Patient Care

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 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.


Common Causes of Medical Errors & What You Can Do

images (1) The Florida Board of Medicine has a "One Strike - You're Out" Rule.  This means if a physician performs a surgery on the wrong patient, does a wrong procedure, wrong side or wrong site surgery, the physician loses his or her medical license. This law was enacted after an incident which occurred n 1995.  An orthopedist in Tampa amputated the wrong leg on  a patient. His medical license was suspended for three years.  After three years, the physician went back to the same hospital and amputated the wrong leg on another patient!

Common Medical Errors

According a US News & World Report publication dated March 20, 2015, medical errors claim more than 200,000 lives each year. Most medical errors are preventable.  According to this report, the top 5 preventable medical errors are:

  1. Medication Errors
  2. Too many blood transfusions
  3. Too much oxygen for premature babies
  4. Health-care associated infections
  5. lnfections from central lines

What You Can Do

Double check medication orders, the patient name, drug name, strength and dosage before you administer any medication. Then double check again.                                                      Be sure to always document the correct eye on the chart - especially when the patient is or may be scheduling surgery.  Many wrong site surgeries occur due to an error in charting.   You can't be too careful when caring for your patients.

When in doubt, double check and if anything doesn't seem right or if the patient questions the validity of orders STOP and don't do anything until you're certain everything is correct.

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.

Efficiency Tips for Ophthalmic Technicians

download (1)I know.... I know... you're sick of hearing about the need for increased efficiency.  But keep reading. 'Efficiency' is not a four letter word.  Efficiency makes your work EASIER. Yep - you heard me right. When you work efficiently you're working smarter not harder. I was at the McDonald's drive through the other day. I got an unsweetened iced tea (I do love some Mickey D's iced tea). I asked the lady at the drive through for Splenda then I watched while she walked all the way over to the far side of the counter where the ice cream machine was to get Splenda.  Now, I'm pretty sure I'm not the first person who ever asked for Splenda at the drive through but why didn't anyone think to stock the drive through window with Splenda? Putting Splenda at the drive through window is more efficient... and creates less work for employees,

1. Keep your exam lane stocked. Having to retrieve items all day long is a real drag and makes you work harder.

2. Keep the following in your pocket:  *  Post it notes and pens  You can never have too many post it notes available   * A retractable measuring tape if you do refractions, measure convergence or accommodation. * a pupil gauge  *  a pen light  * a copy of the days' schedule  to keep you in the loop

3. Do away with the "Box 'o Bulbs" so many of us have in our office.  You know that box: it has bulbs, batteries and fuses in it. You never can find what you need, it's easy to take the last one and not know it and it's difficult to know what you need to re-order.  Here's how: Buy a bulb, battery and fuse for every instrument you have that needs one. Tape it (in its box or wrapper so you have the reorder number) to the instrument out of sight of the patient (such as underneath the slit lamp table or on the side of the projector that's toward the wall). When your bulb burns out, you'll have a bulb at your fingertips. When you take the new  bulb leave the box taped to the instrument. Once a month walk through the office and look for empty bulb, battery and fuse boxes. Remove them, noting on the empty box which room and equipment it goes to. Reorder from the product numbers on the package and re-tape each bulb to its instrument when the new bulb comes in. No paperwork - no muss, no fuss!

4. How to politely cut short a 'talker'.  "Mrs. Jones,  the doctor is probably wondering where you are. Let's get you finished up so we can get you in to see the doctor."

Can you think of some other efficiency tips? If so, share below in 'comments'.

Happy Tech-ing!


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 Can't Always Get What You Want

Today's patient is a more savvy consumer than years past. They are more informed and more demanding of a satisfactory encounter. As care providers, we are invested in this.  A satisfied patient is more likely to continue their relationship with our practice. This can be both good AND bad. images (1)

Patients who are proactively engaged in their care are more likely to be compliant with treatment. However, problems can arise when these patients demand treatments or medications that are not in their best interest.  The patient who visits their doctor for a cold and leaves with a prescription for an antibiotic may be satisfied but they did not get optimal medical care.

Trust sets a foundation for good patient/physician relationships. hen it is absent, patient care can be compromised.Patients who attempt to dictate their care do not trust their doctor's judgement.

Giving the patient what they NEED and not just what they WANT may be "just what the doctor ordered".