ergotamin made on the basis of an increased blood sedimentation rate “ e tartrate :and its derivattees” which and by the presence of giant cells in the temporal artery, as tans Vadoconstriction of the blood vessels inthe visual determined by temporal artery biopsy (Smith, tape no. 64). _ cortex. In addition, many migraine suffefétSfirfd that a cup Smith described the treatment of temporal arteritis as the WS or two of strong coffee may help to bring the attack to an’ / aggressive use of systemic steroids and emphasized that an end. cS “inadequate use of steroids increases the chance that the For many years I have experienced the visual aura‘on a central artery of the retina will close. number of occasions. It tends to occur during a period of NS unusual stress; but I have never experienced..¢ migraine Muscular Contraction Headache. Also known as tension headache. First of all, I’m aware of a “scMtingting” appear- headache, muscular contraction headache has been ance located to the right or left side of what I’m looking described by many authors as the most common form of at—very close to the fixation point. Within a few minutes headache. Ryan (1954) described tension headache as a vas- the scintillating:scotoma, which occurs in the left or right cular headache, occurring usually in the letdown phase that visual field of both eyes, begins to move outward, toward the follows a prolonged period of stress. He déScribed it as either - left or the right side ‘of my visual field, after which it dis- a vicelike pain in the forehead, a pain located in the vertex, appears. I have found, repeatedly, that one or two cups of or a pain in the occipital area accompanied by muscular coffee will almost always end the visual aura.’ ‘stiffness in the neck.. Many authors consider muscular contraction headache Hypertension Headache. According to Laragh (1974), to have a psychogenic origin. Prophylactic treatment is. _ hypertension is the single biggest causative factor of death usually directed toward altering the patient’s behavior:  es _106— ; PRIMARY CARE OPTOMETRY _ oa a Symptomatic treatment includes the use of analgesics, In a few cases the be due to more threatening condi- muscle relaxants, and sedatives. Because eyestrain ie includingtu: ctsdnd glaucoma. Oe headaches tend to occur in the same areas (frontal and occipital) as those described for muscular contraction fedhdn thing and Burning. Symptoms of mild itching and OO headache, it is likely that muscular contraction may be a burning may accompany small amounts of hyperopia, contributing cause of an eyestrain headache. astigmatism, or a binocular vision problem. These symp- toms may occur in conjunction with hyperemia of the lid i Cluster Headache. Also known as histamine cephalgia, margins and conjunctiva. In many cases the correction of oY cluster headache is a severe, boring, unilateral headache the refractive error or binocular vision problem will not occurring in the tempofal région and oftén accompanied by only relieve the itching and burning, but may also relieve ipsilateral lacrimation and nasal congestion. Most sufferers the hyperemia. OO Of Cluster Headache are/middle- aged men. Why this occurs is not well understood; one possibility The term cluster refe -to-the tendency for one or more is that a part of asthenopia is a triggering of the local axon OP headaches to occur daily within a short period of time. reflex. Efforts to compensate for the refractive error may Attacks typically occur at night and are more apt to occur stimulate sensory nerve endings and, therefore, be respon- OY while the person is lying down; sometimes the sufferer can sible for a local increase in blood supply, manifested as abort an attack by getting up and walking around or even hyperemia of the conjunctiva and lid margins. This hyper- OY by sitting up in bed. Patients often describe the pain as emia is responsible for sensations of itching and burning OY / /. \y unbearable. Treatment, particularly prophylactic, is similar U/ tothat used for migraine. and causes the individual to rub his or her eyes. It is thought that eye rubbing can increase the bacterial DY é content of the tears to the point that an inflammatory } Nasal Sinusitis Headache. According to Ryan (1954), process may occur (conjunctivitis or blepharitis). It has even OD headache is the most predominant symptom of acute nasal been suggested that one of the main factors in the etiology sinusitis, but not of clfonic nasal sinusitis. The pain is most of styes may be the rubbing of the eyes due to a small refrac- NY often in the frontal region and is most pronounced ci tive error. the person is stooping down. Other ae mets Blepharitis. A common cause of itching and burning of coughing due to"postnasal drip, low-grade anda sak. the eyelids is blepharitis, an inflammatory process affecting porary loss of the sense of smell. the lid margins. In the seborrheic form, numerous small Ss scales, or “dandruff,” may be seen clinging to the lid Trigeminal Neuralgia. Also known as tic douloureux, margins. Using the slit lamp, these scales are most easily trigeminal neuralgia is an extremely sharp) Blpiercing, knife- visible when the patient closes his or her eyes and focuses NS like pain, of sudden onset, in the fact egion. It can be due on the wide beam along the upper and lower lid margins. to inflammation of any of the three divisions of the trigem- Treatment involves washing the hair and scalp with a inal nerve, but it least commonly occurs in the ophthalmic shampoo such as Selsun and removing the scales from the NN division. According to Smith (tape no. 47), trigeminal néu- lid margins with a damp cotton applicator or with half- ralgia is characterized by a trigger zone, and the pain can be strength Selsun or baby shampoo. brought about by touching a specific area in washing the In ulcerative blepharitis a bacterial infection is present, ww face, cleaning the teeth, or shaving. Many sufferers of this the most common cause being staphylococcus. The ulcerated condition, who are usually middle-aged or older, live in a areas along the lid margin lead to loss of eyelashes. The pres- constant state of fear, dreadirig the occurrence of the next ence of the bacterium and its toxins in the lower conjunc- attack. ~ — tival sac during the night may cause symptoms of the lids There is little danger of confusing trigeminal neuralgia sticking together on arising, and it may lead to conjunc- NNN with other headache types, "because it occurs in the facial tivitis and superficial keratitis involving the lower portion area—usually in the areas of distribution of the maxillary of the cornea. If untreated, a chronic form of blepharitis and mandibular divisions—and it involves a trigger. zone. and conjunctivitis may result and may persist for months Anticonvulsive agents, including phenytoin (Dflant tin) and or even years. ee eee Allergic conjunctivitis. Intense itchingis the most promi- Ne forms of treatment. nent symptom of allergic conjunctivitis.. A mild, nonspe- cific form of conjunctivitis known as atopic, or hay fever External Eye Symptoms conjunctivitis, occurs in association with allergic rhinitis. Among the external eye symptoms most often given as Symptoms include itching, tearing, and redness of the eyes patient complaints are the following: along with edema of the bulbar conjunctiva. ¢ Itching and burning of the eyes - Vernal conjunctivitis. A form of allergic conjunctivitis * Pain or a foreign body sensation occurring mainly in the spring and summer months, vernal ¢ Sensitivity to light conjunctivitis, most commonly affects young males. The ¢ Excessive tearing main symptom of vernal conjunctivitis is extremefitching ¢ A feeling of dryness (if there is no itching, it is not vernal). In addition, thereis In many cases these external ocular symptoms are mani- a stringy or ropey discharge. Vernal conjunctivitis can occur festations of enero gaane can be relieved by correcting in both palpebral and limbal forms. In the palpebral form, the patient's réfractf ror or binocular visionanomaly. In giant cobblestone papillae are found in the upper tarsal _other cases the symptoms are due to pathological processes conjunctiva, while in the limbal form, papillae occur as involving the ocular adnexa, such as conjunctivitis, ble- thickened, gelatinous opacifications in the conjunctiva ‘sur- _ pharitis and other lid conditions, and tear film deficiencies. rounding the limbus. wv Yew 7S Ve Chapter 6 The Patient History 107 oe Gy ps Treatment of nonspecific allergic conjunctivitis, accord- drops and cold compresses), but once the subepithelial ing to Vaughan and Asbuyy (1977), includes local instilla- YY opacities occur, steroid treatment may be indicated if tion of vasoconstrictors¥ cold compresses¥fo relieve the marked acuity loss 1s preset (Dawson, 1979). itching, and antihistamine#taken orally. This form of treat- Congenital glaucoma. Extreme sensitivity to light and ment may also suffice for mild cases of vernal conjunctivi- VY excessive tearing in the first few months or years of life tis, but for the more severe cases Allansmith (1978) should cause the practitioner to suspect the presence of con- wy recommends what she calls “pulses” of steroids: topical genital glaucoma. These symptoms may occur prior to a prednisolone is given for a period of 4 days, which usually noticeable enlargement in the size of the eye (buphthalmos) we controls symptoms sufficiently to allow the use of other or glaucomatous cupping of the optic nerve head. forms of therapy. : wwe Bacterial conjunctivitis. The most prominent symptoms Excessive Tearing. Apart from those conditions in which of a bacterial conjunctivitis are irritation and redness of the excessive tearing occurs as a result of stimulation of the eyes, a mucopurulent discharge, and complaints of the eyes ophthalmic division of the trigeminal nerve, it may be Vy sticking together in the morning. Jrgatment is by topical caused by any condition that interferes with the lacrimal WV application of antimicrobial agerifs? the choice of agent drainage system. These conditions tend to occur at the depending on the responsible bacterium. extremes of age: in infants as stenosis_of the nasolacrimal J dict and in older adults assenlécaopion) Pain or Foreign Body Sensation. A patient who reports og Stenosis of the nasolacrimal duct>~tfGne of the naso- wow ocular pain will ‘usually bp able to state, on questioning, lacrimal ducts fails to open in early life, dacryocystitis whether the pain is a Superficial, foreign-body pain or a (inflammation of the nasolacrimal sac) may result. In addi- deep-seated pain. If a foreign body is present, it will usually tion to treatment with antimicrobial agents, probing of the Vw be embedded in the upper tarsal conjunctiva and can be nasolacrimal duct may be necessary. removed by everting the upper lid and carefully dislodging Ectropion. In an older individual, loss of tone of the it with a sterile cotton applicator. If a foreign body is orbicularis muscle may allow the lower lid to become Ye embedded in the corneal epithelium, it sometimes may be everted, or turned outward. When this occurs, the inferior dislodged by the use of irrigating solution. If this fails, the punctum fails to make contact with the marginal tear strip, YS foreign body will have to be removed with a foreign body so tears overflow the lid and run down the cheek. If an older spud. patient complains of always having to carrya handkerchief YY A foreign body sensation in the absence of a foreign body to wipe away the tears, ectropion is almost sure to be the may be due to a corneal abrasion or recurrent corneal. cause. Surgery designed to shorten the tarsal portion of the erosion. In either case, staining of the precorneal tear film Ye lower lid is indicated. with fluorescein should make it possible to find the cause of the problem. : Feeling of Dryness. A complaint of a feeling of dryness Deep-seated ocular pain may ¢ caused by more of the eyes can be due to any of a number of tear film severe conditions, including corneal ulcers, acute iritis, and abnormalities. Lemp (1980) discussed these abnormalities acute glaucoma. An important indication of an internal (as in terms of aqueous deficiency, mucin deficiency, lipid opposed to an external) condition is the presence of ciliary injection /This is a lilac-colored injection of the deep con- abnormalities; and “‘lid-surfacing "abnormalities. More serious possible causes of a feeling of dryness are degenera- junctival vessels fanning out from the limbus, as opposed tions and dystrophies affecting the anterior portion of to conjunctival injection, which is a bright red injection of the cornea, one of the most common of which is Fuchs’ superficial anastomosing vessels and is more prominent dystrophy. toward the fornix Aqueous deficiency. Also known as keratoconjunctivitis Visual acuity is also an important guide. A corneal ulcer, sicca, aqueous deficiency is an absolute or partial deficiency iritis, or acute glaucoma will usually result in lowered visual in aqueous tear production. In addition to the complaint of acuity, whereas a foreign body or abrasion will not.... a feeling of dryness, the patient may complain of a sandy. »p (238 or gritty feeling in the eyes, a burning sensation, and sen- ?. Sensitivity to Light. The triad of pain, photophobia, and sitivityto light. Keratoconjunctivitis sicca Occurs most often ¢ yy? lacrimation is the well-known response to stimulation of the id in older“women, although it can occur in men and in ophthalmic division of the fifth cranial nervey Any condi- younger women. If combined with dry mouth and rheuma- tion just described, in which pain is a symptom, may be toid arthritis, it is known as Sjégren’s syndrome. accompanied by a complaint of increased sensitivity to. Clinical signs of keratoconjunctivitis sicca include the light. Conditions in which sensitivity to light is a predom- following: inant symptom are epidemic keratoconjunctivitis and| con- 1. A deficient marginal tear stripV genital glaucoma, 00 2. Excessive debris in the tear film J _Epldepiegeratoconjunctivitis, This highly contagious 3. Mucous threads and filaments in the tear film form of viral Conjunctivitis begins as an acute follicular con- 4. Poor tear production when measured by means of the J junctivitis with pain, injection, and tearing. After about Z_ Schirmer tear test days, raised epithelial lesions, staining with fluorescein, The presence of mucous threads and filaments in the tear may be found scattered over the cornea. At this stage and. film is due not to excessive mucin production but. to the in the stage to follow, photophobia may be a marked. lack of sufficient aqueous tear production to wash away the symptom. After approximately 7 more days, subepithelial - mucus..The main form of treatment for aqueous tear defi- ' opacities will be found under the epithelial lesions. Inthe ciency.is the use of artificial tears. These can be used several early stages, only supportive treatment is used (astringent times.a day, if necéssaty, to Maintain ocular comfort. In  peopl! f is : A: cf ee po a} 2 v ’ weed KO” : ; ~ ee fe - rel yo Dial Dar vient by a PRP 108 PRIMARY CARE OPTOMETRY deevin. -~ severe cases, particularly if filamentary keratitis is present, | over a S- to 10-year period. Complications of pars planitis os therapeutic soft contact lenses are sometimes used. include posterior subcapsular“cataracts ¢ and | cystoid macular and Mucin deficiency. The presence of a mucin deficiency edema, ~~~ cs a can be determined by the use of the precorneal film breakup Retinal hemorrhages. Complaints of seei red spots test, described in Chapter 8. A precorneal film breakup time may be cus d by hemorrhages within the retitfa-or-inte- { of less than about 10 seconds indicates the presence “of a the vitreé&s/ Conditions in which retinal or vitreous on mucin deficiency. However, before concluding thata mucin hemorrhages commonly ocguy include diabetic _retinopa! xs deficiency is present, the breakup test should be repeated a _thy, ni etetiive vetinophity , and the various blood ‘ ANY number of times. If the breakup occurs repeatedly in the — dyscrasias. Any complaint of red spots in the visual field same area, an epithelial defect rather than a mucin defi- ciency may be the cause (Lemp, 1980). The most common cause of mucin deficiency is a reduced goblet cell population due to avitaminosis A. A ate th poor breakup time may be caused by a number of other _ vitreous bade seldom detaches an ly, wheré the vitre- conditions, including aqueous tear deficiencies and lipid ous base straddles the ora serrata, but posterior vitreous ae abnormalities. Treatment for mucin. deficiency involves detachment is.a relatively common occurrence in eyes in the use of artificial tears, particularly those (called which partial vitreous liquefaction has taken place. The liq- mucomimetics) designed to have an action similar to that of _ uefied posterior portion of the vitreous collapses, and the mucin. ringlike posterior attachment at the Optic nerve head , Lid-surfacing abnormalities. Normal blinking has the becomes detached. \ effe