V551#9 prac#2review2010 [autosaved]

V551V551 PracticalPractical Review Review

Richard E. Meetz, OD, MSRichard E. Meetz, OD, MS

20102010

The Practical:The Practical:

PatientsPatients

The PatientsThe PatientsWhat to expect?What to expect?– The AIs will NOT be sitting as your patientsThe AIs will NOT be sitting as your patients

Will be grading as outside observer with minimum Will be grading as outside observer with minimum interaction with youinteraction with you

– Patients will be 2Patients will be 2ndnd and 3 and 3rdrd years yearsWill be myopes of varying degreesWill be myopes of varying degrees

– Range -0.50 to -9.00Range -0.50 to -9.00

All will have cylinder to some degree, All will have cylinder to some degree, – May only see on ret and patient may run you or kick it all May only see on ret and patient may run you or kick it all

outout

Good VAs & No suppressionGood VAs & No suppression

The PatientsThe PatientsWhat to expect?What to expect?– ScenariosScenarios

If the patient’s Rx is under -3.00If the patient’s Rx is under -3.00– You will be told they have lost their glassesYou will be told they have lost their glasses

– You will only be able to take unaided VAs You will only be able to take unaided VAs

If the patient’s Rx is over -3.00If the patient’s Rx is over -3.00– You will be told they have lost their current glasses and are You will be told they have lost their current glasses and are

wearing a old pair of -#.## powerwearing a old pair of -#.## power– You will take the aided acuities You will take the aided acuities

May also take take unaided VAs if you like May also take take unaided VAs if you like

The patients will give you the VA correlating to the The patients will give you the VA correlating to the approx. error they are portrayingapprox. error they are portraying

TimingTimingSet up & VAs?Set up & VAs?

KsKs

RetRet

RefractionRefraction

A&PA&P

Auxiliary testsAuxiliary tests

TimingTimingSet up & VAs?Set up & VAs?– Not timed for points but will be observed and Not timed for points but will be observed and

scored for efficiencyscored for efficiency

KsKs– Same time as the 1Same time as the 1stst practical practical– Starts with cleaning if not done as part set-up Starts with cleaning if not done as part set-up

or focusing the eye pieceor focusing the eye piece

– Stops after you have recordedStops after you have recorded– Predicting the cylinder on “set-up” time Predicting the cylinder on “set-up” time

TimingTimingRetRet– Starts with the Fog stepStarts with the Fog step

If fogging is not needed MUST state to graderIf fogging is not needed MUST state to grader

– Will be paused for the VA checkWill be paused for the VA checkIf 20/40 time will hold as you do the quarter and axis If 20/40 time will hold as you do the quarter and axis rockrockIf 2If 2ndnd ret is needed, time is not reset but continues ret is needed, time is not reset but continuesif 2if 2ndnd ret is indicated it must be done ret is indicated it must be done

– Can not skip to R-GCan not skip to R-G– But only need be done on the eye >20/30But only need be done on the eye >20/30

If 2If 2ndnd ret >20/30 no 3 ret >20/30 no 3rdrd try, record & go to aux Sph ck try, record & go to aux Sph ck

TimingTimingRet time pointsRet time points– Ret time ends with recording the findings & VARet time ends with recording the findings & VA– Notice 2x points at 1Notice 2x points at 1stst cut-off: 4min cut-off: 4min

Gives you two min / eyeGives you two min / eye

The time now matters on a real patient!The time now matters on a real patient!

– At 10 min penalized -1 / min over!At 10 min penalized -1 / min over!

– No pause No pause between recording the ret and the start of between recording the ret and the start of the refraction timethe refraction time

Only long enough to record your time and re-set the stop watchOnly long enough to record your time and re-set the stop watch

TimingTimingRefraction timeRefraction time– Starts with the Fogging stepStarts with the Fogging step– Refraction time ends with recording the BVA Refraction time ends with recording the BVA

findings & the VAsfindings & the VAs– Will be given extra time for a difficult patientWill be given extra time for a difficult patient

TimingTimingA&PA&P– Not timedNot timed

But they are But they are NOT NOT going to give you all daygoing to give you all day

Auxiliary testsAuxiliary tests– Not timed for points but will be observed and Not timed for points but will be observed and

scored for efficiencyscored for efficiency

Total time should be < 45 min eachTotal time should be < 45 min each– Wait time < 1 hourWait time < 1 hour

Trouble Shooting the Practical:Trouble Shooting the Practical:

What do I do What do I do when things go wrong?when things go wrong?

Trouble Shooting the Practical:Trouble Shooting the Practical:What do I do when things go wrong?What do I do when things go wrong?

Patient’s vision is >20/200! Do I PinHole?Patient’s vision is >20/200! Do I PinHole?

- No they are all refractive cases- No they are all refractive cases

Do I need to take both distance and near VAs!Do I need to take both distance and near VAs!

- Yes, std testing- Yes, std testing

- The near can tell you if a sig or large cylinder is - The near can tell you if a sig or large cylinder is presentpresent

- 20/80 DVA & 20/15 NVA = little to no cyl- 20/80 DVA & 20/15 NVA = little to no cyl

- 20/80 DVA & 20/25 NVA = sig cyl- 20/80 DVA & 20/25 NVA = sig cyl


Can’t focus the Keratometer!Can’t focus the Keratometer!

- Check the eyepiece- Check the eyepiece

- Check the headrest- Check the headrest

Can’t find the meridians!Can’t find the meridians!

- Check the focus?- Check the focus?

- Place the mires tip to tip? Try slightly over lapped.- Place the mires tip to tip? Try slightly over lapped.

- Suppressing an eye? Try switching to dominate.- Suppressing an eye? Try switching to dominate.

- Check the powers are they the same or close?- Check the powers are they the same or close?


Can’t see the ret reflex!Can’t see the ret reflex!

- Is patient centered? Patient Awake? - Is patient centered? Patient Awake?

- Refractor tipped? Re-align refractor?- Refractor tipped? Re-align refractor?

- Flip out the ret lens; it may be fogged or dirty- Flip out the ret lens; it may be fogged or dirty

- Suppressing an eye? Or using non-dominate? Try - Suppressing an eye? Or using non-dominate? Try closing or occluding dominate. Try switching to closing or occluding dominate. Try switching to dominate .dominate .

- Reflections? Re-align refractor. Try using R-G - Reflections? Re-align refractor. Try using R-G Filter in projector? Cuts glare but increases pupil Filter in projector? Cuts glare but increases pupil size.size.


Can’t tell the movement!Can’t tell the movement!

- “Make it move” add +/- 1.00DS.- “Make it move” add +/- 1.00DS.

Can’t tell which is the sphere/cylinder Can’t tell which is the sphere/cylinder meridian on the ret reflex!meridian on the ret reflex!

- Use your K prediction as a starting - Use your K prediction as a starting meridian.meridian.

- However - However do not dial in do not dial in your prediction and try your prediction and try to ret, remember the cross-cyl issue!to ret, remember the cross-cyl issue!


Still can’t tell which is the Still can’t tell which is the sphere/cylinder meridian on the ret sphere/cylinder meridian on the ret reflex!reflex!

- Just start neutralizing one meridian and - Just start neutralizing one meridian and as you get closer the difference will as you get closer the difference will become more obvious.become more obvious.

- Watch out for the 45° reflex shift- Watch out for the 45° reflex shift


I’m dialing in power and nothing I’m dialing in power and nothing changes!changes!

- Are you on the correct knob or wheel?- Are you on the correct knob or wheel?- on cyl knob but sweeping the sphere- on cyl knob but sweeping the sphere

- Are you sweeping the correct meridian? - Are you sweeping the correct meridian? -From arrow to arrow for Sphere,-From arrow to arrow for Sphere,

-align with both arrows for cyl?-align with both arrows for cyl?


I’m dialing in cyl power and can’t find I’m dialing in cyl power and can’t find neutral!neutral!- Are you sweeping the correct meridian? - Are you sweeping the correct meridian?

-Aligned with both arrows for cyl?-Aligned with both arrows for cyl?

--Watch the K’ prediction, Watch the K’ prediction, --The cyl power is usually within +/- 0.50 DCThe cyl power is usually within +/- 0.50 DC

-Watch out for the center with reflex shift-Watch out for the center with reflex shift --Watch out for the 45° reflex shiftWatch out for the 45° reflex shift

--Usually within +/- 0.50 DCUsually within +/- 0.50 DC


I’m seeing a scissor reflexI’m seeing a scissor reflex - Is it a 45° reflex shift?- Is it a 45° reflex shift?

- Are you sweeping in line with the meridian? Are you sweeping in line with the meridian? - Aligned with both arrows for cyl?Aligned with both arrows for cyl?

- Does the patient have large pupils?Does the patient have large pupils? - Watch out for the center with reflex shiftWatch out for the center with reflex shift- Make the pupil smallerMake the pupil smaller

– - Flip out the R-G to a white chart- Flip out the R-G to a white chart– - Turn stand light on “dim”- Turn stand light on “dim”

–


Got 20/30 after the ret!Got 20/30 after the ret!

- Did you take the WD lenses out? - Did you take the WD lenses out? Correctly?Correctly?

- Click -0.25 DS, if the VA improves start - Click -0.25 DS, if the VA improves start step down, if not step down, if not redo ret.redo ret.

- If > -1.00 cylinder in refractor, rock +/- - If > -1.00 cylinder in refractor, rock +/- 1010° check for VA improvement. If not ° check for VA improvement. If not redo ret.redo ret.


Still over 20/30 after the 2Still over 20/30 after the 2ndnd ret!! ret!!

- Go to R-G sphere check and clock dial.- Go to R-G sphere check and clock dial.

Patient not able to read 20/20 after Patient not able to read 20/20 after sphere check!sphere check!

- If < 20/30 Use VA line 2 lines larger - If < 20/30 Use VA line 2 lines larger then sphere check VA for JCC.then sphere check VA for JCC.

- If > 20/30 go to Clock Dial.- If > 20/30 go to Clock Dial.


Patient not able to see JCC choices!Patient not able to see JCC choices!

- Do you still have them fogged? - Do you still have them fogged?

- Remove fog! - Remove fog!

- Can they see the target? - Can they see the target?

Patient not able to make JCC choices!Patient not able to make JCC choices!

- Move off ret axis by 15- Move off ret axis by 15° & move back.° & move back.

- Change line or Isolate a single letter target - Change line or Isolate a single letter target

- Drop back to clock dial- Drop back to clock dial


Patient still not able to make JCC choices!Patient still not able to make JCC choices!

- If small cyl; Go to eliciting cylinder procedure.- If small cyl; Go to eliciting cylinder procedure.

- If large cyl; redo Ks and set at predicted then - If large cyl; redo Ks and set at predicted then check clock dial.check clock dial.

Patient runs me around dial on JCC!Patient runs me around dial on JCC!

- Following correct dots? - Following correct dots? -Either side of flip knob. Same side of cyl bank?-Either side of flip knob. Same side of cyl bank?

- Go to eliciting cylinder procedure.- Go to eliciting cylinder procedure.


Patient can’t pin down axis on JCC!Patient can’t pin down axis on JCC!

- You pick axis to nearest 5- You pick axis to nearest 5°.°.

Patient can’t pin down power on JCC!Patient can’t pin down power on JCC!

- Pick smaller power.- Pick smaller power.


Patient calls “white” on the power Patient calls “white” on the power check when I’m at zero in the cyl check when I’m at zero in the cyl bank. Am I done?bank. Am I done?

- NO. Your axis is 90- NO. Your axis is 90° off! ° off!

- Change - Change 9090° or Go to eliciting cylinder ° or Go to eliciting cylinder procedure.procedure.


Patient already blurred for MPMA at end Patient already blurred for MPMA at end of JCC!of JCC!

- Did you remove JCCs? Remove.- Did you remove JCCs? Remove.

- Maintain sphere check during JCC? Redo - Maintain sphere check during JCC? Redo sphere ck & JCC.sphere ck & JCC.

- Patient accommodating? - Patient accommodating?

Go to Humphriss.Go to Humphriss.


Patient can’t see two charts on Patient can’t see two charts on balance!balance!- Both eyes open?- Both eyes open?- Fogged too much? Reduce fog.- Fogged too much? Reduce fog.- Prisms set correctly? Reset/Increase.- Prisms set correctly? Reset/Increase.

Patient can’t be balanced!Patient can’t be balanced!- Too fogged? Reduce fog.- Too fogged? Reduce fog.- Step down to 20/30.- Step down to 20/30.


Still patient can’t be balanced!Still patient can’t be balanced!

- Do alternate occlusion balance. - Do alternate occlusion balance. – Leave dominate eye clearer.Leave dominate eye clearer.

On final step down patient sees 20/15 On final step down patient sees 20/15 right after prism removed!right after prism removed!

- Fog back up to +0.75 and step down.- Fog back up to +0.75 and step down.


Patient keeps calling better!Patient keeps calling better!

- Stop with the lens of no “letter” improvement.- Stop with the lens of no “letter” improvement.

The BVA’s monocular VAs are not the same!The BVA’s monocular VAs are not the same!

- Return to balance.- Return to balance.

- Start from MPMA. Or Recheck JCC.- Start from MPMA. Or Recheck JCC.

- Do MPMA balance.- Do MPMA balance.

- Do alternate occlusion balance if still off.- Do alternate occlusion balance if still off.

The A & PThe A & PWhat to expect?What to expect?– On both the practical and the 2nd written On both the practical and the 2nd written

expect both trouble shooting problems and expect both trouble shooting problems and prescribing scenariosprescribing scenarios

Know now to do K predictionsKnow now to do K predictions

Recognize when a procedure has been done Recognize when a procedure has been done incorrectlyincorrectly

– Missed step, wrong steps, lighting, instructionsMissed step, wrong steps, lighting, instructions

Be able to ID the most likely error source or bad Be able to ID the most likely error source or bad datadata

– VA, Ks, Ret, SubjectiveVA, Ks, Ret, Subjective– VA rules VA rules

The A & PThe A & P

What to expect?What to expect?-You will be asked if all your data makes sense-You will be asked if all your data makes sense

-do the K’ predict the cylinder found on either the ret or -do the K’ predict the cylinder found on either the ret or refraction?refraction?

-+/- 0.50? Axis?-+/- 0.50? Axis?

-Did the K’s & ret predict the final refraction?-Did the K’s & ret predict the final refraction?-+/- 0.50? Axis?-+/- 0.50? Axis?

-If not be able to come up with a why not?-If not be able to come up with a why not?- Over minus ret, ΔK too small, etc- Over minus ret, ΔK too small, etc

The A & PThe A & PWhat to expect?What to expect?

-You will then be given 2 senarios either-You will then be given 2 senarios either– Where the patient should have their Rx Where the patient should have their Rx

changed and whychanged and why

– One where you should not change the Rx One where you should not change the Rx and why by giving the general guideline and why by giving the general guideline rule that best appliesrule that best applies

Know the rulesKnow the rules

The A & PThe A & P

What to expect?What to expect?Example: Hab Rx none 20/25-1Example: Hab Rx none 20/25-1

Ks predict -0.25 x015Ks predict -0.25 x015

Retinoscopy gives -0.50- 0.50x030 20/20Retinoscopy gives -0.50- 0.50x030 20/20

Subjective gets -0.25-0.25x060 20/20+2Subjective gets -0.25-0.25x060 20/20+2

Error? Ks? Ret? Or patient?Error? Ks? Ret? Or patient?

Rx give or not?Rx give or not?

The A & PThe A & P

What to expect?What to expect?Example: Hab Rx -2.00DS 20/20-2Example: Hab Rx -2.00DS 20/20-2

Ks predict -1.00 x180Ks predict -1.00 x180

Retinoscopy gives -1.75 - 0.50x030 20/20+1Retinoscopy gives -1.75 - 0.50x030 20/20+1

Subjective gets -1.50-0.75x010 20/15-1Subjective gets -1.50-0.75x010 20/15-1

Error? Ks? Ret? Or patient?Error? Ks? Ret? Or patient?

Rx give or not?Rx give or not?

The A & PThe A & P

What to expect?What to expect?– You will then be given a blank Rx slip will write You will then be given a blank Rx slip will write

out what you think the patient should have. out what you think the patient should have. Be able to give the rational for giving or not an RxBe able to give the rational for giving or not an Rx

– Know the rulesKnow the rules

Know how to correctly write a prescriptionKnow how to correctly write a prescription

The Alternate ProceduresThe Alternate Procedures

What to expect?What to expect?– You will be given a alternate procedure to You will be given a alternate procedure to

perform of the AI’s choosingperform of the AI’s choosing– 11stst You need to give them 2 indications for the You need to give them 2 indications for the

procedureprocedure– Next you will conduct the step with the AI Next you will conduct the step with the AI

playing the part of the patient playing the part of the patient You will give all patient instructions and test steps as You will give all patient instructions and test steps as if there is a patient behind the refractor, do NOT if there is a patient behind the refractor, do NOT simply say “I would do this then this…” you must simply say “I would do this then this…” you must actually do the steps.actually do the steps.

LastlyLastly

What to expect?What to expect?– You will be given a briefing after you have You will be given a briefing after you have

completed the practical by both the AI and the completed the practical by both the AI and the patientpatient

– You will be notified of scores with in three days You will be notified of scores with in three days – There will be no section redos There will be no section redos – Retakes for scores <75% will be the last week Retakes for scores <75% will be the last week

in class during the normal scheduled labin class during the normal scheduled labIf your score >75% you do not have lab the last If your score >75% you do not have lab the last week.week.

LastlyLastly

Monday lecture class will not meet next Monday lecture class will not meet next MondayMonday– I will be in my office for questionsI will be in my office for questions

It is best that you email ahead to checkIt is best that you email ahead to check

Monday the 26th we will have a Review Monday the 26th we will have a Review session for the final examsession for the final exam

Documents

V551#9 prac#2review2010 [autosaved]