hands-on practical lab - optla.org€¦ · hands-on practical lab m. patrick coleman, aboc, ......
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HANDS-ON PRACTICAL LAB
M. Patrick COLEMAN, ABOC, COT
RECOGNITION & THANKS TO:
Dr. Robert JANOT, OD
Survey to determine what we teach Soliciting (and getting!) equipment we need Most support I’ve EVER rec’d for a paraoptometric
program! Amy Goudeaux (CPOT), Shonna Daigle (CPO), & Anne
Schlicher
Volunteered to help teach & run “learning stations” High stress & No pay! Be nice to them. THANK
THEM! Dr. James D. Sandefur, OD
Spectacle frames for us to use/abuse!
RECOGNITION & THANKS TO: Chris North & Bayou Ophthalmic Instruments,
Inc. e-mail: [email protected]
5601 Jensen Street New Orleans, LA 70123 Phone: (504) 734-9399 www.bayouophthalmic.com Provided:
SLIT LAMPS with tables & stools PUPILLOMETERS
RECOGNITION & THANKS TO: Carol Aphonse & Mid-Gulf Instruments http://midgulfinstruments.com/ 158 Kingspoint Boulevard, Slidell, LA,
70461 (800) 359-2089 or (985) 649-6336 E-mail: [email protected] Supplied: Three (3) Topcon LM-80 LENSOMETERS
RECOGNITION & THANKS TO: Enhanced Medical Services 1202 Hanley Industrial Ct, Brentwood, MO,
63144 Phone: (888) 781-4458 E-mail: [email protected] Provided: Two (2) LENSOMETERS
INTRODUCTION & OVERVIEW The OBJECTIVE for the next 3 hours will be to review: SLIT LAMP (basic operation, checking angles, CL
assessments)
LENSOMETER (manual)
SPECTACLE FRAME ADJUSTMENTS
COVER TESTING / EXTRAOCULAR MOTILITY (EOMs)
PUPILLARY ASSESSMENTS
PD MEASUREMENT (PD ruler vs. Pupillometer)
CASE HISTORY (& HPIs)
SLIT LAMP Basic operation Checking angles CL assessments
SLIT LAMP (cont.)
BASIC OPERATION:
• Lots of PARTS!
• Best to “show” you & have you “do” it!
SLIT LAMP (cont.) GRADING ANGLES:
• Set beam @ 60 degrees; fine slit; aim at iris close to limbus so light goes through cornea.
• The ratio of the thickness of the cornea to the amount of ‘dark space’ between the back of the cornea & the iris is evaluated.
• Wide gap? Good! Open (3 or 4)
• Narrow (or no?!) gap? BAD! Narrow (1 or 0)
SLIT LAMP (cont.) GRADING ANGLES:
SLIT LAMP (cont.) GRADING ANGLES:
SLIT LAMP (cont.) ACA = Anterior Chamber Angle
ACD = Anterior Chamber Depth
Pic A =
NARROW ANGLE (lens pushing iris
forward)
Pic B =
OPEN ANGLE (lens removed &
IOL in eye)
SLIT LAMP (cont.) Evaluating CLs (soft)
• Does it center on cornea well? (or ride high, low, temporal, or nasal; does edge rub or ride on limbus?)
• Does it move? (want 0.5mm to 1mm of movement when pt blinks; no move = bad!)
• Toric SCL? Where are the ‘hash’ marks? Some have one hash, some have two hashes, some have three hashes, and one lens has a series of ‘dots’ on each side of the lens. Arggghh! Need to know lens type to know where ‘marks’ should be…
SLIT LAMP (cont.) Evaluating CLs (soft)
• Toric SCL? Where are the ‘hash’ marks? DEPENDS ON THE LENS!
• One hash? (want it at 6 o’clock)
• Two hashes? (want them @ 3 o’clock & 9 o’clock or 12 & 6 o’clock! Depends on the lens!)
• Three hashes? (want middle hash at 6 o’clock)
• And then there is the lens with four DOTS on each side of the lens (180 degrees apart) – want them at 3 o’clock and 9 o’clock
SLIT LAMP (cont.) Evaluating Toric SCLs
SLIT LAMP (cont.) Evaluating Toric SCLs
SLIT LAMP (cont.) Evaluating Toric SCLs
LENSOMETRY (manual) • Parts (Power Wheel, Lens Table, Axis Wheel, etc.)
• SPHERE, CYL, AXIS & ADD – figuring it all out!
• The key concepts?
• DIRECTION TRAVELED
&
•DISTANCE TRAVELED
( ) (cont.)
1. Focus the EYEPIECE for you! (CCW ‘til stops; then CW ‘til clear image!)
2. Check “calibration” of machine (focus SPH/CYL lines without a lens in machine; PWR WHEEL should read “O” (zero)
3. Put glasses in lensometer 1. Temples AWAY from you 2. Both lenses touching the LENS TABLE 3. Start with RIGHT LENS (OD)
4. Put PWR WHEEL at +9.00 5. Start rotating in the “minus direction”; when something starts to come
into focus, manipulate AXIS WHEEL and PWR WHEEL to bring the SPHERE LINES into focus FIRST
6. Write down number from PWR WHEEL as SPHERE power (black is
PLUS + and red is MINUS -) 7. Write down number from AXIS WHEEL as the AXIS of the Rx (NOTE: If the SPHERE & CYLINDER LINES came into focus together, at
the same time, you have a SPHERICAL lens & are done. Yea! They )
LENSOMETRY (manual) (cont.)
SPHERE lines out of focus;
Use the AXIS WHEEL & PWR WHEEL to make them
crisp, sharp, & perfect
When SPHERE lines & CYLINDER lines come into focus @ the same
time? You have a SPHERICAL LENS!
( ) (cont.)
SPHERE LINES
(skinny; close together)
CYLINDER LINES (fat; far apart)
LENSOMETRY (manual) (cont.) 8. Continue by rotating the PWR WHEEL in the
MINUS direction until you see the CYLINDER LINES come into focus
9. Now it is “math” time. Your CYLINDER POWER is how far you traveled from your SPHERE PWR to your CYLINDER PWR. Your CYLINDER “SIGN” is based on the direction traveled (in this case, you were going in the MINUS direction, so your CYL will be a minus power.)
10. Let’s say the SPHERE lines came into focus @ BLACK 3.00 (+3.00). Your CYLINDER lines came into focus @ BLACK 2.00. You traveled in the MINUS direction & you went one (1) diopter.
Your CYLINDER POWER will be -1.00
LENSOMETRY (manual) (cont.) What s the RX?
LENSOMETRY (manual) (cont.) BIFOCAL “ADD” Power? Put PWR WHEEL back on your DIST SPHERE
POWER number Slide lens up so you are measuring thru the NEAR
SEGMENT Rotate the PWR WHEEL in the plus (+) direction (ADD
PWR is always PLUS!) until the SPHERE lines come into focus. (Do NOT touch the AXIS WHEEL!!!)
Now it is “math time” – Direction & Distance TRAVELED?
EXAMPLE: Distant SPHERE LINES were in focus at red 3.00 Near SPHERE LINES came into focus at red 1.00 You traveled in the PLUS DIRECTION and… you went two (2) diopters: ADD PWR is: +2.00!
LENSOMETRY (manual) (cont.) What’s the RX?
SPECTACLE FRAME ADJUSTMENTS
FOUR POINT BALANCE – It’s where you BEGIN, not where you END UP!
Check alignment of Frame Front first! (if twisted EVERYTHING ELSE is messed up…)
Temples next Move in the direction of the problem! BRACING IS KEY Desire: 5 to 7 degrees PANTOSCOPIC tilt
Nose Pads? Spread apart to lower glasses Move closer together to raise glasses
SPECTACLE FRAME ADJUSTMENTS (cont.)
Start with 4 point ‘balance’ Now put on Patient Adjust specs to fit THAT PERSON When you are done, probably WON’T have 4
point balance! That’s okay. Do they fit the patient? GOOD!
SPECTACLE FRAME ADJUSTMENTS (cont.)
Move TEMPLE in direction of the problem R. lens sits HIGHER than L. lens?
Move the R temple UP! (or L temple DOWN) L. lens is CLOSER to eye than R. lens?
Move L temple IN more, closer to head! (or R temple OUT more) ------------------------------------------------------------------------ Move NOSE PADS to adjust height on face
Moving nose pads CLOSER TOGETHER (toward each other) will RAISE the glasses on Pt’s face
Moving nose pads FARTHER APART (away from each other) will LOWER the glasses on Pt’s face
NOTE: Doing this affects SEG HT position! Be AWARE.
PERFORM SKILLS!
COVER TESTING & EOMs
Two different tests here: COVER TESTING tells you if the patient is
ORTHO Heterophoric Heterotropic TWO PARTS to the TEST! “ALTERNATING” &
“COVER/UNCOVER”
Ocular Motility (EOMs) tell you if the six extraocular muscles are:
NORMAL UNDERACTIVE OVERACTIVE
COVER TESTING (cont.) COVER TESTING has ‘two’ parts: 1) ALTERNATING test 2) COVER/UNCOVER test 3) Do them in this order! (Please?) 4) Done at DISTANCE then NEAR 5) Pt wears the “correct” Rx for test distance --------------------- ALTERNATING tells you DIRECTION of DEVIATION
(if any) ESO, EXO, HYPER/HYPO No movement? Pt is ORTHO! Yea! (Don’t have to do
COVER/UNCOVER test )
COVER TESTING (cont.) COVER/UNCOVER test Only done if MOVEMENT during the ALTERNATING
test! Observe LEFT EYE as you COVER RIGHT EYE
Did it move? (Yes = TROPIA; No = PHORIA) Repeat for other side… Observe RIGHT EYE as you COVER LEFT EYE
Did it move? (Yes = TROPIA; No = PHORIA) ---------------------------------------------------------------------- UNCOVER only matters if you saw MOVEMENT when
you COVERED! (i.e., had a TROPIA) Do you see movement AGAIN when you UNCOVER?
UNILATERAL TROPIA! No movement when you UNCOVER?
ALTERNATING TROPIA!
COVER TESTING (cont.)
WHAT DOES THIS CHILD HAVE?
COVER TESTING (cont.)
• PHORIAS are a “latent”, or hidden condition
• Can’t just “see” a PHORIA
• Can only detect it with testing
• TROPIAS are a “manifest”, or obvious condition
• Sometimes you can just look at a person & see TROPIA!
• If not easily “seen”, it is easily detected when tested
OCULAR MOTILITY (EOMs) Muscle-H Test Checks “ocular motility” controlled by six (6)
EOMs attached to each eye When you are “done” you will have checked
all 12 muscles! (EOMs for both eyes) Patient follows your penlight 14” to 16” away is ‘best’ Move light in a “H” pattern, pulling the eyes in
the 6 “CARDINAL” positions Observe the eyes
Do they track together? Do they go the “same amount” in the “same direction”? This is also considered ‘checking pursuit’ movement
OCULAR MOTILITY (EOMs) (cont.)
Six (6) ExtraOcular Muscles (EOMs) for each eye: Four (4) RECTUS muscles
Pull the eye the direction they “say”; EASY! Superior RECTUS (SR) pulls eye superiorly (up) Inferior RECTUS (IR) pulls eye inferiorly (down) Lateral RECTUS (LR) pulls eye laterally
(temporally) Medial RECTUS (MR) pulls eye medially (nasally)
------------------------------------------------------- Two (2) OBLIQUE muscles
Obliques are “unique”; work the OPPOSITE of name! Superior OBLIQUE (SO) pulls eye inferiorly (&
across nose) Inferior OBLIQUE (IO) pulls eye superiorly (&
OCULAR MOTILITY (EOMs) (cont.)
RECTUS MUSCLES
OBLIQUE MUSCLES
OCULAR MOTILITY (EOMs) (cont.)
(cont.)
PUPILLARY ASSESSMENT Follow the PERRLA format & you’ll do great! PER = Pupils EQUAL & ROUND? RL = Pupils REACT TO LIGHT?
Direct Consensual
A = Accommodate? (i.e., pupils get SMALLER when focusing on a NEAR object)
But what about MARCUS GUNN (MG)? Also called APD for “afferent pupillary defect”
(APD) or… The “Swinging Flashlight Test”
PUPILLARY ASSESSMENT (cont.) Check for “equal & round” FIRST! (put the penlight down!) Perform direct & consensual response to light (“reacts to
light”) DIRECT – shine in OD & observe OD; repeat for OS INDIRECT – shine in OD but observe OS; repeat for other
side Evaluate “accommodative” response (pupils constrict @
near) Hold a pen tip 6” in front of Pt’s eyes (yes, that’s close!) Have the patient look at the 20/200 “E” Then have Pt look @ the pen tip; PUPILS should
CONSTRICT when attempting to focus on the near object! That’s all that matters. (Don’t care if blurry or double!)
At this point, you’ve covered P E R R L A ! Not done… Check for an Afferent Pupillary Defect (APD), also called the
“Marcus Gunn” (MG) test, or the Swinging Flashlight test
PUPILLARY ASSESSMENT (cont.)
WHAT DO YOU THINK ABOUT THESE PUPILS?
PUPILLARY ASSESSMENT (cont.)
PUPILLARY ASSESSMENT (cont.)
PUPILLARY ASSESSMENT (cont.)
PUPILLARY ASSESSMENT (cont.)
PD MEASUREMENT PD or Pupillary Distance (often referred to as IPD, for “inter-pupillary distance) is CRITICAL for an optical department to know & do correctly!
GOAL is for the Optical Centers (OCs) of glasses ordered to MATCH the Patient’s PD
Two ways to measure PD: PD Ruler (millimeter ruler)
Gives you a BINOCULAR measurement (GOOD!)
Pupillometer Gives you a BINOCULAR ‘total’ and a
MONOCULAR measurement for each eye (BETTER!)
PD MEASUREMENT (cont.) In THEORY, you are measuring from the
center of one pupil to the center of the other, as shown in the picture…
PD MEASUREMENT (cont.) In REALITY, you will measure from OD
temporal limbus to the OS nasal limbus! Why? Much easier to SEE & MEASURE!
(meaning “more accurate”)
PD MEASUREMENT (cont.) Instruct Pt “Look at my LEFT eye” (it will be the
ONLY eye you have open!) Line up the ZERO mark with Pt’s R. Lateral
Limbus
PD MEASUREMENT (cont.) With Pt still looking at your LEFT eye (the only one
you have open), you look over at the Pt’s LEFT eye & get the NEAR PD reading from their Left Nasal Limbus
In this case, their NEAR PD would be 62mm
PD MEASUREMENT (cont.) Now have the Pt look at your RIGHT EYE (you will
close your LEFT eye and OPEN your RIGHT EYE.) You will look at the Pt’s LEFT eye (again) & get the
DIST PD reading from their Left Nasal Limbus
In this case, their DISTANT PD would be 65mm
PD MEASUREMENT (cont.) PUPILLOMETER Can set to measure
DIST or NEAR Pt looks @ object in
unit Optician slides tabs to
put “lines” through Pt’s pupils
Read-out shows you the PD!
EASY…LOVE IT!
PERFORM SKILLS!
CASE HISTORY & HPI Evaluation & Management (E/M) Codes: All levels have same four basic history-taking
components in common: Chief Complaint (CC) History of Present Illness (HPI) Review of Systems (ROS) and Past, Family and/or Social History (PFSH)
CASE HISTORY & HPI: Chief Complaint (CC) CHIEF COMPLAINT dictates the exam process!
(Reimbursement intimately linked to the chief complaint.)
CC: should detail primary reason(s) patient scheduled an examination
At times, should be in the patient's own words (put in “QUOTES” to show it is verbatim from Pt)
The chief complaint also suggests what tests you'll need to perform (saves time; impresses the doctor; gets Pt care they need & deserve)
CASE HISTORY & HPI (Chief Complaint, cont.)
"I'm just here for checkup" or, "I want new glasses" These two responses would disqualify
reimbursement by some payers (e.g. Medicare) How OLD is Pt? What is PRIMARY insurance?
Pts returning for eval of chronic conditions such as Glaucoma or AMD can be reason enough for visit (even in absence of specific pt complaint)
If pt complains of blurred or decreased VA, get a specific “lifestyle” issue it is negatively impacting!
CASE HISTORY & HPI (HPI) History of Present Illness (HPI) Try to elicit @ least four HPI bullets (or status of
three or more chronic or inactive conditions) Signs & symptoms (decreased VA, pain, tearing,
discharge, redness, FB sensation, etc.) Context (while driving, after take pills, when CLs
in) Duration (date of onset; duration of problem) Location (R. eye, L. eye, lid, behind eye, etc.) Quality (blurry, double vision, etc.) Modifying Factors (Art tears help, bright light
aggravates, blinking makes it better, etc.) Severity (degree of pain or loss of sight)
Timing (a m p m upon waking at end of day
CASE HISTORY & HPI (HPI, cont.) Example of an HPI:
Mrs. Braxton gives this CC (HPI), w/your help! “My right eye is red” “It began 3 days ago” “It doesn’t hurt” “Lids stick together in the morning last two
days” “Art Tears soothe it, but redness remains”
You did GREAT! You got more than FOUR of the HPI elements & info the doc can use to help Pt
CASE HISTORY & HPI (ROS & PFSH) Review of Systems (ROS) Most time-consuming! Most offices use pre-printed forms that can be filled out
by patients online or at home before exam. Go here for lots more info on this!
http://emuniversity.com/ReviewofSystems.html A review of 10 or more systems will qualify any E/M
code Past, Family and/or Social History (PFSH)
Past History of Pt (illnesses, injuries, surgeries, other treatments)
Family History (most interested in diseases which may be hereditary and/or place the patient at risk)
Social History (review of past & current activities like smoking drinking drugs)