PEARLS Better Patient Care Starting Monday Morning

Jeff Peterson, OD

My goals for you: • To teach you what I have learned that helps me get through my day efficiently and with superior PT care • To NOT confuse you in this process • You are not me • If you have it figured out and it works well for you, leave it alone • For every 5 minutes – learn at least one procedure or idea to put into practice next week.

Monday morning  Start by sitting in your exam chairs: comfort, position of mirrors, equipment, proper lighting

Proper room brightness to control pupil size • Chart brighter than a light-colored wall

Phoropter • Check where vertex distance is set • Zero forehead rest and push it out a bit • Position phoropter and check the tilt – level • Check PD

Estimate how much change you might expect before starting the refraction • Know or suspect 20/20 vision and PT tests 20/30, expect 2-3 clicks of power • Don’t over-think this, especially with higher amounts of , reduced-vision eyes or large changes • KEY: Final Rx should make sense; if it doesn’t explore why • Whenever possible start with habitual Rx in phoropter • Previous manifest refraction or auto-refractor • when you have nothing else or something isn’t making sense

All of this works with plus or minus cylinder – examples in plus  Motto: MPMA – Maximum Plus / Maximum Acuity  Make them earn every click of minus and cyl  “What should I look at?” The smallest line you can easily see / it will change • Blink, blink and blink some more • The 3rd choice: SAME

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SPHERE Always start by adding plus • +.50 for under 30 • +.25 for 30 and over • If no change then add more plus until PT reports blur • “Sorry, but I need to make it a little worse before I make it better.”

Once PT notices blur then add back -.25 and start there • “What’s better, 1 or 2?” • Move toward your estimation • Make them earn all minus and cyl • Example: 35 y.o. -2.00 DS with 20/25 vision  Estimate final to be around -2.50 max  With a presbyope they could be over-corrected  PT likes the additional -.25  Continue adding -.25 until there is no change  Now at -2.50. Done or double-check? • Add +.25 and ask “Is this worse?” • If not they are probably over-minussed  If worse add back -.25 and be done with sphere • Remember that adding too much minus power will often result in the letters getting smaller and/or darker or bolder or brighter • If unsure have them concentrate on a small line and ask them to tell you if the next change is less clear, or just less dark • If they cannot see any change IN CLARITY then they do not get the extra -.25

Assure them that if they cannot tell the difference then you know what to do

CYLINDER & AXIS Adding too much cyl power can be just as bad as over-minussing your PT

Bracketing cyl power and axis • Axis rule-of-thumb first adjustment based on cyl power: • .25 - .50: 20 degrees • .75 – 1.75: 10 degrees • 2.00 – 2.75: 8 degrees • 3.00 – 3.75: 6 degrees • 4.00 and up: 4 degrees

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HANDHELD JCC • 20/50 or worse vision • +/- .50, but if 20/100 or worse +/- 1.00 • The black and red lines are for power, the dots for axis • Line up the proper meridian with the axis markings, keep it parallel, and spin it • Be smooth • Start with 20 degree changes in axis • Use right hand for right eye, left hand for left eye • Remember to compensate for the sphere • +/- .50 cyl adjustment = 0.25D sphere adjustment • +/- 1.00 cyl adjustment = 0.50D sphere adjustment • Due to reduced vision may be hard for to see changes • If starting to see 20/40 or better switch to the phoropter JCC

ADDS Age: rules of thumb • Around 40: +1.25 • Rarely Rx +1.00, especially with PALs • Most PTs wait too long and need the extra power • Want it to last for at least 12 months • Around 45: +1.50 • Late 40’s: +1.75 • Around 50: +2.00 • Early 50’s: +2.25 • Around 55: +2.50 KEY: Observe your PT: height, arm length, where they want to hold it Nationality – earlier presbyopia • Change add after cataract surgery Sometimes reduced NVA requires reducing the add power! No add unless they first report having near vision issues – don’t fix a problem they don’t have

COMPUTER RX  Have your PT demonstrate the distance to their computer screen(s)  I tend to use half their add plus .25 for adds of +1.75 and greater  +1.75 add => +1.00 with +0.75 add  +2.00 add => +1.25 with +0.75 add  +2.25 add => +1.25 with +1.00 add  +2.50 add => +1.50 with +1.00 add  For an add of +1.50 or less the computer add will usually will be +0.75 or +1.00  Ex: -3.00 sphere with +2.00 add: Computer Rx = -1.75 with +0.75 add  Prefer a lined bifocal design for computer Rx  Best for PTs who spend significant and uninterrupted screen time  Not so good if they are up and down a lot – switching glasses

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Deaf PTs  If you have an interpreter use them for everything but the refraction  Great success using a one or two finger touch on their wrist  Instruct them that you are going to use a light touch on the back of their hand  A one finger touch represents choice one and a two finger touch lens number two  If they look the same use zero  Go to this link to get a copy of my tablet script: https://www.dropbox.com/s/2ikg7wdcp0zjha8/Deaf%20PT%20Script.txt?dl=0

OTHER TIPS • Demo changes with loose over glasses or phoropter • Dominant eye influences vision and refraction • Nationality and possible refractive errors  Hispanic: Astigmatism  Asian and East Indian: • Balancing – see last page • Binocular check to finalize – MPMA • Fusing issues • Head tilts • Wheelchairs – special lane or trial frame refraction

Websites:

Eye muscle and cranial nerve simulators: https://somapp.ucdmc.ucdavis.edu/eyerelease/Interface/TopFrame.htm https://edtech.westernu.edu//3D-eye-movement-simulator/ https://www.aao.org/interactive-tool/strabismus-simulator https://www.aao.org/interactive-tool/complex-strabismus-simulator

Refraction and retinopathy simulators http://www.refraction-tutorial-online.com (Not free) https://www.aao.org/interactive-tool/retinoscopy-simulator

On-line photo atlas of ocular pathology: http://www.atlasophthalmology.com/

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Binocular Balancing

Do this on PTs who you suspect are accommodating enough to skew the refraction  Can be done on presbyopes but usually done on younger PTs  Requires fairly even vision between their eyes  Is easier to do than what the following appears to be

Darken room Isolate 20/30 line, can go larger if they are not 20/20 each eye With both eyes open and your best MR in place add +0.50D to both eyes Confirm that this created some blur; if not add another +0.25D OU until there is some blur Explain they are going to see double and turn the OD occlusion knob to the 6^U setting  This places 6 prism diopters base up in front of their right eye  Causes the OD image to move DOWN and the OS image to appear UP First you need to remove extra minus that they may have called for during the MR  Ask which line of letters looks clearer, or perhaps darker  Your goal is to make them as equal as possible  If they report the TOP image is clearer, then their OS has too much minus, add plus OS  If they report the BOTTOM image is clearer their OD is over-minussed, add plus OD  Ask again which line is clearer and continue to compensate as above until they report equal or as close to equal as they can get  Careful not to spend too much time with this: it can drive them and you crazy Once the two images are as equal as possible, remove the prism and make sure they are fused Isolate the 20/20 line (or the line of their best-corrected vision) and add another +0.50 OU Inform PT you are trying to completely blur out the line of letters; add more plus OU if needed Say “Now let’s make it clearer. Without squinting or working too hard, tell me when you can just make out one or two letters.”  Add -0.25 OU and ask if they can see a letter  Continue adding -0.25 OU until they report they can see one or two letters  At this point you are 0.50 to 0.75D away from their final Rx  Add -0.25 OU and ask “Better?” It will be  Repeat – it will be  Repeat: if it is better without getting darker or smaller that is your final Rx  If it looks the same or darker or smaller then add +0.25 OU; that is the final Rx

Like to check by quickly comparing the vision between their eyes to see if it is fairly even, especially if you made some larger changes in one eye during the balancing  This is not a perfect technique  PT can “fool” you so make sure your final Rx makes sense

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