Career Growth

Strategies for Preparing for the COA Exam

                                   Sharon teaches subjective refraction in Texas

                                   Sharon teaches subjective refraction in Texas

Edit 7/17/18: Still looking for tips? Find an updated version of this article, with everything you need to know about the COA exam here

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"

COMT Exam: How I Prepared


More than twenty years ago; fresh in the field, I confided to a COMT that one day I, too wanted to be a COMT.  She scoffed and said "You can't possibly have enough knowledge to pass the exam unless you work in a large University Clinical setting or go to a formal COMT level training program."  I was bummed but I never let go of my dream.  In 2013, I became a COMT and proved her wrong. The day I took and passed my COMT Skills exam was one of the happiest days of my life.  Here are before and after pictures of that day...


I am here to tell you that YOU CAN become a COMT if you work hard enough and want it bad enough. Here's how I did it:  

  1.  I purchased or borrowed every book I could on JCAHPO's recommended reading list and read them each multiple times.   I studied for two full years for the exam. Six months before the exam I gave up all recreational reading material and TV, signed off of Words with Friends and Facebook and spent all of my spare time studying. I even kept a book in my car so if I found myself stuck in traffic I could use the time to read.  
  2. I went to JCAHPO's ACE meeting (the annual CE meeting held in conjunction with the AAO meeting) and took only Master's Level classes concentrating on subject which I felt were my weakest. If you get an opportunity to attend, I highly recommend the course on Clinical Mathematics by Kenneth Woodward, COMT. 
  3. I attended the COMT Review course at the ACE meeting but did not find it helpful. It is a REVIEW course. A Review course is a brief overview of the topics on which you will be tested. It doesn't actually give you the information in the content areas you need to know.  In contrast, a PREP course is a long, comprehensive course and actually gives you all the information you need to know to pass the test.
  4. Every spare minute I studied.I DID find JCAHPO's COMT Skills Review Course very helpful.  They had a team of COMT's who helped the group of COMT hopefuls as we went through various skills stations. They had stations on FA's, Motility, Lensometry and more.  The instructors were wonderful in explaining the skills and the pathology we were looking for. It was immensely helpful!
  5.  I found two mentors, Jessica Barr, COMT from PA and Sergina Flaherty, COMT from Texas who were helpful in answering questions I had about various pathologies and skills.
  6. I purchased several JCAHPO's Learning Systems modules and other CE courses on These complemented the Masters Level courses I had taken at  the ACE meeting. I especially found the motility courses helpful. 
  7. I wrote all the optics formulas I needed to know for the exam in a notebook and studied that the morning of my exam so it would be fresh in my head.

I scheduled my written exam for a Wednesday afternoon.  My plan was to spend Monday and Tuesday cramming and Wednesday morning studying my optics formulas.   On Monday morning I sat down to read and thought "If I put one more thing in my head something else is going to fall out!"  My brain was saturated.  I was also a growing more and more anxious.  That was when I decided to close the books. Instead of studying, I spent that Monday and Tuesday nurturing myself. I got a pedi and mani, went to a movie, watched dumb TV and got lots of rest. The helped my anxiety level be manageable.  On Wednesday morning, I went to the test site four hours early, found a nearby coffee shop with wifi and studied my formulas.  I took my exam and finished in just 1 1/2 hours. I had aced the test!    YOU can do it too!!! 

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!

"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!

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.


Rising Through the Ranks

Whether one is a natural born leader or has been identified as having the potential for developing leadership skills, it can be a challenge rising through the ranks. Typically the most difficult aspect is gaining acceptance from those you lead. What Your Staff Will Want to Know:


I rose through the ranks and found myself supervising technicians who had been at the practice many years more than I. Immediately after the staff meeting at which my promotion was announced, one of the technicians who I was now supervising approached me and said "Nothing is going to change - right?". Her question brings to light what most staff members' primary concern is: how the changes will affect them. Yes, things WILL change - not just for your colleagues but also for you. Be prepared for your actions to be scrutinized and for resentment by some.

What You Can Do

Work on developing your leadership skills by:

1. Finding a mentor who has been successful in positions of leadership.

2. Read books on leadership such as Dale Carnegie's  "How To Win Friends and Influence People" and Stephen Covey's  "7 Habits of Highly Successful People".

3. Praise publicly, correct privately.

4. After you have been in your position for 6-12 months, ask your staff for feedback about how you're doing.  Make surveys which allow staff to respond anonymously. Then, be open to what they have to say.

5. Be honest if you are still refining your leadership skills. Others will understand that. You will may mistakes and when you do, apologize to those involved. Learn from your mistakes and move on. Don't beat yourself up.

6. Keep your ego in check and be humble. Elevate and encourage your staff. Leaders don't need to prove they're better than anyone else. Be a king among kings rather than a king among paupers!  Your job is to develop others to their fullest potential.

7. Hold people accountable. Nothing drags team morale down faster than when someone isn't doing their job and then isn't called out on it by a supervisor. This DOESN'T mean that you call them out publicly. It means holding everyone accountable in doing their job and doing it to the best of their ability.

The Journey

Life is a journey of learning and new experiences.  Professional development can be a wonderful part of life so embrace your new position, be humble and always keep your staff's and the practice's best interests foremost in your mind.

Strategies to Excel in the COT Skills Test

images  The COT Certification testing process includes two key evaluations; a written test and a skills evaluation. The written test is multiple choice computerized exam. The skills test is a simulated virtual environment in which the candidate must perform 7 key skills. The COT candidate must successfully pass the written portion before being eligible to take the skills test.  The candidate has one year following the written exam to successfully complete the skills portion of the test. The  Skills Test includes:

  • Retinoscopy (plus or minus cyl)
  • Refraction (plus or minus cyl)
  • Manual lensometry (plus or minus cyl)
  • Ophthalmometry (Keratometry)
  • EOM evaluation including cover tests
  • Goldmann Applantion Tonometry
  • Humphrey Visual Field

How to Prepare

After you pass the written portion of the exam, JCAHPO will send you a list of the skills you must perform and a list of steps you must perform for each skill and the order in which you must perform the steps.  MEMORIZE THE STEPS ON THIS LIST.  They will also send you a pdf with screen shots of the computer interface. This will teach you how to interact with the computer interface, how to open and close drawers, turn on room lights, instruct the patient, grab equipment, submit your skill and more.  GO THROUGH THIS PDF MULTIPLE TIMES.

Also, consider purchasing JCAHPO Learning Systems modules that you need for each skill.  You only need to buy the modules with which you feel you need help. These modules are very similar to the computer interface you will use for the actual exam so they will not only prepare you for the skill, but also help you become more comfortable with the computer interface.  These modules aren't expensive and include CE credit, which you need anyway.

How It's Scored

JCAHPO will score you on two key components of each skill: Accuracy and Technique.  For example, when performing GAT, you will be scored on how accurate your TA is and also how you performed the skill. For instance, don't go on and off and on and off the cornea multiple times as you align your tonometer prism because you will be counted down in technique for that.  You want to approach the cornea in the approximate alignment you need and then make small adjustments to position to tonometer correctly.

You will have one hour to perform all of the skills.  You can decide which skills you perform first. If you are in the middle of a skill and forgot a step or feel like you made a mistake, you can restart the skill and the computer will 'forget' everything you've done on that skill. Once you 'submit' the skill and move on to the next skill you will NOT be able to make any changes to any previous skills.

Learning Your Results

JCAHPO will notify you within a few weeks via email about your results.  If you have successfully passed each skill (technique and accuracy), you are a new COT! Congratulations!  If you successfully complete some but not all of the skills, you will have a conditional pass and another opportunity to pass the skills you didn't successfully perform the first time.

A last tip: your new credential will be posted on your JCAHPO account before you receive the written notification, so if you just can't wait for the mailman, log onto your JCAHPO acct about 7-10 days after your exam and take a peek. Good luck!

What is ATPO?

You may have heard of ATPO but weren't sure what it was all about. I'm here to set the record straight on what ATPO can do for YOU!titlebar ATPO is the Association of Technical Personnel in Ophthalmology.  They are our representation organization. It represents a diverse group of ophthalmic medical personnel including orthoptists, ophthalmic registered nurses, contact lens technicians, ophthalmic assistants, technicians and technologists, ophthalmic photographers and ophthalmic surgical assistants.

What They Do

I liken ATPO to the AMA (American Medical Association).  The AMA represents physicians to their accreditation boards (i.e. the American Academy of Ophthalmology). Likewise, ATPO represents us to JCAHPO (our accreditation board).  When you become an ATPO member, you are a member of an organization which promotes and supports your professional success through access to continuing education courses, discounts on training materials and courses, job boards, salary surveys and more.

Member Benefits

Consider joining ATPO today at  Group memberships are available for the entire office for $65 per person or for an individual for $75 a year.  When you sign up, you will automatically get up to 5 free CE credits and special member pricing on certification exam prep materials such as flash cards.

How to Join/More Information


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!

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.

Inside the Hiring Manager's Head Part IV

left-brain-right-brain1-283x300Job interviews can be nerve-wracking. Knowing what the hiring manager is thinking may give you an edge. This is the final post in this series. What's Next?  So, you've interviewed, you've sent your thank you note... now what?  After all the candidates have been interviewed,  the hiring manager will check references. Be sure you've provided quality references because they can make or break your chances for a job when there is more than one well qualified candidate.

How The Decision Is Made  The manager will compare qualifications, communication skills and the candidate's goals to find the best match for the position. For instance, if the open position is for a front desk position, and the candidate states her goal is to be an RN, that may not be the best match of candidate to position.

The manager will narrow the candidates down to two or three top candidates and bring them in for a second interview when the physicians or other department heads may meet the candidate. They are looking for someone whose demeanor will "fit" with current staff and enthusiasm for the position.

Do Research This is a good time to ask questions of the staff which show your interest, eagerness and passion.  Be genuine and read social clues so you demonstrate that you want the job but are not intrusive.  This second interview is likely the time to discuss pay and benefits but it's best to let the manager broach this subject. Do research about pay ranges for the position in the area. The manager will have a pay grade in mind so if you are asked what salary you desire, be realistic and keep the area pay scales in mind. Usually it's better to state a range rather than a firm number.

The Offer  By this point, the manager will likely be ready to offer you - the top candidate the position! The manager wants you to succeed and is pulling for this 'marriage' to work so put your best foot forward as you accept the position and begin your new job.  Continue to demonstrate enthusiasm and as you integrate into your new 'work family' nurture your new professional relationships, ask questions and hold yourself accountable for learning and mastering new skills.  Congratulations on your new job!

Inside the Hiring Manager's Head Part III

left-brain-right-brain1-283x300Job interviews can be nerve-wracking. Knowing what the hiring manager is thinking may give you an edge. This is part III in a series. The first interview helps the hiring manager get to know you. Just relax and be yourself. The hiring manager is looking for:

- The ability to communicate clearly. Do you express yourself in a linear fashion with well structured thoughts, complete sentences and evidence based conclusions?

- Friendliness.  You will be expected to interact in a positive manner with coworkers, patients and others. The manager is looking for someone who can integrate into the workplace and work well with others.

- Intelligence and aptitude.  If you're intelligent and teachable, you can be trained.

- A Self-Observing Ego: The ability to observe reality as it is and to evaluate oneself and take action based on that reality.  Are you able to self evaluate and correct behaviors which are not ideal?  This is an essential part of making changes to your thoughts, your behaviors, and ultimately, your life.  Staff with self-observing egos are more easily managed because they are open and respond appropriately to feedback.

Here are a few tips:

1. Avoid discussing personal details such as your age, religion, national origin, marital status, number of children. They are not appropriate to discuss nor for the manager to take into account when making a hiring decision so don't offer this information.

2. Don't talk too much. When you're asked a question answer it fully and completely, then stop talking.

3. Let the hiring manager take the reins. He or she will decide when the interview is done and will steer the conversation but don't be afraid to ask questions. The manager will be looking for you to ask intelligent questions about the job.  Don't ask about salary unless the manager brings it up first. Know ahead of time the salary you expect and do your research to make sure it's appropriate for the job and your level of experience.

4. Don't exaggerate your knowledge or skills. It's okay to not know how to do everything but it's NOT okay to lie or exaggerate.

5. Research the company before your interview.  Know who the principal doctors are and what services they offer.

6. Ask for the hiring manager's business card.

At the end of the interview, stand, make eye contact and extend your hand for a firm handshake. Thank the hiring manager for his time and ask when a decision may be made and/or what the next step is.

After the Interview  Take a thank you note and postage stamp with you to the interview. As soon as the interview is done, write a note thanking the manager for his or her time and express your excitement at the prospect of joining the organization. Address it from the business card you got at the interview and drop it in a mailbox as soon as you leave the interview. Not only will the manager be impressed that you sent a thank you note, but the expeditiousness with which you sent it will make it memorable.

In the next part we'll discuss what happens after the interview from the Manager's standpoint.

Inside the Hiring Manager's Head Part II

left-brain-right-brain1-283x300Job interviews can be nerve-wracking. Knowing what the hiring manager is thinking may give you an edge.  This is the second article in a series. The First Impression  The first verbal contact may be when the hiring manager calls to make an appointment for an interview. This is your opportunity for a first impression.

Since you will likely answer phones at least occasionally at the office, the manager will be observing how you sound on the phone. Do you speak in a friendly voice? Do you interrupt? Do you say please and thank you?

The hiring manager will make special note of whether you arrived on time or not.  Allow twice as much time to travel to the appointment than you think you'll need to ensure you're on time.  If necessary, make a trip to the interview location before the day of your interview so you now where you'll park and exactly where to go.

Professional Appearance  The hiring manager knows that most of us present our "best self" at job interviews.Select your wardrobe and make sure it's clean and pressed.  If you have to ask whether your wardrobe selection is appropriate or not, assume it's not. Think "conservative and professional".   Ensure your clothes are neat and clean.  If you smoke, avoid doing so immediately before your interview. Non-smokers can smell it a mile away and cigarette smoke odor is a real turn off.

When you meet the hiring manager, smile, make eye contact and offer a firm handshake. Take a deep breath and don't be intimidated.  The hiring manager is not there to grill you or make you feel uncomfortable. She knows you will have a degree of nervousness, but her job is to help put you at ease so she can get to know the real you. She is probably pulling for you to do well so relax, smile and just be yourself.

In Part III we will cover the interview itself.  Stay tuned....

A Peek Inside the Hiring Manager's Head Part I

left-brain-right-brain1-283x300Job interviews can be nerve-wracking. Knowing what the hiring manager is thinking may give you an edge. Over the span of my career in ophthalmology, I have interviewed thousands of potential employees one-on-one and as part of a panel interview including department heads and physicians.  I have been privy to the debate that goes on after the candidate has left as qualifications, work history and performance of the potential employee is scrutinized.  Let's peek inside the hiring manager's head...

RESUME & COVER LETTER  This is typically the first thing that is evaluated. The manager is looking for pertinent work history and education, length of tenure on jobs, reasons for leaving jobs and any time-gaps in work or education.

Pertinent work history which may seem unrelated to the job for which you're applying may have provided you with transferable skills the manager desires. For instance, a restaurant server who has not worked in the medical field may have valuable customer service skills to bring to the table.

If you've held many different jobs of short duration be prepared to explain why. As a hiring manager, I eschewed "job hoppers".  Why would I want to invest time in hiring and training someone whose history strongly suggests they won't stay long? Also be prepared to explain gaps on your resume.  Gaps due to illness, pregnancy or a spouse being relocated as well as family emergencies are understandable. Gaps due to vague reasons or because you "needed to take a break" may paint you as being "flighty".

The cover letter and resume must be pristine in grammar and spelling. I know you've heard this before BUT you would be shocked how many resumes and cover letters have grammar and spelling errors.  With spell-check readily available there's simply no excuse for an error.

Be sure to type your name and contact information clearly and in a large font on your resume and cover letter. I regularly received resumes that were faxed or scanned which did not come through clearly. The resumes which used small fonts for the contact information were frequently illegible.  Seeing a stellar candidate's resume but not having proper contact information was frustrating.

Part II will cover the initial contacts via a phone call and how to prepare for the interview itself. Stay tuned....


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.

Spill the Beans on the Best Kept Secret

imagesFew of us sought to have a career as an OMA; rather, most of us 'fell into the field'.  Ophthalmic Medical Assisting is one of the best kept secrets in our country today. Help spill the beans and spread the word by sharing this blog post  with high school students and adults you know who are searching for a rewarding career. 

Share your career with others who are searching for a rewarding career and share this blog post with them. If you'd like more information about Ophthalmic Medical Assisting as a career visit . To find a formal ophthalmic training program visit . To learn more about certification visit .3. Generally requires no nights, weekends or holidays are required.


Why You Should Consider a Career in Ophthalmic Medical Assisting:

1. OMA's are in demand. If you are  skilled and have quality professional references, you can go virtually anywhere and get a job in short order.

2. It doesn't require a college degree. On the job training is common

4. Most positions include a full benefits package and are well paying.

5. We rarely perform tasks that cause our patients pain, there is little or no blood

6. Work is in a pleasant, professional environment.

7. The medical field is well respected.

10. Best of all, OMA can positively effect patients' quality of life. Fitting a patient with their best glasses or helping them through an eye surgery can help patients maintain their independence. it may make the difference between them keeping their driver's license and not and can keep them living independently longer.

There are many different jobs and sub-specialities an OMA can pursue:  Contact Lens Technician, Surgical Assistant, Low Vision Technician, Surgery Counselor, Scribe, Ultrasound Biometrist, Diagnostic Ultrasonographer, Optician, Imaging Technician, Refractionist, Clincial Supervisor, Practice Administrator and more.


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.

YOU Are the Key to Success

Practices must continually drive new patients in the door in order to maintain a viable practice.  Marketing, professional referrals and good word of mouth brings them in the door. After that, it’s up to YOU, the practice staff whether they stay or they don’downloadt.  Whether a patient remains with your practice is dependent on the experience you provide. Providing a positive and memorable experience for your patient is the key to long term success in your career. “Success in your career” does not simply refer to financial rewards, promotions or the like. These are all great things, but they are not what I would consider to be true success. True career success comes from the deep satisfaction you’ll have when you bring your personal best to everything you do .