Introduction

The purpose of Clinical Procedures for Ocular Examination is to provide students and practitioners with detailed step-by-step procedures for a comprehensive battery of techniques used in the examination of the eye. These procedures include tests for assessing refractive error, accommodative function, binocular coordination, the health of the eyes, the fit and condition of contact lenses, screening tests for neurological and systemic health conditions, ocular imaging, and advanced procedures. The book contains detailed, step-by-step instructions on how to perform each technique. For each procedure, the reader is provided with comprehensive information on the purpose of the test, what equipment is needed, how to setup the equipment and the patient properly, and how to record the findings. Expected findings are listed for most tests. The text includes diagrams and photographs to reinforce the descriptions of the techniques.

The emphasis in this book is technical. It provides little in the way of the theory of the test and limited management following the procedure. Removal of the theoretical discussion leaves a pure, concise description of the techniques and allows the reader to concentrate on the psychomotor mechanics of the procedures. Mastery of the techniques and interpretation and management of the findings, however, cannot be obtained solely through the use of this book, but requires supervised clinical practice as well as a thorough understanding of the theoretical basis for each technique. Included in the References section at the end of the book are the cited sources that will provide the reader with more information on the necessary theory and background for each of the procedures.

The first chapter of the book deals with patient communication, clearly the most important aspect of patient care. Good communication improves patient outcomes and makes the encounter more enjoyable for both the patient and the doctor. The first time the patient and doctor meet is usually during the case history, a critical phase of the examination. In addition to establishing rapport with the patient and setting the tone for the exam, the history marks the beginning of the doctor’s diagnostic thought process. Knowing the patient’s concerns, the examiner can now begin to develop their examination strategy and differential diagnosis. Based on the patient’s chief complaints and routine background information gathered in the case history, the examiner can decide which phases of the examination to concentrate on and which problem-specific testing should be done. Good communication techniques should be utilized throughout the duration of the exam. Specifically, the examiner should also explain what they are about to do and why they are doing it before they perform any of the procedures contained in this text. Professional communication with other healthcare providers regarding patient information is outlined in the verbal presentation and written communication procedures. A new section has been added outlining best practices for patient privacy as this should be considered when transmitting any patient information whether verbal, written, or electronic.

The second chapter describes the entrance tests. These techniques are the first procedures performed following the case history. They are relatively simple procedures that use minimal, primarily handheld equipment. These tests often require patient contact with exam equipment or with the examiner and so a section on infection control has been added to highlight some best practices in patient care. The entrance tests screen for problems in each of the three major problem areas: refraction, visual function, and health. Most of the entrance tests screen for problems in more than one of these three areas. Thoughtful interpretation of the results of the entrance tests can greatly increase the efficiency of the examination. Augmented by the information gathered in the case history, entrance test data aid the examiner in pinpointing the patient’s problem areas and appropriately directing the examination strategy.

Chapters 3, 4, and 5 correspond to the problem areas of refraction, visual function, and ocular health, respectively. The tests chosen by the examiner to assess each of these areas will depend upon the patient’s age, symptoms, screening results from the entrance tests, and physical mobility. Many states, health insurance companies, and optometric organizations will set recommendations or requirements for procedures to be included in a comprehensive eye exam. It is then up to the examiner to determine which additional procedures will help confirm or rule out suspected diagnoses developed during the course of the history and exam. There also may be times when sound professional judgment dictates the need to omit certain tests from the routine examination. Each of these three chapters include common, essential tests used in the majority of comprehensive eye care encounters such as the distance subjective refraction, slit lamp biomicroscopy, and dilated binocular indirect ophthalmoscopy, to name a few. Also described in these chapters is a variety of problem-specific tests, by which the examiner explores a specific area of concern in detail. These tests are not done on a routine basis but are selected based on the patient’s case history and the results of other testing. Problem-specific tests are not placed in a separate chapter. They are included in the chapter corresponding to their problem area.

Included within Chapters 3, 4, and 5 are flowcharts that illustrate how tests might be grouped or sequenced in order to promote examination efficiency. These charts do not represent the only appropriate sequencing of the techniques, but they do illustrate one sequence for efficiently combining the procedures. Separate flowcharts are presented for the most commonly applied core entrance tests, refractive tests, and ocular health assessment tests. Since functional testing and problem-specific testing are almost always customized to the patient and depend strongly on the individual patient’s problem or complaint, there is no standard flowchart for these parts of the ocular examination.

Individual flowcharts could not possibly work for all patients. Rather, they are intended to provide a standard sequence of testing for the majority of patients seen in most examiners’ practices. This standard test order can be compared to the itinerary of a trip. The traveler plans the trip from start to finish along a standard pathway, or “main route.” Similarly, the flowcharts depict a standard itinerary of ocular tests that lead from the beginning to the end of the routine exam.

However, many patients need problem-specific tests, which can be compared to points of interest along the main route. When indicated, the examiner takes a “side trip.” That is, they perform certain tests that are supplemental to the main route. The flowcharts and text show when side trips are indicated. Once the necessary side trip is completed, the examiner should usually return to the main route and continue the examination from there. For the sake of examination efficiency, however, some side trips may be postponed.

Chapter 6 concentrates on the procedures necessary for basic fitting and monitoring of contact lenses. It is possible to quickly and efficiently incorporate these procedures into a comprehensive ocular examination as shown in the flow chart at the beginning of Chapter 6. This chapter includes soft lenses, rigid corneal and scleral lenses, and a new section describing the fit and assessment of orthokeratology (ortho-k) lenses. Fit and assessment of the multifocal contact lenses wearer and monovision patient are also discussed.

Chapter 7 deals with procedures used to screen a patient’s systemic health. The eye care professional may be the patient’s entry point into the health care system. Therefore, they have the responsibility to evaluate the overall health of the patient. The examiner may select to perform certain procedures based on the patient’s age, medical history, or presenting symptoms or as the result of information gathered during the comprehensive examination. Alternately, the examiner may prefer to perform some of these screening procedures routinely on all patients. Patients with abnormal results should be referred to the appropriate health care provider for more thorough evaluation, diagnosis, and management.

Chapter 8 concentrates on procedures used to assess the cranial nerves when screening for neurological disorders. These techniques are rarely used for routine screening, but they are particularly helpful when a problem is suspected on the basis of the patient’s case history or ocular examination findings. Many of these screening procedures should be performed as side trips from corresponding entrance tests.

Chapter 9 outlines commonly used ocular imaging techniques. Imaging technology has proven to be a useful tool in disease diagnosis, documentation, monitoring, and patient education. Many of these instruments are now key components of the ocular examination and should be employed when indicated based on patient symptoms and ocular examination findings. The use of imaging technology highlights the importance of the examiner’s analytical abilities and critical thinking. Used intelligently and critically, imaging will enhance an examiner’s capabilities.

Chapter 10 addresses advanced ocular procedures which are to be used on a problem-specific or as needed basis. These techniques are generally therapeutic for anterior segment maladies. Several of the procedures outlined in this chapter may require additional licensure and certification in order to perform them in the patient care setting and restrictions may be in place in certain states and jurisdictions. The examiner should consult with regional authorities to ensure the proper training and credentials are obtained before performing these procedures in patient care.

Throughout the text, the singular “they/them” is used as a generic third-person singular pronoun when referring to the patient during a procedure. This form is intentionally used for the purpose of simplicity as well as eliminating assumptions or implications regarding the gender of the patient referenced in the procedure.