Advanced Basic Procedure

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Advanced Basic Procedure
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Handheld Autorefractor

• Welch-Allyn SureSight
• Retinomax

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• SureSight
• Important points
• make sure it is in the correct mode for child
  or adult
• Move the unit to lefft eye after to right eye
  measurements
• Remind the patient to look at the red light
• If confidence number is less than 6, retest eye
• Reprint if black boxes are on the printout.
• You can test a max of 3 times for each eye

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• Retinomax
• Important points
• Dimming lights may help obtain adequate
  confidence numbers
• If the confidence level is less than 8, retest
  eye
• A confidence level of E is not a valid reading
• It may help to put your thumb on pt forehead and
  place the forehead rest on your thumb instead of
  directly above the pt brow.

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• See handout for specific instuctions and
  recording.

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Drop Instillation
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Tono-pen

• In the ER, or with patients who are difficult to
  examine, we can check pressure using a handheld
  electronic Tono-pen.

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• Prepare patient by instilling a drop of topical
  anesthetic onto the eye
• Position patient in front of a fixation target
• Hold the tono-pen like you would a pencil
• Brace the heel of your hand on the patients
  cheek for stability while hold the unit
  perpendicular to and within ½ inch of the
  patients cornea

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• Depress operator button once
• Within 15 sec, Touch the unit to the cornea
  lightly and briefly, then withdraw. Repeat
  several times
• A chirp will sound and IOP measurement will sound
• After four valid reading are obtained, a final
  beep will sound and the average will appear

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• http//youtu.be/bdVOItixpvo?t37s

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• Calibration
• CAL followed by row of dashes ----
• Point the tip straight down towards the floor
• Hit operators button two times quickly
• Wait 15 sec for the beep and the display UP
• Then flip so the tip is directed to the ceiling
• Display Good or Bad

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• http//www.youtube.com/watch?vAWamV6oIuasNR

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Extraocular muscles(EOM)
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• Check EOM in six positions of gaze right, upper
  right, upper left, left, lower left, lower right.
  One eye muscle is the prime mover in each
  position of gaze.

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• Right gaze is mainly moved by the right lateral
  rectus muscle and the left medial rectus muscle.
• Upper right gaze is by the right superior rectus
  and left inferior oblique.
• Upper left gaze is by the left superior rectus
  and right inferior oblique.
• Left gaze is by the left lateral rectus and right
  medial rectus.
• Left lower gaze is by the left inferior rectus
  and right superior oblique.
• Right lower gaze is by the right inferior rectus
  and left superior oblique.

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• Check EOM motility by asking examinee to watch
  your light while keeping the head still, move
  your finger across in H pattern, at a distance
  about 10-14 inches away from the examinee.
• http//youtu.be/vd7OOJ7c1q4

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Confrontation Fields
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Confrontation Fields

• Test peripheral vision
• Sit about 3 ft directly in front the patient.
• Ask patient to cover one eye while you close the
  opposite eye
• Present varied number of fingers in each four
  quadrants while patient fixates on your nose

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Pupils
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• To examine the pupils, the level of the ambient
  light should be reduced and, to relax
  accommodation, the patient should be directed to
  look at a distant object. Using a penlight
  directed from below, just barely illuminating the
  pupils, one inspects for symmetry in pupillary
  size. The patient continues to view a distant
  object, and each pupil is tested separately for
  constriction in response to bright light. Also,
  check the pupils with near-vision, as they should
  constrict with accommodation.

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• The penlight is then quickly moved from one pupil
  to the other, shining light directly into each
  eye (the "swinging penlight test" to elicit
  afferent pupillary defect) In this test, one is
  specifically looking for a pupil that dilates as
  the light is first directed toward it,
  demonstrating greater consensual than direct
  response. The afferent pupillary defect is also
  known as a Marcus Gunn pupil.
• http//youtu.be/HSYo7LhfV3A

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• If any discrepancy of more than 1 mm in pupillary
  size is found, the pupils are measured in both
  bright and reduced ambient light. Differences in
  pupillary size (aniso-coria) tend to be
  physiologic and not pathologic if such
  differences are only 1 to 2 mm and remain the
  same in differing levels of ambient light.