Staff Training

Strategies for Preparing for the COA Exam

                                    Sharon teaches subjective refraction in Texas

                                   Sharon teaches subjective refraction in Texas

I am preparing for the COA exam - my first JCAHPO exam,  the most difficult part of the process for me is not knowing the depth or breadth to study in each content area. I constantly wonder "Am I over-studying? Am I understudying?  Am I studying the right things?".  - Sharon Alamalhodaei, 1993

Once you have taken your first JCAHPO exam, you have a better idea of how the questions and answers are phrased and the testing process as a whole.  Knowledge is power. Unfortunately, when it's your first JCAHPO exam you don't have this knowledge.   This, my friends is the real challenge of test preparation.

Strategy #1 Study Material & Prep Courses

Review the suggested reading material for the exam. Click on the link "Study Resources" here

Due to the cost, most people cannot purchase all of the study resources listed, so you must either select a few broad texts or be creative by leveraging as a group and buying and sharing books with colleagues. Even better, ask your practice to build a library of resources which you can 'check out'.  If you can only choose a few books here are my recommendations: 

1. Ophthalmic Medical Assisting: An Independent Study Course (Newmark, O'Hara) Any edition newer than a 4th edition will do and they are readily available used on Amazon. Unless you have attended a formal accredited Ophthalmic Training Program, this book and the test you can purchases separately is a prerequisite for the COA exam - so you need it regardless. 

2. The Ophthalmic Assistant (Stein, Slatt, Stein) Again, any recent edition will do and they are also readily available used on Amazon. The trick with this book is there is a TON of information in it that you don't need to know for the COA exam. So, refer to the test content areas and study just that content in this book.  Think "Basic Level Proficiency" and read to that depth and breadth

3. The COA Study Guide, available from JCAHPO is terrific. It's practice exam questions and is only $15. The depth and breadth of questions closely resembles what you'll see on the actual exam.

4. I teach in person COA Exam Prep Courses throughout the country.  Check here for more information and to see if I'm coming to your area soon.  I also teach an online COA Exam Prep Course which allows you access for 6 months. You can pause and re-review any part of it.  It includes a 200 Question practice exam plus individual tutoring with me. A free sneak peak is available here. You can click through a link below the sneak peek to purchase it.

4. Some people like using flash cards to study.  ATPO has a set for the COA exam which you can find here:  Flash Cards

Strategy #2 Find a new COA

Talk with colleagues who have recently taken the exam. JCAHPO does not permit one to share actual questions on the exam, but these colleagues can help guide you as to whether you're studying the right material and depth and breadth of material. 

Strategy #3 Study Buddies

Get a study buddy.  It' s much more fun joining forces with someone who is facing the same challenge you are.  It holds you accountable for progressing with your studying and you can quiz one another.  

Strategy #4 Break it Down

"How do you eat an elephant? "One bite at a time!"  

Set a  goal date to take the exam. For example, 6 months from now.  Then, divide up your study material accordingly.  For instance, if you're taking the exam in 6 months (26 weeks) divide up the study material into 20 sections. This leaves a little wiggle room in case something comes up in your life that precludes you from studying that week and leaves a week or two right before your exam for last minute review and memorizations. Then, stick with your study schedule.  

Strategy #5 Phone a Friend

Do you have physicians or senior techs who like to teach? Take advantage of their knowledge. Be inquisitive and ask questions about anything you study but don't understand.

Strategy #6 Join In

Join Ophthalmic Tech Facebook groups. One of my favorites is "Ophthalmic Techs on Facebook".  Like and Follow me on Facebook and Twitter at "Eye Tech Training". Subscribe to this blog where I post a wealth of information about technician skills and technique. 

You CAN do it if you put your mind to it! Please feel free to reach out to me if I can help you. My email is or message me on Twitter @EyeTechTraining or Facebook at "Eye Tech Training"

Newbie Training: Contradictions In Technique

       Becoming an Experienced "Baker"

      Becoming an Experienced "Baker"

When I Was a Newbie

I was new to the ophthalmology field.  I had a designated trainer who put me on the fast track to proficiency.  I became confused, though when colleagues would contradict what I was taught.

For example my trainer taught me to check vision repeatedly during a refraction. Colleagues told me I should only check vision when the refraction is complete.  My trainer taught me to isolate letters on the Snellen Eye Chart, but others told me to keep the chart open.   Was my trainer correct? Were my colleagues correct?  I was confused and began to doubt my trainer.  I worried I was doing things wrong. 

What I Did Not Know  

I did not know that there's more than one way to skin a cat. (I so hate that saying, but it's most appropriate in this circumstance).  My trainer and my colleagues were both right.  

It's difficult being a new trainee and when you add multiple opinions to the mix it is even more difficult.  I encourage techs to avoid giving advice to trainees. Instead defer to the trainer (even if you'd do things differently).  It will likely only add to the newbie's confusion, not add to their proficiency.  

Learning To Bake a Cake

A new baker follows the recipe as it is written because he doesn't have the knowledge to or an opinion about changing the recipe.  However, once the baker has made the cake a number of times, he might decide to add nuts or substitute caramel for chocolate.  The cake will still turn out tasty even when those ingredients are changed.  However, what would happen if the baker changed ingredients like yeast or flour?  

An experienced baker knows what ingredients he can tweak and what he shouldn't change. A new baker doesn't have the experience to know this so he should follow the recipe as it is written.    

The Experienced Tech

Once the Ophthalmic Assistant gains experience, she learns what parts of her work up can be tweaked and what should never be changed.  She is now an "experienced baker" and can add all the nuts she wants to her cake!

Taking Charge in the Exam Lane


Managing encounters with patients is both an art and a skill.  Either you run the encounter or the encounter will run you.  This is frequently one of the most difficult skills for new technicians to master. Conflicting Goals?

It seems we have competing interests: On one hand,;we strive to provide a welcoming and friendly demeanor, yet there are real time constraints dictated by appointment templates. Is this a no win situation?    I have found there are ways to satisfy both customer service and time constraints.

How to Manage Your Encounter with Finesse

Have you ever worked up a patient who wanted to engage in seemingly endless social conversations? What about the patient who won't stop joking around?  A simple yet effective way to get your encounter back on track without offending the patient is to say "Mrs. Smith, the doctor is probably wondering where you are. Let's get finished up so we can get you in to see him."  This is TRUE! The doctor probably IS wondering where your patient is. He is probably standing in the back hall looking at his schedule and wondering why he has yet to see Mrs. Smith whose short follow up appointment was 45 minutes ago!  The statement will not offend your patient; if anything, it may flatter them... ("Dr. Jones is looking for me and wondering where I am!").  I have used this technique many times over the years and it has worked without fail.

If you don't manage your encounter, it will manage YOU.  Take charge (but in a nice way).

How to Deal With Conflict in the Office

Conflict is one of the toughest issues one has to deal with in the office. Business bring people together from many different backgrounds. This is good because varying experiences and capabilities enhance the efforts of the team.  However, the differences in and variety of people and experiences can cause conflicts to arise.

Strong leadership evokes respect, authority and a sense of grace.  When leadership is lacking, resentments arise. Trust is essential for any work environment.  Divisiveness, back-biting and internal politics can lead to distrust causing morale and essential  office functions can go downhill fast.

By the same token, a manager's job is not to simply resolve employees' conflicts.  It is to ensure that everyone is respected and understood.  Staff members should be empowered by management to resolve conflict among themselves in a mature, "grown up" way.

Here are some strategies to resolve conflict:  

  1. Ask yourself "Could this reaction be caused by something else?". For example, perhaps the other person has a sick family member and isn't responding to you as she normally would due to these personal circumstances.
  2.  Restate your position politely and respectfully. Avoid being defensive or seeming to    grind your heels in.  This provides the opportunity  to correct misunderstandings.
  3.  Mentally separate the people from the problem.  Realize that most people have good  intentions and aren't trying to cause conflict.  Give others the benefit of the doubt.  Separating the issue from the person helps to maintain good relationships once the  conflict is resolved.
  4. Listen and try to understand the other party's point of view.  Listen first, talk second and be open minded.
  5. Discuss observable FACTS (no opinions or suppositions).
  6. 6. Explore resolutions together and be open to the fact that a third option (other than your opposing positions) may be the best option.

The keys to successfully resolving conflict in the workplace are to be non-confrontational, open minded and respectful and when this happens, everyone wins!

How I Saved a Practice Tens of Thousands of Dollars

download (2)The administrator called me asking for help. She said her doctors had been getting a lot of glasses remakes and unhappy optical patients. Additionally, the doctors had lost faith in their technicians' VA's and IOPs measured with a Goldmann Applanation Tonometer.  The doctors and administrator were befuddled because their 30+ technicians had been doing well but seemed to have faltered over the past year.  They asked me to come to their office and spend three days with their technicians. Evaluating the Problems

I began by simply observing each technician as they processed patients. This took a full day given the fact that there were more than thirty technicians, but by the end of the first day I knew exactly what the problems were.  What I discovered is that a technician with many years experience  had been hired a year prior and had been put in the role of head technician and trainer. Unfortunately, this technician was not as well skilled as she (or the practice) thought she was. She had spent the past year re-teaching all of the technicians erroneous skills.


This practice worked in plus cylinder but the technicians had been trained to 'chase the red' (!) This one error was perpetuated from technician to technician until only spherical patients were getting accurate refractions.  Additionally, the technicians were measuring VA incorrectly. They recorded VA as the last line of letters they read all of the letters easily. The technicians were also taught to align the Goldmann applantion tonometer mires into the shape of an 'S' rather than 'just kissing' resulting in erroneously low IOPs.

Light Bulb Moments

I spent the next two days re-training the technicians on VA, refraction and GAT and by the end of the third day, they were all accurately refracting, measuring VA and GAT. The technicians had many 'light bulb moments' and It was a happy ending for everyone except the head technician who unfortunately, was demoted from that position. It was sad, but necessary.

My Two Cents

When you're new to the field, you only know what you're taught. If you're taught incorrectly you won't KNOW you've been taught incorrectly. This is why it's critically important to ensure technician trainers know their stuff.  Don't be shy about doing 'working interviews' with even the most seasoned technician. It's the only way to be sure they have good skills.

When you assign a lead tech or technician trainer, TRAIN THE TRAINER.  Ensure this trainer gets support from the practice in the form of continuing education and feedback and mentoring from the physicians.

A Happy Ending

In the end, the fixes for this practice were easy, but it took an outside person who could devote the time to evaluating each technician's work up to find the root of the problem. I called the administrator a few weeks later and asked how the clinic was going.  She said the doctors were thrilled with the quality of the technicians' work and their glasses remakes were down dramatically and the technicians said they felt more confident in their skills. She told me they estimated my services had saved the practice 'tens of thousands' of dollars.   That was great to hear... but the best part for me?  Better patient care. 

"Difficult" Refractions

phoropter (4)Most refractions are straight-forward but what happens when you're faced with one that's not?  Knowledge is power. With the proper training and guidance you can handle even the most challenging  refractions. Let's discuss some common challenges you may face and how to meet them head on. First, let's learn an important formula to know when scrutinizing your refraction. Generally, a one diopter change in spherical equivalent should equal approximately three lines of improved VA on the Snellen eye chart. A spherical equivalent is calculated by taking half of the cylinder and adding it to the sphere power, then dropping the cyl and axis.  For example, the spherical equivalent of -1.00 +1.00 x 180 is -0.50.

Patient Refracts To a Lot More Plus Cyl AND a Lot More Minus Sphere:                  Probable Cause:  Too much minus sphere, inaccurate refraction.                                                        Try This: Decrease spherical equivalent (0.25 sph to each 0.50 cyl)                                            Example:  WRx: plano +1.00 x 180 20/30   MRx: -2.50 +3.00 x 180 20/20

Explanation: This refraction doesn't make sense.  The spherical equivalent of this patient's WRx is +0.50. The spherical equivalent of their MRx is -1.00. They have only 2 lines of improvement on the chart with 1.50 D change in spherical equivalent.  You wouldn't expect that big a change in Rx for only two lines improvement of VA.

What to Do:  Decrease the spherical equivalent until BVA is obtained.  This is accomplished by removing +0.50 cyl and 0.25 sphere at the same time and checking VA after each change of the lenses.  The end point is when you determine the least change in spherical equivalent which gives the best VA.  Then, recalculate the change in spherical equivalent vs. the improvement in VA and see if it makes sense.

Patient Refracts to  > 3.00 D Difference Between Their Two Eyes.                                                Probably Cause: Anisometropia                                                                                                                    Try This: With both of patient's eyes open: Show pt changes in sphere of 0.50 or pulling sensation in RF increments so that both eyes’ sph powers are brought closer together.  Example: Pt refracts to:  -3.00 +1.00 x 180 OD   +1.00 +1.00 x 180 OS                                                                     Show the pt:   - 2.50 +1.00 x 180 OD   +0.50 +1.00 x 180 OS                                                  Ask the patient to compare this Rx with the refracted Rx.   “Does this lens look about the same?” Remember to show them binocularly - not monocularly.  Recheck binocular VA.

Explanation: Anisometropia means the patient has > 3D difference in refractive errors between their two eyes. Minus lenses minimize images, plus lenses magnify them. Patients who have anisometropia may have a difference in perceived image size known as anesekonia. Our brains can only fuse images that are of similar size, so when the patient has anisometropia they may have double vision or a pulling sensation.

What To Do: Give the patient the Rx which gives them the sharpest vision possible without causing a pulling sensation or diplopia.  It's critical to trial frame the new Rx. Be certain to center the lenses in the trial frame so the patient is looking through the optical center to avoid induced prism. With the trial frame on, encourage the patient wander around the office and look outdoors to make sure they don't have any diplopia or pulling sensation in the Rx.


Every refraction is a learning opportunity for the technician. Follow up with your doctor after he or she sees these challenging refractions and ask the doctor why he Rx'd what he did so you can learn from it. With practice and exposure to many different types of special situations you will become a seasoned refractionist. Happy Refracting!

Why Refract?

I prepared to refract my patient, Mrs. Turner who had just read 20/70 but she refused.  "I'm not getting new glasses" she said,  "I just want the doctor to check my cataract."  phoropter (2) Why Refract?

There are many reasons we refract patients. Some are obvious. The patient wants new glasses or contact lenses. Others are not so obvious.

Doctors can detect, follow the progression or improvement of certain eye diseases by measuring best corrected vision.   For example,  the primary symptom of macular edema is decreased VA so patients who are being followed for macular edema should be refracted to determine what their best corrected VA is since this is a direct indicator of whether the disease is improving or worsening.

The Role of the Ophthalmic Technician in Patient Education

Patient Education is key. When your patient refuses a refraction yet clearly doesn't understand the purpose for the refraction, it's up to the technician to educate the patient. I encountered this with my patient, Mrs. Turner.

"Mrs. Turner,  the reason we are doing this test is so the doctor can determine what your best vision is - not necessarily to prescribe new glasses.  This is important so the doctor can determine if your cataracts are indeed the cause of your decreased vision."  Once I explained this, Mrs. Turner was amenable to having a refraction performed and my doctor had all of the information he needed to make medical decisions which benefited Mrs. Turner.  

Your Role in Patient Satisfaction

download Your job security is directly related to your practice's success and your practice's success is directly related to patient satisfaction. Therefore, your job security is related to your patients' satisfaction. 

How can you contribute to patient satisfaction?

Efficiency  No one enjoys waiting.  A study done recently found that patient satisfaction correlates with wait time. The study found "Minimizing the time patients spend waiting to see a provider can result in higher overall patient satisfaction scores" *

Go the Extra Mile Give patients more than they expect. For instance, if it's pouring rain outside and a patient doesn't have an umbrella, offer to walk them to their car with an office umbrella.  It's the little things that mean a lot.

Use Positive Language  Instead of saying "I don't know" say "I'll find out".  Instead of "I can't do that - it's against our policy" say "Here's what I CAN do for you..."  

Be "On Stage"  You're at a work place, not a social occasion. When you are anywhere a patient can see or hear you be 'on stage". This means you have a professional demeanor and keep conversations and actions patient centered. When you're "off stage" (out of patient's hearing or sight) it's okay to let your hair down.

Avoid Calling Patients Pet Names like "honey" "dear" or "sweetie".  Some patients may be offended or feel patronized by these names. Terms of endearment should be reserved for close friends and family, not patients.

Work as a Team Avoid gossip and conflict with coworkers.  When everyone works together and pitches in to help each other out for the common goal of patient satisfaction work is seamless and both job satisfaction and patient satisfaction soars! It's a beautiful thing when everyone works as a team toward a common goal.


Change is a-comin'!

imagesThe only constant in life is change.  Autumn is upon us; leaves are changing and the weather is cooler. Great things lie ahead; however, in order for us to experience those great things, change must happen.  Today is the official beginning of ICD-10 coding. Most - if not all of us have dreaded this for a few years now. This new coding system is a mandate by the World Health Organization and the US is the last country to make the transition to it.  Hopefully you've had a good amount of training in this new coding system and have tools at your disposal to help you meet this challenge.

One of the keys to success in life is learning to embrace change.   Embrace this new ICD-10 challenge and realize that years from now you'll  likely look back and may not even be able to remember what ICD-9 was all about!  ICD-10 will become your "new normal". Without change there is no progress. Change is GOOD!

The Mysterious Case of the Elusive 5 Diopters of K

Tdownloadhe Patient was 80 years old and the father of a prominent doctor in town. He had traveled from the Phillipines to have cataract surgery performed in his right eye by my doctor. Pt Complained of gradual decrease in overall VA OD > OS x 3 yrs. ROS, PFSH were noncontributory and he had no history of ocular surgery. WRx was -2.00 sph OD with VA 20/100 and -1.50 sph OS with VA 20/50. download (3)Uncorrected VA was not measured.

The Refraction His BCVA (MRx) was 20/80 OD with -2.50 +0.75 x 180 and 20/30 OS with -2.00 +0.50 x 180 OS. Pupils, VF to C, Motility were all unremarkable.There were no auto-refractor findings as we did not have an AR in our office then and old records were not available due to him being from overseas.

Exam revealed dense NS and dense cortical opacities OD > OS with healthy maculas and ONs although the view of the macula was difficult OD.

Impression & Plan: Medically ready cataracts OD > OS. After informed consent was obtained, Cataract Extraction with a standard IOL OD was scheduled with a target refraction OD of plano. The patient was counseled that he would likely need only reading glasses OD after cataract surgery.

Pre-opdownload (4) Measurements: I was tasked to perform this patient's pre-op IOL measurements and calcs. This patient was one of my favorites not just because he was always smiling and friendly, but also because he was known for his cool ties. He always came into the office in a suit and tie and it was great fun seeing what funny or cool tie he would wear. Tdownload (1)his day he was wearing a 'Flintstones' tie.  Time to do the scan! Yabba Dabba Do!

Manual Keratometry  K's showed OD were 42.00/47.00 @ 90 and OS were 41.87/47.00 @ 90.  I was surprised by this as he was not wearing nor was he refracted to anything close to 5 D of cyl at 90!

Thimages (1)is Calls for Some Sleuthing  I decided to perform streak retinoscopy to rule out uncorrected refractive error. It was important to document more data to prove or disprove that this cyl was real.  It was important to perform the retinscopy prior to the AScan so the cornea is not altered.

If this patient needed 5 D of cyl but wasn't wearing it, the tech who did his refraction may have missed it as it is sometimes difficult to find in a standard refraction. Many times patients with large uncorrected refractive errors can't lead the tech subjectively to their true correction there because their VA is so blurry. If his VA could be corrected with the cylinder enough to satisfy his patient's visual demands, then cataract surgery was not warranted now.

Retinoscopy findings were close to the MRx: - 2.75 + 0.50 x 180 OD and -2.00 + 0.50 x 180 OS. Hmmmm... there was only one explanation.

The AScan was performed and showed an average AXL OU.

Time to Talk with the Surgeon  I presented this chart to the surgeon. I told her I suspected he had lenticular AND corneal astigmatism oriented at opposite axes and the lenticular astigmatism essentially cancelled out the corneal astigmatism. This explains why his retinoscopy findings and subjective refraction were nearly spherical but the keratometer revealed otherwise.  She called the patient to come into the office for a talk.

The Surgeon Counsels the Patient The surgeon explained to the patient that our download (6) measurements showed he had significant astigmatism and would have it also after the cataract was removed. She explained why. He said was not aware that he ever had astigmatism.  The surgeon explained she would perform an additional procedure during the cataract surgery to minimize the amount of residual corneal astigmatism he would have but likely she could not eliminate it and he WOULD need glasses for distance AND near post operatively. This discussion was documented in the patient's record and his target Rx OD remained at plano, with a note that he was told he would require spectacle correction for distance and near.

The surgeon proceeded as planned without complications.  The surgeon performed Limbal Relaxing Incisions which decreased his post operative residual  corneal astigmatism to 2 D. The patient was fit with Bifocals postoperatively and was pleased with his visual outcome (after he become accustomed to wearing 2 D of cyl!).  A month later he had cataract surgery OS with a similar outcome. The patient flew home to the Philippines pleased; however, we sure did miss seeing him after he left.

Lesson Learned  This case demonstrates why ophthalmic medical personnel must have a thorough knowledge of anatomy, physiology, refractive errors and instrumentation and be able to put 2 and 2 together. If this patient had not received appropriate testing and counseling, he may have been disappointed and surprised to learn he had a significant postoperative refractive error. He also may have been displeased that he had to become accustomed to astigmatic correction. Additionally, if the retinoscopy was not performed prior to the AScan there may have been a question as to whether cataract surgery was medically (7)

As you work up your patient ask yourself "Does this make sense?"  Using all of your collective knowledge helps you know if things are adding up. If they don't, do additional investigations to determine why. Happy Sleuthing!



Train The Trainer

imagesStaff Training is essential but can be a challenge due to staffing and time constraints. One strategy to consider is to identify someone on staff who can be trained to be the trainer. Essential Qualities the Trainer Must Have lnclude

  1. Clinical skills and knowledge
  2. Patience
  3. The ability to alter one's teaching strategy to meet the trainee's learning style
  4. Good communication and listening skills
  5. A thirst for knowledge
  6. A desire to mentor and help others

How To Make it Happen

lt would defeat the purpose of having a trainer if the trainer does not have proper skills themselves and many technicians are informally trained on the job and may not have been taught the skills correctly themselves.

It is best to bring in an outside person such as a formal trainer or consultant to train the trainer. The ensures the trainer learns the clinical procedures correctly. A formal trainer or consultant can also help the trainer learn teaching strategies (train them how to train).

An lnvestment that Pays Off

By investing in one or two key staff members and teaching them how to train, the ophthalmology practice can develop a perpetual in-house training program which will elevate all staff members in competence and confidence.

Plus Cylinder Retinoscopy Step by Step

images (1) Retinoscopy is a technique to obtain an objective measurement of the refractive error of a patient's eyes. The examiner uses a retinoscope to shine light into the patient's eye and observes the reflection (reflex) off the patient's retina.

Step 1: Select Your Scope and Place the Focusing Sleeve in the Correct Position

If you select a Welch Allyn, Keeler or Reichert scope, place your focusing sleeve in the 'down' position, Copeland or Nikon, sleeve up. (see 'Continuous Rotation External Focusing Sleeve' in picture below):


Step 2: Establish Your 'Working Distance'.

This correlates to your arms' length to account for the distance between your retinoscope and the patients' eye. If you have an average length arm, this is 67 cm which correlates to 1.50 D 'working distance'.  This means you must SUBTRACT 1.50 D sphere from your retinoscopy findings as your final step.  If you have a shorter than average arm, select a working distance of  50 cm which correlates to 2.00 D 'working distance' and SUBTRACT 2.00 D sphere from your retinoscopy findings as your last step.

Step 3: Learn How to 'Streak'

'Streaking' means you move your retinoscope intercept (the light from your scope) perpendicular to the orientation of your intercept.  This means when you orient your streak vertically, you are 'sweeping' (moving) your streak horizontally and vice versa.  When you orient your streak vertically, you are checking the refractive power of the 90 degree meridian. When you orient your streak horizontally, you are checking the refractive power of the 180 degree meridian.

Step 4: Learn What 'With Motion', 'Against Motion' and 'Neutrality' Looks Like.

When your intercept moves in the same direction as the reflex from the pupil, you have WITH motion. This means you must add plus sphere or cylinder (more on this later).

When your intercept moves in the opposite direction as the reflex from the pupil, you have AGAINST motion. This means you must add minus sphere or cylinder.

When the pupil fills with light and there is no movement, you are at neutrality.


Step 5:  Position the Phoropter in Front of the Patient

Step 6: Level the Phoropter 

Step 7: Fog the Fellow Eye With +1.50 sphere

Step 8: Ask the Patient to Look at the 20/400 E

Step 9: Observe Reflex in Both Meridians

If you see anything other than 'with' motion in both meridians, add minus sphere until both meridians are 'with' motion.  Don't be shy about dialing in the minus sphere - just throw it in.  Once you see 'with' motion in both the vertical and horizontal meridians, you are ready to begin to neutralize the patient's refractive error.

Step 10: While Checking Both Meridians, Add Plus Sphere.

Continuously check back and forth to the vertical and horizontal meridians until the first meridian is neutralized.  This first meridian that neutralizes is your sphere meridian.  Note: if both meridians neutralize at the same time, the eye is spherical (this rarely happens).

Step 11: Move to the Opposite Meridian and Neutralize with Plus Cylinder

Add plus cyl until the opposite meridian neutralizes. This is your cylinder meridian and approximate axis.

Step 12: Refine Axis

Use the 'skew phenomena', 'bracketing technique' and the 'straddling technique' to refine the axis.  (Explanation of these techniques is beyond the scope of this text. Many of the resources below will explain these techniques).

Step 13: Confirm Neutrality

Move in slightly closer than your working distance (10-20 cm), streak both meridians. You should see WITH motion. Move back slightly beyond your working distance (10-20 cm), streak both meridians. You should see AGAINST motion. If you do, you are AT neutrality.  If you do not, recheck neutrality in both meridians at your working distance.

Step 14: Remove Working Distance

Subtract your working distance from whatever the phoropter shows.  If you have an average working distance of 67" you must subtract 1.50 D sphere. Example: If the phoropter reads -1.00 +1.00 x 180 you subtract 1.50 D sphere and their final retinoscopy finding is -2.50 +1.00 x 180.


  1. Maintain your working distance at all times.
  2. If you get confused during the process, dial the phoropter back to plano and start over.
  3. Look at every reflex you can - even if you don't have time to use the phoropter. Just pick up the scope and look at every patient's reflexes.  Knowing what 'with motion' 'against motion' and 'neutrality' look like are half the battle.
  4. Practice - Practice - Practice
  5. You don't have to dilate the patient, but if they have a small pupil it will be more difficult to see the reflex. If the pupil is < 2 mm or so, it may not be possible to see the reflex.
  6. Patients with media opacities (cataracts, cornea opacifications or clouded posterior capsules) may be difficult or impossible to streak... but TRY (what do you have to lose?)
  7. If you see a 'scissors' reflex - meaning it appears there are two reflexes oriented in the same direction but moving in opposing directions, the patient has an irregular refractive error.
  8. Realize that this is an advanced technique. It's the most difficult skill I learned.  Don't give up - keep practicing and you will eventually master it. Happy Scoping!!!

See resources below.  

How to Perform Retinoscopy Part I: 

How to Perform Retinoscopy Part II:  

How to Perform Retinoscopy with loose lenses:

Free Retinoscopy Simulator:


Errors in Pupil Assessment

Proper pupil assessment technique is THE most important skill every ophthalmic assistant must possess.  If you employ improper technique you will miss pupillary abnormalities which may be a sign of a life threatening conditionimages. Why We Check Pupils

Life threatening conditions such as brain aneurysms, brain tumors, optic neuropathies cranial nerve palsies, carotid artery aneurysms and cancerous tumors can cause abnormal pupillary responses.  You can help save a life by discovering pupillary abnormalities.

Error #1:  Not using a bright test light or blocking the test light with your finger.  You cannot properly assess pupils without using a bright test light. Some technicians erroneously think they are doing light sensitive patients a favor by dulling the test light with a finger; however you will miss subtle pupil abnormalities if you do.   In many ways, subtle pupil defects are more important to identify than obvious pupil defects because eyes with subtle defect frequently do not not have associated signs and symptoms.

Patients who are photo-phobic may need what I like to call 'vocal anesthesia' meaning you talk them through it.   Encourage the patent by saying 'I know it's bright... you're doing great..  bear with me... we're almost done."

Error #2: Checking pupils with room lights on.  How can you observe the pupils' full response to light if you begin the test with the pupil already constricted due to the room light?  Use ambient room light, which is just enough light to observe the patient but not enough light to constrict the pupils.

Error #3: Not measuring pupil size. Pathological and life threatening conditions such as Horner's Syndrome, III Cranial Nerve Palsies and brain aneurysms can cause anisocoria, a condition in which the pupils are > 1 mm difference in size.  When anisocoria is present, measure and document pupil size with indirect illumination with the room lights on and off.  Pupils that vary in the amount of anisocoria in dark and light are more suspect of having a pathological condition.

Proper pupil assessment technique is a critical skill every ophthalmic assistant must develop. Never take short cuts when it comes to pupil assessment. If you're in doubt about whether pupils are abnormal, ask your physician to assess the pupils prior to dilation.

How to Triage Chemical Injuries of the Eye

Chemical Burn (Bleach from Splash) A long term patient calls your office. He is in a panic because he splashed a liquid fertilizer in his eye. He is in pain and can barely open his eye.  He is counting on you to make sound decision to save his eye sight.

A True Eye Emergency  Ocular chemical burns are true eye emergencies and can cause irreversible damage to the eye and adnexa if appropriate treatment is not initiated quickly.  Some chemicals can penetrate the eye in as little as five minutes. Time is of the essence!

About Chemicals  Chemicals can be solid, liquid or  gas and can be alkali or acidic. Alkali agents such as ammonia, lye, firework sparklers, lime and cement have a high pH (> 10).    Acidic agents such as bleach, battery acid, vinegar, swimming pool cleaners and hydrofluoric acid which is found in refrigerants, fluorescent bulbs and other products have a low pH (< 4). 

First Things First   When a patient has a chemical injury start irrigation Immediately! Ask the patient what chemical the eye was exposed to, the time and what first aid has been provided. ***Start irrigation NOW! DON’T WAIT!***  The eye should be copiously irrigation with water, ideally at the location where the exposure occurred.  if the patient is at home, they can get in the shower, at work use an eyewash station and outdoors use a garden hose. In the office use an eyewash station, a Morgan lens or a nasal cannula positioned and taped to the bridge of the nose.

If irrigation begins immediately, normal pH is restored to the eye typically after thirty minutes (3 liters) of continuous irrigation, however if irrigation is delayed, irrigation volumes may need to exceed 20  liters before normal pH is restored to the eye as measured by pH paper.


Manual Keratometry for Beginners

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Don't be intimidated by the Keratometer.  Manual Keratometry is not difficult and is an important skill every technician who works in an anterior segment practice should have.

Begin by mounting the steel calibration balls that came with your Keratometer. These are spherical, so they are easy to measure and good for practice. The curvature value is imprinted on the steel balls so you can verify your findings.

After you have mastered the calibration balls, practice on coworkers.  A good tear film is essential so encourage blinking. Don't forget to focus your eyepiece.  With practice, you can become accomplished at performing this important task.

The Hows and Whys of Ocular Motility Testing

images (1)Ocular motility disturbances can be a sign of life threatening conditions.  Causes of ocular motility disturbances include: Diabetes, Thyroid Eye Disease, Brain Tumors, Strokes, Multiple Sclerosis, AIDS, Myasthenia Gravis, Arteriosclerosis and more. We check ocular motility to determine if there is an underlying medical condition which needs treatment.  Evaluation strategies include:

1. Check versions.  Versions are binocular movements of both eyes in the same direction. Have the patient look in each of the six cardinal positions of gaze (R, Up and R, Up and L, L, Down and L, Down and R). These six cardinal positions of gaze require each extra ocular muscle in each eye to work at some point in time, so if the patient's versions are 'full' (meaning both eyes can look in each of those gazes) and the patient has no complaints of diplopia, you are done with ocular motility assessment.  If the patient's versions are not full or the patient has complaints of double vision, you must perform more testing.

2. Perform cover tests.  The Cover/Uncover test is used to determine if there is a tropia. A tropia is present with both eyes open and is a sign of an underlying condition. Have the patient fixate on a distant fixation target. Cover OD, then uncover OD. Allow the patient to be binocular in between the times you cover the eye. Repeat at least three times OD. If OS moves to take up fixation when you cover OD you have discovered a tropia. Look at the uncovered eye. 

If the uncovered eye moves in to take up fixation it's an exotropia of the uncovered eye. If it moves out, it's an esotropia. If it moves down, it's a hypertropia.  This can be confusing.  Here's a take home message: We are observing the uncovered eye recover from it's deviation - not observing the deviation itself. Therefore, if the uncovered eye moves in to take up fixation that means it was deviated out (an exotropia)

The Cross Cover (aka Alternate Cover) test is used to detect a phoria.  A phoria is only present when you cover one eye. It's a latent (hidden) deviation kept in check by binocular fusion. Phorias are normal, however some patients have "decompensated phorias", where they can no longer control their phoria. These patients may need prism. Here's how to perform this test: With the patient looking at a distant fixation target alternately cover one eye, then the other.  DO NOT allow the patient to be binocular (in this test you must break fusion). Look at the eye as you uncover it.  If the eye moves as you uncover it, you have revealed a phoria. if the uncovered eye moves in, it's an exophoria. If it moves out it's an esophoria and if it moves down it's a hyperphoria.

3. Other tests to identify and measure deviations include Hirshberg and Krimsky tests, Bielschowsky head-tilt test, Worth 4 Dot test and Maddox Rod test.  The scope of this text precludes covering these tests in detail.

By checking versions and performing cover testing most deviations can be revealed. Further motility testing is required to determine the magnitude of the deviation, the most affected muscle and whether the muscle is overacting or underacting.

Does this Refraction Make Sense?

Your doctor will scrutinize your refraction, so why not learn to do it yourself first? Following are some strategies for analyzing your refractive findings: images (2)1.  A one diopter change in Rx should equal 3 lines of improvement on the Snellen eye chart.  Compare the spherical equivalent of the WRx and the MRx.   A spherical equivalent is a way to express a refractive error in a simpler spherical format for comparative purposes. Learn to do spherical equivalents in your head to compare prescriptions.

Here's how:  Take half of the cylinder, add it to the sphere and drop the cylinder and axis. For example: If the prescription is -1.00 +1.00 x 180 the patient's spherical equivalent is -0.50.  

If the patient had a one diopter change in spherical equivalent but only one line of improvement in VA, the refraction doesn't make sense. Recheck the refraction, the VA or both. 

Here are some refracting rules of thumb:

1. Always give the least amount of minus sphere or most amount of plus sphere that maximizes VA.

2. Give the least amount of cylinder that provides the best VA.

3. If there is a change in axis, ask the patient to compare their VA at the new axis and VA at the wearing axis. If the patient doesn't notice an improvement in VA at the new axis, keep the patient's RX at their wearing axis.

4. The more cyl the patient has, the more precise the axis must be.

5. If the patient refracts to 0.50 D cyl or less,  take away the cyl and ask the patient if they notice any difference. If they say it looks the same with and without the cyl, take it away.

6. The more ADD power, the closer the patient will hold things to read. If the patient is tall with long arms, they will likely need less ADD power. If they are short in stature, they likely will require more ADD power.

7. Give the patient the least amount of ADD that enables them to read the smaller print on the near card at their preferred reading distance.

8. The average reading distance is 14"-16". if the patient prefers to read much closer than 14" or much farther than 16"measure and note that reading distance on the chart.

Strategies for Technician Training

download (2)The vast majority of today's ophthalmic medical assistants are trained on the job. The U.S. Bureau of Labor Statistics projects employment in this field will grow 30% from 2012-2022. Some regions of the US have tremendous deficits* of trained OMP therefore, training will continue to be a challenge that must be met head on for the foreseeable future. It can be a real challenge to find the time and resources for technician training. Various methods can be used in conjunction with one another to accomplish your training goals.  Training should be an ongoing pursuit over one's entire career  - not a one time event. Effective training pays for itself through increased competency and efficiency. Here are some strategies to consider:

1. Mentoring:  Identify your most proficient technician who also has good communication skills and interpersonal skills. Ideally, a formal outlined training program should be developed and followed so there is consistency, thoroughness and accountability for each new trainee.  Advantages: relatively inexpensive, hands on training is ideally suited for this type of training.  Disadvantages:  It may be difficult to identify an ideal trainer, training requires staff time which detracts from the trainer's productivity during training period.

2. Brown Bag Seminars: These are ideal for ongoing training in bits and pieces. Typically they are held during lunchtime. A variety of topics can be covered by the doctors, outside equipment or pharmaceutical reps or staff members (i.e. billing and coding can be covered by your billing staff).  Advantages: Inexpensive, typically require little advance planning, can be conducted frequently, doesn't interfere with office flow. Disadvantages: The short duration limits the complexity of topics that can be covered.

4. On Site Consultant: Bringing a seasoned trainer into your office for a specified period of time can help make the learning curve significantly steeper.  The quality and quantity of training provided immerses the trainee in the process and can catapult the trainee toward proficiency.  Advantages: You choose consultant and training based on your needs. You can schedule training at a time that is convenient for your practice. Training frequently can be conducted without interfering with patient flow. Consultants are typically experts in their respective fields, but be sure to check references. Hands on and classroom training typically offered. Training can take place at a time that's convenient for your office. Interactive by nature, trainees can ask questions of consultant trainer.  May be accredited for CE Hours.  Disadvantages:  May be more costly than some other alternatives unless many staff are trained at once (in which case, it may actually be cheaper than some other methods).

5. Off Site Seminars (i.e. Continuing Education Meetings):  Nothing can match the excitement of being at a large meeting with other technicians! Most technicians say they were inspired after attending a large meeting or convention. Typically faculty is fully vetted and well versed on topic. Advantages: Peer to peer interaction, competent faculty, CE hours, hands on training frequently offered. Disadvantages: Travel expenses must be taken into consideration.

5. Self Paced Study (i.e. books, videos, webinars):  This type of training is best used in addition to other modalities to augment learning.  Advantages: Relatively inexpensive especially considering you can train multiple staff members at once using same resource. Doesn't interfere with office flow.  Disadvantages: Hands on training difficult or impossible, usually accomplished through a virtual interface. Usually requires initiative on the part of the trainee