Routine eye Examination

Introduction

For the majority of optometrists, routine eye examination is the activity that occupies most of their professional life.The workingday may be punctuated by contact lens appointments, dispensing or management, but “The Routine” is there like a heartbeat. It becomes an extension of the practitioner, and will eventually become as personal as a fingerprint.This is a desirable evolution, driven by the acquisition of knowledge and experience, but it does create problems for those starting out.The diversity of methods and interpretations encountered, even in undergraduate clinics, tends to create confusion rather than the wide breadth of useful variation intended.This is perhaps a controversial statement, but it is based on experience. The term “routine examination” becomes most familiar to optometrists as part of their professional qualifying examinations.

The term is used to describe the various procedures required during a full eye examination in order to properly assess both the optical status of a patient (and be able to prescribe an appropriate optical correction) and the ocular health. For the best part of a decade, the authors have been members of a team that was created to help optometric graduates through their pre-registration year and professional qualifying examinations (PQE).The job involved regular teaching in undergraduate clinics,as well as on postgraduate courses in preparation for the PQE. Experience as examiners for the College of Optometrists was also brought to bear, so over the years we have seen a lot of people go through university clinics, pre-registration year and their professional examinations.Initially,“Routine” gave us more headaches than any other section of the PQE and had traditionally the poorest first-time pass rate of any of the sections.We tried the usual refresher course approach, but it seemed to have no effect on the pass rate, though it did in other sections. It was only when we became more proactive that the results started to improve measurably.

Essentially we caught the pre-regs early in their year with a routine designed by a number of examiners, in an attempt to avoid some of the confusion that we were seeing in our tutees. The process involved one of us writing out an instruction manual which was then reviewed by a further ten examiners, who were between them teaching in all of the optometry departments then in existence.To everyone’s surprise we managed to settle all disputes without war breaking out. In fact, there really wasn’t that much that was controversial at all.The final version was then agreed and the result passed on to the graduate optometrists as they began their pre-registration year. It is from this work that much of this book has been developed, though it is hoped that it will prove as useful to a pre-registration optometrist as it may be to an experienced practitioner who, through years of developing a particular routine, may wish to revise a lesser used technique.Those entering the profession from university often have little reliable basis upon which to make informed choices, due to lack of contact with patients during their undergraduate period. Choices between different techniques during an eye examination become randomized, likely to be influenced more by ease of application or under the influence of one particular supervisor. What new practitioners need, we believe, is for experienced practitioners to take the responsibility of choosing a method that works, rather than a range that might or might not. As the new practitioner gains experience, they can begin to evolve their own routine, provided the roots are sound. The methods described are not the only ones, and maybe not even the best ones, but they have been thoroughly road-tested, both in the professional examinations and in practice. The authors have between them worked in every type of optometric practice from high street to hospital, and from locum to LASIK clinic, and these are the methods we have used.The book may prove particularly useful to those approaching the newly trialed pre-registration year, with its assessor visits and final examinations. The working environment is composed of legal, moral and

commercial elements. Guidance on what constitutes a proper examination has been provided by the College of Optometrists Code of Ethics and Guidance for Professional Conduct, which the General Optical Council tends to regard as the “peer view” in disciplinary cases. On the routine eye examination the guideline is as follows:

“The optometrist has a duty to carry out whatever tests are

necessary to determine the patient’s needs for vision care as to both

sight and health.The exact format and content will be determined by

both the practitioner’s professional judgment and the minimum legal

requirements”.

“(1) When a doctor or optician tests the sight of another person it shall be his duty

(a) to perform for the purpose of detecting sign of injury, disease or abnormality in the eye or elsewhere

(i) an examination of the external surface of the eye and its immediate vicinity

(ii) an intraocular examination, either by means of an ophthalmoscope or by such other means as the doctor or optician considers appropriate

(iii)such additional examinations as appear to the doctor or optician to be clinically necessary”

The essential message here is that if you test someone’s eyes with the aim of issuing a visual correction, you can’t just do a refraction.You have to screen the health of their eyes as well.This fact has shaped the structure of the routine as well as making its internal logic rather more difficult to follow at first.There are two end points rather than one and the efficient organization of the routine requires that both end points are arrived at with the minimum expenditure of effort and in a reasonable time. What constitutes a reasonable time is open to debate.At

undergraduate level, examinations are measured by the calendar rather than the clock, yet essentially the same ground is covered in 20 minutes in what is often rather disparagingly called “High Street practice”. Purists may sniff, yet the 20-minute sight test interval, which is the de facto industry standard, has not apparently caused widespread loss of sight among the population, and the remake rate has not gone into orbit. So it seems likely to stay.

In many smaller practices, 30 minutes is allowed between appointments, but that often includes 10 minutes for dispensing.

In larger practices, with dispensing a separate function, tonometry, fields and the use of autorefractors are often delegated to support staff. Provided that these staff are well trained, this can save considerable time. Either way, as a fully-fledged optometrist you may well have about 20 minutes maximum to carry out a “routine”. The other factor that needs to be taken into account is the patient. Research has indicated that they are unimpressed by prolonged sight testing. In fact, as will be discussed in Chapter 2, if the quality of the communication and the technique is good enough, the actual testing time bears little influence upon the patient’s satisfaction with their assessment, their recall of information, and their compliance with any instructions given. The routine can be regarded as a process of information gathering and decision-making and the fundamental difference between the undergraduate refraction and that performed by the fully-fledged practitioner is the approach to the gathering of information. Undergraduate refractions adopt what has been called a “database” approach.The less polite term for this is “box-filling”. Essentially, the same information is collected for every patient, whether it is directly relevant or not.The advantage of this approach in university clinics is that it is less likely that any essential information is missed or not recorded, so the supervisor will have enough information to make the clinical decision at the end of the clinic. Unfortunately, a drawback to this approach is that, for the student, information gathering and recording becomes an end in itself, and the crucial process of clinical decision-making becomes a delegated function. Furthermore, much of the information gathered will be essentially useless, which wastes time. If this approach was used extensively by experienced practitioners, the number of patients seen in a working day would be uneconomic and arguably less effective clinically. The experienced practitioner tends to have a smaller database to fill, though a certain amount of information is required for legal reasons, and some baseline information is useful to compare against future values (e.g. intraocular pressures, visual fields) for the early detection of trends.What was once “routine” may have become “subroutine”, brought in when the patient’s symptoms and history, or clinical findings, indicate their relevance. The more knowledge and experience the practitioner accumulates, the better this approach works. It follows that the routine is not fixed, it evolves. Not so many years ago, optometrists ascribed enormous significance to small differences in intraocular pressures and to the presence or absence of visual field changes, while largely ignoring the optic disc. Now we know that half of all glaucomas are normotensive, and that a patient can lose half of their nerve fiber layer without displaying a glaucomatous field loss, our approach to early glaucoma has changed significantly. It seems that optometrists will shortly be involved in the prescribing of therapeutic agents to treat a range of anterior eye conditions.The type of consultation needed to do this well is unlikely to be the same as one resulting in a pair of bifocals. For the moment, we shall concentrate on the more usual type of consultation, where the object is to arrive at a suitable optical correction, if required, and to screen the health of the eyes and adnexa.The precise order of the tests used will vary from practitioner to practitioner, and in many cases it makes little difference. However, there are some general principles to apply. Tests with the patient wearing their accustomed correction should be done before testing without it, in order to get an idea of their normal status before the testing process completely disrupts it.Tests should be done in such an order that each test makes subsequent ones easier. If you want to know what target to use for your cover test, it is helpful to know what the patient’s visual acuity is. If you are about to start retinoscopy, knowledge of

the symptoms and history and aided and unaided vision will help you to make a sensible choice of correcting lens, thus saving time. At the very least, they should not make the next test more difficult, or invalid. An example here would be to perform a fixation disparity test after a dissociation test (though this is frequently done), or to cover one up during the test and say “which line can you see now?” Binocular tests should precede ones that dissociate unless the reverse is unavoidable, and binocular vision should be stabilized before it is tested. Similarly, a patient with maculopathy should not be examined with an ophthalmoscope before all measurements of vision are completed, as the resultant after-image may take some time to clear. In most other cases, ophthalmoscopy can be done before or after the refraction. If done before, any pathological findings can be taken into account when you come to refract. Leaving ophthalmoscopy to the end allows refractive findings to point toward likely pathology, prevents a disabling after image, and allows the patient time to get used to the practitioner before the necessary invasion of personal space that accompanies ophthalmoscopy. But most of the time either way works just as well.