I thought I would write a post on what I do in practice and why.  This started out as a quick post but has turned into a bit of a monster so I’ll separate it into a few parts.  This post deals with the first part of the eye test, up to refraction.  The next part will be on refraction and the final part on the health check and management.

So, without any further ado, my routine:

Each working day, I arrive at my practice with some time to spare.  I usually get there 15 minutes early to set everything up – this involves little things like switching on the computer, test chart and slit lamp console.  While the computer is booting up or logging in, I lay out all the things I’ll need.

Chef’s have a thing called mis en place, which is having all ingredients prepared before service.  It’s what happens in Jamie Oliver’s TV kitchen before the cameras are turned on: every ingredient is peeled, chopped, weighed and set out in a logical and accessible place before the cooking begins.  Like chefs, we have time limits.  No-one wants to wait an hour for their meal because the chef has to hunt high and low for each ingredient and no sane patient would leap at the chance of spending double the time in the test room because their optom was inefficient.

So here’s my optom version of mis en place:

I lay out my occluder, budgie stick, +/-0.25DS flippers, lens cloth (very important in my practice as the cyls don’t have handles so are always covered in fingerprints), pen torch, pen, spare pen (for when the first one stops working or a patient/staff member* steals first pen), confrontation stick and my cross cyls.  I’ll unpack my ret and ophthalmoscope and have them handy as well.  If there are children in the clinic, I’ll put the Titmus and Ishihara within reach and if someone is attending for contact tonometry and pachymetry, I’ll have both the Perkins and Accupen in my room before the start of the day.  I also make sure I have an Amsler handy and that there are enough leaflets on common conditions in my room.

On the slit lamp table, I put my Volk lenses, Wratten filter, cotton buds and the little box I keep Sterets and needles in.

Before my first patient, I’ll make sure the slit lamp isn’t on some weird setting (like 40x mag, tiny spot and green light) and go through the computerised test chart to make sure when I hit the xcyl button, it gives me dots instead of circles (weird, I know, but I prefer the dots).  We also have one of those test charts where, if you press the wrong button on the fixation setting, you end up with a terrifying clown face so I make sure that it’s on the green dot not Pennywise.

By taking a few minutes to set everything up, I’m saving myself time during the day.

The patient will be pre-screened by the optical consultants.  In my practice, they usually do a mini history and symptoms and write any concerns on the front of the record card.  They also ask about work, hobbies, driving and VDU use.  After that little interview, the patient is then autorefracted and has non-contact tonometry done.  They then complete a 24-2 screening test on the Humphrey.  It’s good to have the autorefractor result before fields because you can then choose an appropriate lens for the visual field test.

After the 24-2, the optical consultant takes a fundus photo.  I will have a moment to check the photo on my screen before the patient is brought in.  I find checking the photo before the test helpful because I do fundoscopy after refraction and if the patient is struggling with refraction, there’s a good chance I have an idea why, based on the photo.

When the patient comes in, I introduce myself and ask how they are today.  We have a bit of a chat and I tell them they can pop their bags down on the chair over there then I ask them to have a seat “in the big chair”.  If the patient is unsteady on their feet or using a cane, I’ll make sure I flip the footrest up on the chair, allowing them to get closer to the seat before sitting down, and once they are comfortable, I’ll put the footrest down.  I also like to make sure I’m close by while they are sitting down, to provide a hand if they are struggling.  I usually say something like, “I’m just here if you need a hand or something sturdy to hold onto”.

Once we are both settled, I start history and symptoms.  If they come in with a problem, I’ll go straight to that.  If they have a sore eye or a red eye, I’ll just start with, “So, what’s happened?” and the patient will usually launch into a pretty detailed account of their sore or red eye.  When they are finished, I’ll ask any other questions I need to, again, leaving the patient plenty of time to answer.

Assuming a routine eye test, after confirming their details and their reason for visit, driving etc, my usual history and symptoms goes something like this:

Do you remember your last eye test?

Do you wear glasses at the moment? What are they for? How do you feel your vision is with them? Any situations where you feel you aren’t seeing as well as you should?

Have you had to go to the hospital or GP for any eye problems? Do you ever get flashing lights in your vision? How about floaters – wee black dots or wee black wiggly lines? Do you ever get double vision?

How’s your health at the moment? Are you diabetic? Any high blood pressure? Do you suffer from headaches?

Are you taking any medicines at the moment?

Anyone in the family with eye problems that you know about? Anyone in the family diabetic?

I will then put the chart on and ask the patient, while wearing their current correction, to occlude their left eye.  I’ll hand them the occluder and 9 times out of ten they will cover the right eye and, by right, I mean left.  Ten percent of the time, they’ll cover their right eye, which is the wrong eye instead of the right eye which is the left**.  Sometimes they’ll close one eye and cover the other.  Sometimes they’ll try and wedge the occluder under their glasses.  Sometimes they won’t even use the occluder and instead cover their left eye with one hand while holding the occluder in the other.

Hopefully, at this point, they will have one eye covered and the other open.  At this point, I’ll ask them “what’s the smallest line you can read on the chart?” Eight times out of ten, they will pick a line and read it more or less correctly*** and I’ll then ask them if anything is standing out on the line underneath****.  Those two patients out of ten will do a number of things: read the whole chart from top to bottom, say random letters (maybe throw in some numbers and stars) that bare no resemblance to any line on your chart, read the line backwards or just stare at the chart for an uncomfortable amount of time before saying, “Oh, do you want me to read it out loud?”

This is repeated for the other eye and you now have an idea of how well your patient is seeing with their current correction.  I know at uni they teach you to check vision rather than VA with current Rx but there’s really no point doing that in practice – you want to know if you are improving your patient’s vision with your refraction and, let’s face it, writing down 6/60 and 6/120 doesn’t really tell you much other than your patient needs glasses.  Also, if your patient is 6/5 with their current prescription, don’t give them more minus unless it’s getting them to 6/4, 6/3 or giving them the ability to see through time itself.

After that, I’ll ask the patient to take their glasses off and give them a target to look at for cover test.

I will start with alternating cover test at distance then get the patient to look at an appropriate target on the budgie stick and do cover test at near as well.  If they report having problems with their vision while on the computer, I’ll ask how far the computer is and I’ll do cover test at that distance as well.

I’ve had a few young girls recently attending with no prescription (6/5 N4 unaided) but complaining of headaches when on their phone/tablet/computer – these girls all had large XOPs at near.  A few weeks ago, I saw a patient with a very noticeable cyclophoria which was so cool and unexpected that I may have spent a few minutes just covering and uncovering her eyes, thinking “Wow”.

Anyway, next I do cover/uncover, looking for tropias.

Then I tell the patient that I’m going to dim the lights (which I do) and I test pupils.  During each test, I tell the patient what the test is for, what I’m seeing and reassuring them that the result is normal (unless it’s not, then I come back to that later).  After testing direct and consensual reflexes (three times in each eye, exerting the pupil muscles enough that if there’s an abnormality, you’ll see it after three repetitions) I move onto the swinging flashlight test.  Pupil reflexes are a bit of an art and I was worried that I would miss an RAPD but, believe me, if you are watching closely and doing the swinging flashlight test properly, you won’t miss one.

I then pop the lights back on and we move onto motility.  I always sit for motility although there’s a bit of a debate about this.  This is the part of the test where the patient is likely to start laughing.  I don’t know why, maybe it’s something about the test or maybe my look of intense concentration is hilarious, but I’ve had eighty year old men in stitches during motility.

Next is confrontation, which always involves a bit of mental agility on the part of both myself and the patient because you have to cover the contralateral eye to them to test their field in that eye.  Strangely, this isn’t as much fun for patients as motility.

So, that’s the first bit of the eye test, with a bit of an observational comedy thrown in for you.  I’ll post the next part (refraction) in a little while.


* You know how you are.

** Isn’t English a wonderfully clear language.

*** There is a special place in hell for those who read the whole chart using the phonetic alphabet… Oscar… Mike… Foxtrot… Golf…

**** You should always push your patients to read a little bit more because some people are quite cautious and need an extra nudge to actually admit they can see a bit better.  If we just left it up to the patients to pick a line, their VAs would be all over the place.