PARTNERING WITH OPTOMETRY FOR EDUCATION AND PATIENT CARE Britta Hansen, OD, FAAO March 22, 2014

 Berkeley Optometry  Grew up in Minnesota  Residency at San Francisco VA  Work at Northwest Eye Surgeons

 Components of technical exam History/chief concern(s) Phone/walk-in triage Vision, refraction Confrontation visual fields Extraocular motility Pupillary reaction Intraocular pressure, angles Additional testing  Patient examples

 Base questions upon: What you expect as an answer What diagnoses you’re considering/past experience What they’ve already told you

 Let the patient [briefly] tell you what’s wrong  Ask new questions that make sense: Pain = what scale? Redness, blurry = how long? What scale? Headache = tried to alleviate? Any eye drops = side effects? Any new medications = side effects? Injury = flashing lights, floaters, bruising?

 Some patients will overstate their symptoms  Others will downplay their symptoms  Knowing the right questions, trusting your instincts and continuously re-visiting your process for triage regularly

See ASAPSee Next Available Extreme painBlurriness Extreme, new blurrinessAche, strain Extreme headacheChronic redness Extreme vision lossSymptoms that follow a more “chronic” pattern New double vision New moderate to severe redness Very recent injury to eye or orbit Anything that follows an “acute” pattern *Consider your office’s “specialty,” may want to have the patient scheduled with a more urgent center based on some symptoms

Subjective  History/Chief Concern Objective  Fields  Motility  Pupils  IOP Vision? Refraction?

 Patient medical history  Family medical history  Patient ocular history  Family ocular history Which diseases are inherited? ♦Macular degeneration ♦Glaucoma ♦Retinal detachment ♦Strabismus (eye turns) ♦Low vision disorders: ie Retinitis pigmentosa, ocular albinism

HPI = History of Present Illness Location Severity Quality Duration Timing Context Modifying factors

 Primary eye care setting More weight on refraction, contact lens fittings Less weight (but still important) on chair skills  Tertiary care setting More weight on chair skills to help with diagnosis  There is overlap between the settings, knowing what to do in each instance will help to have a smooth work-up

 Components of technical exam History/chief concern(s) Vision, refraction Confrontation visual fields Extraocular motility Pupillary reaction Intraocular pressure, angles  Triaging patient examples “Chair Skills”

 Finger Counting: all or none  Transilluminator fields: all or none  Automated perimetry: qualify visual field defect Humphrey Matrix FDT  Abnormal fields: Glaucoma, other optic nerve problems Retinal detachments Vein and artery occlusions Stroke, tumor

 Tropia: one eye turns in (eso) or out (exo)  Main question: do you see double?

 “Double Vision:” poor blood flow to muscles around the eye, muscle trapped from free movement

 Patients with SYMPTOMATIC double vision will tell you. PUPILS can be very important in this case.

 Poorly controlled diabetes  Poorly controlled blood pressure  Graves Disease  Congenital  Entrapment from an injury  Anomalies of the nerves  Compression to the nerves or the muscles

 Equal size/shape  Equal reaction to light  Similar movement when the light is in the other eye  Relatively the same movement when swinging back and forth

 Anisocoria- difference between pupil size  Horner’s- miotic (small) pupil  Adie’s- acute dilated pupil  Relative Afferent Pupillary Defect If present, it can be VERY important as a component of the doctor’s exam This is a RELATIVE difference between the two eyes and their brain input

 Asymmetric glaucoma  Blood loss to the OPTIC NERVE in one eye  Retinal detachment in one eye  Blood loss to the RETINA in one eye  Compression on the optic nerve in one eye  NOT: Cataract  NOT: Amblyopia  NOT: Macular Degeneration or Scar

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 One pupil doesn’t work because of an iris injury  A patient has a new concern in the “good eye” where the “bad eye” already has a relative pupil problem

 Monocular? Binocular?  Without correction? With Correction?  Distance? Intermediate? Near?  Pinhole?

 Reduced vision Glasses wrong/outdated Cataract Macular disease (edema, epiretinal membrane, macular degeneration) Sudden loss of vision (vascular disorder, retinal detachment)

 Change from glasses?  Best “corrected” visual acuity

 Glasses change: gradual Can be due to Diabetic shift in blood sugar  Cataract: blurry vision through glasses, glare while driving at night, haloes and starbursts  Retinal detachment: flashing lights, shower of new floaters, dark curtain over vision, blurred vision  Open angle glaucoma: no symptoms until late in the disease, high pressure in this case is painless

 Vitreous detachment: floaters in presence or absence of flashing lights, no vision loss, usually distinct floater(s)  Acute Angle Closure Glaucoma: Recent pupillary dilation, foggy vision

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 Bacterial conjunctivitis: pus-like discharge, eyes stuck shut in morning, usually children  Viral conjunctivitis: white/clear discharge, contact with someone else with a red eye, current or recent past upper respiratory infection, swollen, one or both eyes  Uveitis: sensitivity to light, redness  Scleritis: extreme eye pain, extreme redness

 Allergic conjunctivitis: watering and itching of eyes, usually seasonal, current runny nose/cough/sneezing

 Nerve palsy: symptoms only when both eyes open, certain gazes have less double than others, may have diabetes, hypertension, Graves, or other systemic diseases May have lid droop, pupillary problem as well

 Acute angle closure glaucoma: vomiting, nausea, rainbows around lights, worse in morning, can be precipitated by dilation  Transient ischemic attack: blacked out vision lasting seconds to less than 5 minutes, returns to normal, typically older patients with history of high cholesterol ***IF symptoms coincide with unilateral weakness, trouble findings speech or trouble ambulating, send patient immediately to ER

 Foreign body: patient usually knows when it went in  Penetrating injury: high velocity, either patient or object, globe may be open, check immediately or send to ophthalmology if suspect  Endophthalmitis: extreme pain in the eye, usually after surgery or with other illness, send to ophthalmology

 65 yo female calls with blurry vision  FIRST question to ask: How long has the vision been blurry?  Qualifiers How blurry is it? Does anything make it better? Has anything changed  Accompanying concerns Flashing lights, floaters, diabetes

 Vision blurry x 1 year  Glasses help but not much  Has glare and haloes with oncoming headlights  Diagnosis? Likely cataract, check next available

 5 yo male  Red, painful eye  For the last 2 days  Got poked with a fake candy cane, went to urgent care, was given ointment, is sensitive to light  Likely diagnosis? Corneal abrasion, see same day if possible

 45 yo male  Blurry vision, both eyes Cobweb in the right eye yesterday, left eye now very fuzzy  Since yesterday the left eye has been very bad  Hasn’t seen any Dr. since 2009  Diagnosis: Proliferative Diabetic Retinopathy, see same day if possible

 65 yo female  Blurry vision, right eye, since yesterday  Proceeded by flashing lights/mild floaters  Now sees a curtain over vision  Likely diagnosis: Retinal detachment, see today

 20 yo female  Red, painful left eye  Very sensitive to light, vision mildly blurred  Has systemic lupus  Likely diagnosis: Unilateral uveitis, see today or tomorrow

Northwest Eye Surgeons is the premier eye surgical center in the Northwest and remains committed to its tradition of personalized, high quality patient care, advanced technology and excellent results. SERVICES: Cataract Refractive Surgery Glaucoma Cornea Pediatrics & Strabismus Retina, Vitreous & Uveitis Eyelid Surgery & Facial Rejuvenation PARTNERING WITH OPTOMETRY FOR EDUCATION AND PATIENT CARE Britta Hansen, OD, FAAO