Interpretation of Exam/Progress Notes

Interpretation of Exam/Progress Notes Parts of the Exam- Patient History Referred by: Attended Evaluation: Grade: Will be filled out at both Initial Exam (Background History) and at Progress Exams (Current functioning level and progress in school/work, etc) History: Meds: Allergies: It may be helpful to note any current medications since some do have ocular side effects The Snellen fractions, 20/20, 20/30, etc., are measures of sharpness of sight. They relate only to the ability to identify small letters with high contrast at a specified distance. Parts of the Exam- Acuity w/ Correction Dist. VA OD: Near VA OD: 20/ Habitual Rx OD: Current glasses/contacts prescription Distance acuity with glasses/contacts Near acuity with glasses/contacts Habitual Rx OS: Dist. VA OS: Near VA OS: 20/

Interpretation of Exam/Progress Notes Parts of the Exam- Acuity w/o Correction/Cover Test NVA Unaided OD: DCT: DVA Unaided OD: Distance Visual Acuity w/o correction Near Visual Acuity w/o correction DVA Unaided OS: NVA Unaided OS: NCT: In the alternating cover test the two eyes are alternately covered with an occluder or "cover paddle" while the patient looks at a target which he can see clearly. The test is done while the patient fixates a distant target and again when he fixates a near target. When the occluder covers an eye, it is dissociated from its fellow and moves to its phoria position. When the occluder is removed, the eye resumes fixation. The examiner looks for the direction and amount of movement of the eye when the cover paddle is removed. If the patient is exophoric, his eyes diverge in the phoria position and the eye will move medially when uncovered. If the patient is esophoric, his eyes converge in the phoria position and the eye will move laterally when uncovered. An eye may also be hyperphoric (deviated upward) or hypophric (deviated downward) with corresponding motions down and up, respectively, of the uncovered eye.

Interpretation of Exam/Progress Notes Parts of the Exam- Eye Movements Saccades: Fixation: Pursuits: Saccades Pursuits Saccades are rapid, ballistic movements of the eyes that abruptly change the point of fixation. They range in amplitude from the small movements made while reading, for example, to the much larger movements made while gazing around a room.  Fixation Smooth pursuit movements are slow tracking movements of the eyes designed to keep a moving stimulus on the fovea.  Fixation is the maintaining of the visual gaze on a single location.  Dr. B’s System for Evaluating Oculomotor Skills- Fixation 4 smooth and accurate 3 one fixation loss 2 two fixation losses 1 more than two fixation losses Dr.B’s System for Evaluating Oculomotor Skills- Pursuits 4 smooth and accurate 3 one fixation loss 2 two fixation losses 1 more than two fixation losses or any uncontrolled head movement Dr. B’s System for Evaluating Oculomotor Skills- Saccades 4 smooth and accurate 3 some slight undershooting 2 gross undershooting or overshooting or increased latency (time to initiate movement) 1 inability to do task or any uncontrolled head movement

Interpretation of Exam/Progress Notes Parts of the Exam- Binocular Function Stereopsis: Color Vision: NPC: Test to detect Daltonism  Color blindness of basic colors: Red, Blue and Green A distinction is made between: protanopes, who do not see red; deuteranopes, who do not see green; tritanopes, who do not see either blue or yellow. Stereopsis Near Point of Convergence The closest point to which the two eyes can follow a target in toward the nose without losing fusion (diplopia or suppression). Noted as TTN if no break occurs or noted in inches if there is a break or loss of fusion. Also noted may be discomfort (patient reported) or red face which denotes strain. Tests and evaluates stereo depth perception for both gross stereopsis evaluation using six geometric forms from random dot backgrounds Tells us how the two eyes are working together.

Interpretation of Exam/Progress Notes Parts of the Exam- Binocular Function Continued Maddox Rod Dist: W4D D: +2.00: W4D I: -2.00: Maddox Rod Near: Worth 4 Dot This is a test utilizing red-green color dissociation. The patient wears red and green goggles (as a convention red in front of right and green in front of left). The test can be performed separately for distance and near vision. The interpretation of this test is as follows- A) The patient sees all the four dots. normal binocular response with no manifest deviation B) The patient sees five dots. uncrossed diplopia with esotropia, red dots appear to the right; crossed diplopia with exotropia, red dots appear to the left of the green dots. C) The patient sees three green dots, suppression of right eye. D) The patient sees two red dots, suppression of left eye. E) This test is performed as various distances near, intermediate and distance to watch for variations. Doctor will typically “start where they are” where the patient is likely to have fusion based on previous testing. W4D N:

Interpretation of Exam/Progress Notes Parts of the Exam-Fusional Facility/ Accommodation Examination of Pupils MEM OD: Doctor notes pupillary response to light. In most cases you may see the abbreviation PERRLA—pupils equal, round, and reactive to light and accommodation. You may also see notes about AO Pupil which is Alpha Omega Pupil where pupil does not hold constriction in bright light after a few seconds. Fus Facility CPM: Acc Facility CPM: Pupils: MEM OS: Fails: Fails: MEM Fusional Facility- Cycles per Minute The doctor uses the Retinoscope to perform this test. The '''monocular estimate method''' is a form of dynamic retinoscopy used to objectively measure accommodative response through a plus lens. Values normally attained when performing MEM are between +0.25 and +0.50 diopters. Look for notes about bright and dim – bright is better than dim. Accommodative Facility- Cycles per Minute Performed at distance with 3D BO/ 12D BI. Patient is instructed to keep a vertical line of 20/30 letters single and clear as base out prism and base in prism is introduced. Similar to the Binocular Prism Rock performed in therapy. This test is usually done with a nearpoint reading card and a flipper with +/-2.00 lenses. The doctor will measure how many cycles of switching (eg. from plus to minus to plus) that the patient can achieve in 1 minute. 

Interpretation of Exam/Progress Notes Parts of the Exam- Retinoscopy/Refraction Retinoscopy OD: Dist OD: 20/ Near OD: 20/ Subjective Refraction OD: Pupils: Dist OS: 20/ Near OS: 20/ Retinoscopy OS: Subjective Refraction OS: Dist OU: 20/ Near OU: 20/ Add: Retinoscopy Distance and Near Acuity with Rx found during Refraction Subjective Refraction This is the lens power determined by doctor to give the best corrected visual acuity.

Interpretation of Exam/Progress Notes Parts of the Exam- Phoria/ Vergence Ranges Dist. Phoria H: Distance BO: Distance BI: V: Near BO: Near BI: Near Phoria H: V: +1.00 Measures horizontal or vertical deviation of the eyes, one with respect to the other, when fusion is interrupted. The phoria may be assessed by alternating cover test. The doctor will repeat this test many times to check for repeatability and stability. To measure subjectively the relative horizontal or vertical deviation of the eyes, one with respect to the other, when fusion is interrupted To measure subjectively the relative horizontal or vertical deviation of the eyes, one with respect to the other, when fusion is interrupted Vergence Ranges- Noted with blur/break/recovery- Performed in phoropter for some patients or with prism bar for patients who have difficulty with in phoropter testing. To measure subjectively the relative horizontal or vertical deviation of the eyes, one with respect to the other, when fusion is interrupted SILO -In this area pay special attention to notes like SI or SO (under BO testing) or LI or LO (under BI testing) - this gives the therapist information as to how the patient perceives space and how reliant they are on visual information- Learn more about tropia/phoria testing here:

Interpretation of Exam/Progress Notes Parts of the Exam- Accommodative Amps Vertical Range Dist: Accommodative Amps OD: Vertical Range Near: Accommodative Amps OS:  The maximum amount of accommodation that can be stimulated, by reducing plus lens power or by adding minus lenses, in an eye. Normal amplitude of accommodation can be determined by using the following formula: 18- 1/3 of patient’s age (Morgan’s Expecteds) Or 15- ¼ patient’s age (Hofstetter’s Formula) Sometimes on Accommodative Amps you will see a # then a dash and another #. The first number is the first “disruptive” lens or prism power but they are able to recover and got up to the higher level.

Interpretation of Exam/Progress Notes Parts of the Exam- NRA, PRA, FCC NRA: FCC: PRA: Fused Crossed Cylinder– this test is done at nearpoint and evaluate how accommodation functions when a target has no meaningful symbols to read or be recognized (i.e. no cognitive demand).  The crossed cylinder tests measure how much plus can be accepted at near and help the doctor in the determination of a nearpoint prescription. This nearpoint test evaluates the amount of increase that can be made in accommodation while convergence is held constant. Normal findings are -2.25 to -2.75 D in the age range of most of our patients.. Values below -1.50 D may indicate an accommodative insufficiency. Our goal is “superhero” on most tests so that “average” becomes easy. This nearpoint test evaluates the amount accommodation can be relaxed while convergence is held constant. Normal findings are in the range of +2.00 +/- 0.50 >2.50: may indicate latent hyperopia <2.50: poor accommodation Most of our patients are low hyperopes so +2.50 should get “easy” with max around +3.00

Interpretation of Exam/Progress Notes Parts of the Exam- Assessment Assessment: Problems found with eye movements will be noted here. Motility: Accommodation: Problems found with accommodation will be noted here. Binocularity: Problems found with binocular function/vergence will be noted here. Visual Acuity: RE: Problems found with visual acuity will be noted here. If normal may be abbreviated to wnl OU OH: Parts of the Exam- Plan/ Recall Plan: The most valuable portion of exam notes for a therapist or administrative staff – Details doctors findings and recommendations for patient’s future care. Special care should be taken to follow these instructions in upcoming VT sessions for therapists. Doctor will note session count for next Progress Visit in case of existing VT patient or specific instructions for perceptual testing and follow-up for new patients Recall: Exam/Provider: