PARTNERING WITH OPTOMETRY FOR EDUCATION AND PATIENT CARE

Getting ‘Worked Up’Ophthalmology Technical

Essentials

Britta Hansen, OD, FAAOMarch 22, 2014

Berkeley Optometry Grew up in Minnesota Residency at San Francisco VA Work at Northwest Eye Surgeons

Who am I?

“Triage”

Components of technical exam•History/chief concern(s)•Phone/walk-in triage•Vision, refraction•Confrontation visual fields•Extraocular motility•Pupillary reaction•Intraocular pressure, angles•Additional testing

Patient examples

Outline

Base questions upon:•What you expect as an answer•What diagnoses you’re considering/past experience•What they’ve already told you

Chief concern/Phone Triage

VS.

Let the patient [briefly] tell you what’s wrong

Ask new questions that make sense:•Pain = what scale?•Redness, blurry = how long? What scale?•Headache = tried to alleviate?•Any eye drops = side effects?•Any new medications = side effects?•Injury = flashing lights, floaters,

bruising?

Where to start?

Some patients will overstate their symptoms

Others will downplay their symptoms Knowing the right questions, trusting your instincts and continuously re-visiting your process for triage regularly

There is an art to this…

See ASAP See Next Available

Extreme pain Blurriness

Extreme, new blurriness Ache, strain

Extreme headache Chronic redness

Extreme vision loss Symptoms that follow a more “chronic” pattern

New double vision

New moderate to severe redness

Very recent injury to eye or orbit

Anything that follows an “acute” pattern

*Consider your office’s “specialty,” may want to have the patient scheduled with a more urgent center based on some symptoms

How to schedule?

Subjective versus Objective testing

Subjective History/Chief Concern

Objective Fields Motility Pupils IOP

• Vision?• Refraction?

Patient medical history Family medical history Patient ocular history Family ocular history

•Which diseases are inherited?♦Macular degeneration♦Glaucoma♦Retinal detachment♦Strabismus (eye turns)♦Low vision disorders: ie Retinitis

pigmentosa, ocular albinism

History

What questions help?

HPI = History of Present Illness

•Location•Severity•Quality•Duration•Timing•Context•Modifying factors

Primary eye care setting•More weight on refraction, contact lens fittings•Less weight (but still important) on chair skills

Tertiary care setting•More weight on chair skills to help with

diagnosis

There is overlap between the settings, knowing what to do in each instance will help to have a smooth work-up

Know Your Patient Base

Components of technical exam•History/chief concern(s)•Vision, refraction•Confrontation visual fields•Extraocular motility•Pupillary reaction•Intraocular pressure, angles

Triaging patient examples

Outline

“Chair Skills”

The Eyes are an extensionof the Brain!

Visual fields Finger Counting: all or none Transilluminator fields: all or none Automated perimetry: qualify visual field defect

•Humphrey•Matrix•FDT

Abnormal fields:•Glaucoma, other optic nerve problems•Retinal detachments•Vein and artery occlusions•Stroke, tumor

Tropia: one eye turns in (eso) or out (exo)

Main question: do you see double?

Extraocular motility

“Double Vision:” poor blood flow to muscles around the eye, muscle trapped from free movement

Extraocular Muscles

Patients with SYMPTOMATIC double vision will tell you. PUPILS can be very important in this case.

Extraocular Muscles

Extraocular movements

Poorly controlled diabetes Poorly controlled blood pressure Graves Disease Congenital Entrapment from an injury Anomalies of the nerves Compression to the nerves or the muscles

Reasons for rare eye movements

Pupillary Action

Equal size/shape Equal reaction to light Similar movement when the light is in the other eye

Relatively the same movement when swinging back and forth

What to look for

Anisocoria- difference between pupil size

Horner’s- miotic (small) pupil Adie’s- acute dilated pupil Relative Afferent Pupillary Defect

•If present, it can be VERY important as a component of the doctor’s exam

•This is a RELATIVE difference between the two eyes and their brain input

Pupillary testing

Asymmetric glaucoma Blood loss to the OPTIC NERVE in one eye Retinal detachment in one eye Blood loss to the RETINA in one eye Compression on the optic nerve in one eye

NOT: Cataract NOT: Amblyopia NOT: Macular Degeneration or Scar

Things that cause an RAPD

http://www.richmondeye.com/wp-content/uploads/2014/01/d097550bb4b088bb4853b2992c86d90a.htm

Pupillary Demonstration

One pupil doesn’t work because of an iris injury

A patient has a new concern in the “good eye” where the “bad eye” already has a relative pupil problem

Complicated Pupils

Monocular? Binocular? Without correction? With Correction? Distance? Intermediate? Near? Pinhole?

Vision

Reduced vision•Glasses wrong/outdated•Cataract•Macular disease (edema, epiretinal

membrane, macular degeneration)•Sudden loss of vision (vascular disorder,

retinal detachment)

Vision

Change from glasses? Best “corrected” visual acuity

Refraction

Glasses change: gradual•Can be due to Diabetic shift in blood sugar

Cataract: blurry vision through glasses, glare while driving at night, haloes and starbursts

Retinal detachment: flashing lights, shower of new floaters, dark curtain over vision, blurred vision

Open angle glaucoma: no symptoms until late in the disease, high pressure in this case is painless

Range of Concerns and Diagnoses

Vitreous detachment: floaters in presence or absence of flashing lights, no vision loss, usually distinct floater(s)

Acute Angle Closure Glaucoma: Recent pupillary dilation, foggy vision

Range of Concerns and Diagnoses

Posterior Vitreous Detachment

http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/weiss-ring.html

Bacterial conjunctivitis: pus-like discharge, eyes stuck shut in morning, usually children

Viral conjunctivitis: white/clear discharge, contact with someone else with a red eye, current or recent past upper respiratory infection, swollen, one or both eyes

Uveitis: sensitivity to light, redness Scleritis: extreme eye pain, extreme redness

Concerns and Diagnoses: PINK EYE

Allergic conjunctivitis: watering and itching of eyes, usually seasonal, current runny nose/cough/sneezing

Concerns and Diagnoses

Nerve palsy: symptoms only when both eyes open, certain gazes have less double than others, may have diabetes, hypertension, Graves, or other systemic diseases•May have lid droop, pupillary problem as

well

Concerns and Diagnoses: DOUBLE VISION

Acute angle closure glaucoma: vomiting, nausea, rainbows around lights, worse in morning, can be precipitated by dilation

Transient ischemic attack: blacked out vision lasting seconds to less than 5 minutes, returns to normal, typically older patients with history of high cholesterol•***IF symptoms coincide with unilateral

weakness, trouble findings speech or trouble ambulating, send patient immediately to ER

Concerns and Diagnoses

Foreign body: patient usually knows when it went in

Penetrating injury: high velocity, either patient or object, globe may be open, check immediately or send to ophthalmology if suspect

Endophthalmitis: extreme pain in the eye, usually after surgery or with other illness, send to ophthalmology

Concerns and Diagnoses

65 yo female calls with blurry vision FIRST question to ask:

•How long has the vision been blurry? Qualifiers

•How blurry is it?•Does anything make it better?•Has anything changed

Accompanying concerns•Flashing lights, floaters, diabetes

Patient #1

Vision blurry x 1 year Glasses help but not much Has glare and haloes with oncoming headlights

Diagnosis? Likely cataract, check next available

Patient #1 continued

5 yo male Red, painful eye For the last 2 days Got poked with a fake candy cane, went to urgent care, was given ointment, is sensitive to light

Likely diagnosis? Corneal abrasion, see same day if possible

Patient #2

45 yo male Blurry vision, both eyes

•Cobweb in the right eye yesterday, left eye now very fuzzy

Since yesterday the left eye has been very bad

Hasn’t seen any Dr. since 2009

Diagnosis: Proliferative Diabetic Retinopathy, see same day if possible

Patient #3

65 yo female Blurry vision, right eye, since yesterday

Proceeded by flashing lights/mild floaters

Now sees a curtain over vision

Likely diagnosis: Retinal detachment, see today

Patient #4

20 yo female Red, painful left eye Very sensitive to light, vision mildly blurred

Has systemic lupus

Likely diagnosis: Unilateral uveitis, see today or tomorrow

Patient #5

Finally!

Northwest Eye Surgeons is the premier eye surgical center in the Northwest and remains committed to its tradition of personalized, high quality patient care, advanced technology and excellent results.

SERVICES:CataractRefractive SurgeryGlaucomaCorneaPediatrics & StrabismusRetina, Vitreous & UveitisEyelid Surgery & Facial Rejuvenation

PARTNERING WITH OPTOMETRY FOR EDUCATION AND PATIENT CARE

800.826.4631www.nweyes.com

Britta Hansen, OD, FAAObhansen@nweyes.com