Department of Optometry and Ophthalmic Dispensing
Visiting Clinician’s Handbook
www.anglia.ac.uk
www.anglia.ac.uk/optometryclinic
Learning Outcomes ......................2 Student Conduct ..........................2 Appearance and Dress Code..............................2 Communication ..................................................3 Food and Beverages ..........................................3 Mobile Phones ....................................................3 Smoking ..............................................................3 Contact with Patients ..........................................3 Dealing with Patients ..........................................3 Confidentiality......................................................3 Care of Clinic and Equipment ............................4 Appointments ......................................................4 Allocation of Patients and Refraction Rooms......4 Attendance ..........................................................4 Record Keeping ..................................................4 Log Book ............................................................4
Final Year Optometry Clinics Low Vision ....................................5 Patient Booking ..................................................5 Eye Examination ................................................5 Low Vision Assessment ......................................5 Measuring Visual Acuity ......................................7 Practical Pointers ................................................7 Refracting the Low Vision Patient ......................7 Measuring Near Vision ........................................7 Amsler Charts ....................................................7 Contrast Sensitivity..............................................7 Ocular Health ......................................................7 Prescribing for the Low Vision Pateint ................7
Core Competancies ......................8 Supervisor Responsibilities ................................8
Allocation of marks ......................9 Eye Exam ............................................................9 Contact Lens Preliminary Visit and Fitting ........10 Lens Collection Visit ..........................................10 Aftercare Visit ....................................................10 Forms ..........................................................12-17
Clinical Marking Scheme ..........18 Anglia Ruskin Abbreviations ......20 Contact Lens Abbreviations ......22 Health and Safety ......................23 Handwashing ..............................................23-25
GOC Certificate of Clinical Competence Criteria ............26-31
This handbook has been designed to outline the operating procedures of the Optometry Clinic. It is here to help you understand what is expected of both you and the students when in the clinic. The guidelines exist to ensure that the clinic operates in an efficient and professional manner, and to assist you in helping the optometry students to develop a professional attitude and approach to optometric practice. Clinical training is a major component of the education of students of optometry. Such training aims to produce graduates who have a sound knowledge of the theory and practice of optometry and are able to carry out clinical examination in a competent, professional and ethical manner. The primary aim of the clinics is to teach good clinical practice. It is the supervisor’s duty to encourage the development of sound, professional and ethical practice. Dr Peter Allen Director of Clinics
Department of Optometry and Ophthalmic Dispensing 1
Learning Outcomes On successful completion of all clinic modules students will be able to: Interpret a patient’s symptoms and history and conduct an appropriate eye examination. Dispense spectacles of appropriate frame and lens types to any prescription. Record clinical data using appropriate manual and computerised systems. Communicate results and findings to the patient, their general medical practitioner, other healthcare professionals or an optometric colleague if indicated.
Student Conduct
Appearance and Dress Code Students must maintain a high standard of personal hygiene.
The following rules and regulations apply to all students undertaking practical sessions in the clinic, and failure to adhere to the rules may result in action being taken against a student for unprofessional conduct. If found guilty of unprofessional conduct a student may be excluded from the university and not allowed to complete the course, they may also be removed from the GOC register. Students will be judged by patients as though they are already members of the optometric profession and should conduct themselves accordingly. Students must conduct themselves as exemplary citizens, with dignity, propriety and decorum at all times.
Students must be dressed in a manner that instils confidence in the clinics patients. Dress should be simple, neat and appropriate for the clinic (i.e. shirt and tie). No jeans, trainers or t-shirts. A white lab coat must be worn at all times in the clinic, unless specific permission is given not to wear the coat - for example during some paediatric clinics. Students will not be allowed in the clinic without a white coat unless they have specific permission – this will constitute a failure to attend (see attendance). Students should wear their name badge so that the name can readily be seen. Anglia Ruskin will provide the first badge, replacements will cost £6. Students should avoid wearing strongly scented toiletries if they are going to perform an eye examination. Students should always wash their hands in front of the patient before starting their examination (see sheet on washing hands). Hair should be worn so that it does not brush the patient's face during the examination.
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Communication Vulgarity, bad language and excessive noise are inconsistent with good professional practice. Students must not congregate for discussions in aisles or passageways.
Contact with Patients Overfamiliarisation with patients is unethical. All discussions with the patient should be based on the eye examination.
Discussions with patients must be simple, clear and related to their clinic visit.
Dealing with Patients
Clinical findings are to be discussed with patients only after consultation with the supervising staff member.
Students have an overriding duty of care to the patient.
Food and Beverages
Patients should be treated with respect. Patients and staff should be referred to by their appropriate title.
Food and beverages should not be brought to or consumed in the clinic.
Students should not enter into verbal arguments or physical conflict with the patient. Difficult and unruly patients should be reported to the supervising clinician.
Mobile Phones
Confidentiality
Mobile phones must be turned off if brought to the clinic.
The optometrist’s duty of care towards their patient includes respecting confidentiality.
Smoking There is a no smoking policy in all campus buildings. Students should not smoke or consume alcohol before coming to the clinic. Students who wish to smoke must not do so in the vicinity of the clinic. Many tests are done in close proximity to the patient and the smell of alcohol and tobacco is offensive.
Cases should not be discussed at any time unless clinically or educationally appropriate. Patient anonymity should be maintained throughout. Any discussion should not contain derogatory comments under any circumstances. Under no circumstances are clinic records to be taken from the clinic.
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Care of Clinic and Equipment At the start of each clinic students should ensure that equipment is present and working properly. Any missing equipment or malfunction should be reported to the supervisor and/or clinic staff straight away. The equipment should be cleaned before the patient is brought into the room. At the end of each clinic all equipment must be returned for storage and the lights and instruments switched off and covered. Cubicles should be kept tidy at all times. Failure to do so will result in a reduction of 10 marks from the student’s clinic session mark without discussion.
Appointments Extra appointments e.g. repeat visual fields etc. should be booked into the shorter appointment slots. Patients should be booked into the appropriate specialist clinics:
Students must not swap clinics with colleagues unless prior approval has been given. Students must show a co-operative attitude towards peers and clinic personnel (a maximum mark of 10% will be awarded for unprofessional conduct). Clinic Telephone No. 08451962070. Clinic Manager, Neil Guest, neil.guest@anglia.ac.uk
Record Keeping For each patient on whom the student conducts a clinical examination, a clinic record card should be completed. It is important that this is completed as they conduct the examination, not filled in at the end from notes. The clinic record (signed by the supervisor and with the patient classification box ticked) should be handed to clinic staff at the end of each session. The permission of the Director of Clinics would be required to use parts of a patient record for academic purposes. Students shall not sign the patient’s prescription form.
• Contact lens clinic • Binocular vision, paediatric and visual stress clinic • Low vision clinic
Allocation of Patients and Refraction Lanes Students should wait in their cubicles as listed on the sign in sheet for their allocated patient and supervisor.
Log Book The students must keep a logbook throughout the course, containing ALL of their patient contacts, whether they are working in reception, dispensing, conducting an eye examination, specialist clinic or attending an external clinic (i.e. hospital / school visit). The logbook should be presented to the supervisor at the start of each clinic. They must get the supervisor to sign their logbook to confirm the details of the patient, and that they have completed the examination. The patient encounters should be entered into the appropriate section of the logbook e.g. primary care or specialist clinics.
Attendance
The log book is a GOC requirement and is therefore very important.
Attendance is compulsory.
All patients seen in the second and third years need to be entered.
Students must attend clinics on the day and time they are scheduled to do so. Absence or late arrival without prior authorisation is unacceptable. Students who arrive at the clinic after ten minutes prior to the starting time (i.e. 8.50 or 12.50) will have their mark capped at 40% for that clinic Students who do not attend a clinic without notifying clinic reception themselves at least one hour before the clinic start, and who do not have an acceptable reason for missing the clinic, will be give a mark of zero for that clinic. The Director of Clinics, Peter Allen needs to be informed of all absences. Tel No. 08451962687. peter.allen@anglia.ac.uk In certain circumstances the Director of Clinics may grant permission for students to be absent. 4
The self assessment sheet is to be filled out after every patient examination, and discussed with the supervisor during the feedback session.
Low Vision Clinics Please read the following information regarding the low vision clinics
Final Year Optometry Clinics Low Vision Patient Booking Low vision patients will first be booked for an eye examination in a general clinic (unless they have had one very recently and do not want another), followed by a low vision assessment on a subsequent occasion. The low vision clinic is supervised by Dr Keziah Latham and runs on Tuesday afternoons in semester 1 and Wednesday mornings in semester 2.
Low Vision Assessment In the low vision assessment emphasis is placed on assessing visual needs and goals. Refraction and visual function evaluation will be done to extend eye exam findings, followed by evaluation and prescription of low vision appliances and non-optical aids, and further referrals to other agencies including CamSight, with whom we have a formalised referral process.
Eye Examination In the eye examination of a low vision patient, emphasis should be placed on ocular health and refraction. Where relevant, dilated fundus examination, fundus photography, pressures and fields should all be done within this appointment. These examinations will offer the potential for students to observe established pathology as well as check for additional undiagnosed pathologies.
Department of Optometry and Ophthalmic Dispensing 5
Hints and tips on the eye examination for low vision patients 6
Measuring Visual Acuity
appropriate working lens (e.g. 25cm with a 4D working lens).
Ocular Health
If VA is <6/24, Snellen charts do not have sufficient letters to either be a good target while refracting, or to give an accurate level of VA pre- and postrefraction. A logMAR / Bailey-Lovie chart should be used.
Bracketing – choose sph and cyl lenses of a power appropriate to the patient’s vision during subjective. There is no point using ±0.25D lenses if VA is <6/7.5! Cross cyls up to ±1.00D are available.
6m and 3m externally-illuminated Bailey-Lovie charts are available for use in clinic. Students should review their 2nd year notes from the contrast sensitivity practical on how to use these charts.
Manual cross-cyl – some patients will struggle to do cross-cyl even with ±1.00. One option is to put an appropriate power cyl into the trial frame at a sensible axis (found during ret?) and bracket the axis manually by using lens rotations of 20 deg until the axis of best vision is found.
There is not time in the low vision assessment to dilate patients and do a thorough ocular health workup: this should be done in the eye examination. Many low vision patients fall out of routine eye exams as ‘there’s nothing more that can be done for them’. This is a great opportunity to give them a thorough examination, with students gaining experience in observing established pathology and screening for unrelated pathologies. Just because someone has AMD doesn’t mean they can’t then get glaucoma! Taking fundus photos is encouraged, as we will be able to build up a database of pathology photos for teaching use.
Practical Pointers: • Overhead lighting in the clinic room is not sufficient for these charts – shine an additional light source onto them. • The chart should be used at 3m initially. With the 6m chart, VA measurements should have 0.3 logMAR added onto them to account for the reduced working distance. Results for a 3m chart at 3m do not need to be adjusted. • If the top line cannot be seen at 3m, halve the working distance to 1.5m. Each time the working distance is halved, 0.3 logMAR should be added to the final score to account for working distance. • If the patient reads the entire of a line of letters without error, they score the logMAR value given at the end of that line. • For each error made on a line, the logMAR score is 0.02 logMAR bigger than the score given at the end of that line. • In logMAR terms, large values are poor acuity (e.g. 1.0 logMAR = 6/60) and small numbers are good acuity (e.g. 0.0 logMAR = 6/6).
Refracting the Low Vision Patient Retinoscopy – a good ret result is very helpful indeed. If the reflex is poor, consider ‘radical retinoscopy’ – work much closer than usual with an
Measuring Near Vision In routine patients, the reading add is generally the lens that allows comfortable vision on N5. In low vision patients, assessing reading acuity is often the first stage in evaluating what low vision aids may be needed. • It is helpful to record near acuity using a +4D add (unit magnification) at a working distance of 25cm. Although the patient may not like the working distance, it gives a good indication of the likely magnification requirements. • N point charts may not have big enough print: consider the use of Keeler A or MNRead charts (both available in clinic cupboard 6).
Amsler Charts Plotting the scotoma of patients with central field loss is important and should be done in the eye examination if possible. Use the chart monocularly at 30cm with a +3D add and good lighting. Attach the plots to the record card.
Contrast Sensitivity CS is important as it relates better to visual quality of life than VA does. It should be measured in the eye examination or in the low vision assessment, using Pelli-Robson or Mars charts. Students should refer to year 2 notes on how to use these charts.
Prescribing for the Low Vision Patient A significant improvement in distance visual acuity for a low vision patient has been shown to be about 0.2 logMAR (2 lines on a Bailey-Lovie chart). Improvements in VA less than this may still be useful to the patient – it may be worth showing the patient the improvement in vision in a realistic setting (e.g. from reception) as well as the improvement on the test chart in order to decide if new glasses will make a noticeable difference to the patient. Improving near vision is as likely to be achieved by improving lighting as by changing glasses. Show the patient how a daylight lamp (kept in the B cubicles) can improve close work – these can be bought from CamSight. When considering the add in reading prescriptions, adds do not stop at +3DS!! Patients can be initially resistant to the reduced working distance used with adds of +4D or higher, but do show the patient how much bigger print can be by holding it closer with a higher add. In 2006/7, the majority of aids that we dispensed from the low vision clinic were high add reading specs with adds from +4 to +14D.
Department of Optometry and Ophthalmic Dispensing 7
Core Competencies On completion of the student’s degree studies at Anglia Ruskin, the department must provide a certificate of clinical competency to the GOC to enable the students to proceed to the pre registration training year. To ensure that the students have obtained the necessary skills, they are required to complete each of the required tasks under supervision during their final year. Students’ progress will be documented on the ‘Clinical Competency’ work sheet. This is the property of the university and must remain in the optometry clinic at all times.
The following protocol should be observed: The supervisor ideally should be informed at the beginning of the clinic if the student wishes a competency to be assessed. If during the examination the student feels assessment is appropriate they can still ask the supervisor, provided this is done before they begin the procedure. In either case, the supervisor will decide if this is acceptable on the day / patient. e.g. retinoscopy would not be assessed if the student has prior knowledge of the patients prescription. The supervisor must be present for the whole procedure being assessed and must check the accuracy of results where appropriate. If the procedure has been completed competently (see guidelines for the various competencies) the supervisor should sign and date the work sheet accordingly, together with comments. If the student has failed to achieve a satisfactory standard, the work sheet should not be signed.
Supervisor responsibilities • The visual welfare (prescription, ocular health, referral letters etc.) of patients attending the clinic. • Student supervision • Giving feedback and a mark to students at the end of the examination • Facilitating the student led small group discussion • Signing the student competency sheet if the technique was fully observed and completed to the relevant standard
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• Accurate and complete record card keeping including signature. • Ensuring the student has completed the correct section of the logbook for all relevant patient encounters and the appropriate self reflection section. • Signing the students’ logbook writing any comments that would be appropriate for any supervisors who will assess the student in the future. (It would be advantageous to look at the students’ logbook before the start of the examination to read any previous comments.)
Students should be encouraged to: • Show an interest in, concern for and respond to the needs of the patient • Show initiative and promptness in the clinic (if late the maximum mark to be awarded is 40%) • Maintain their appearance, hygiene and manner appropriate to a health care clinician (if the student is in inappropriate or scruffy dress then a maximum mark of 40% to be awarded) • Show a co-operative attitude towards peers and clinic personal (if the student is unprofessional then a maximum mark of 10% should be awarded) • Show knowledge and adherence to clinic policies and regulations • Apply the clinical data gathered during the examination. • Record the diagnosis, treatment plan, patient advice and method of patient disposal.
Allocation of marks Within each section the supervisor will use their judgement to allocate marks on the following; this is by no means a definitive guide.
• Ocular Motor Balance Marks may be deducted for inappropriate tests Assessment of
Accommodation Phorias or Tropias Stereopsis Convergence
Eye Exam
• Investigative Techniques Marks may be deducted for inappropriate tests
• History and Symptoms
Visual Field Analysis
Chief complaint
Tonometry
Ocular history
Slit lamp examination
General health (including medications)
Indirect Ophthalmoscopy
Family history
Colour vision
• Preliminary Examinations
Contrast sensitivity
Vision and visual acuity Pupils
Advice given to Patient
Motility Cover test • Retinoscopy Measurement of pd and fitting of trial frame Technique and speed •
Sphere power
•
Cyl power
•
Cyl axis
• Ophthalmoscopy and External eye Full assessment of the optic nerve head Macular region
Third year students should be proactive in clinical decision making. The patient should be advised on the health of their eyes (referral protocol if necessary), prescription changes (if any), and the dispensing options available and on the date of their next appointment.
Record Card Keeping • The card should remain neat and legible. • The card must be filled-in in ink. • Only Anglia Ruskin approved abbreviations should be used.
Evaluation of the retinal vasculature Peripheral retina Media assessment Ocular adnexa assessment Assessment of cornea • Subjective Refraction Technique and speed Sphere power Cyl power Cyl axis Binocular balancing Binocular addition Reading additon where necessary
Department of Optometry and Ophthalmic Dispensing 9
Contact Lens Preliminary Visit and Fitting • History and Lens-Related Symptoms Reason for visit / Chief complaint Contact lens history Habitual wearing schedule Number of hours of wear today • Technical Skills Slit lamp Keratometry Tear tests Lens verification Lens handling Ophthalmoscopy (if appropriate) • Choice of Lens Lens type and material, related to patient needs • Fitting Procedure • Communication with Patient
Lens Collection Visit • History and Lens-Related Symptoms Reason for visit / Chief complaint Pertinent Contact lens history • Technical Skills Slit lamp Lens verification Lens handling • Recognition of Clinical Signs • Communication with Patient Instruction in lens handling, insertion and removal. Instruction on lens care procedures and hygiene • Advice Given To Patient Clinical decision making. Advice regarding their lens wearing pattern and lens care procedures. Emphasising the importance of aftercare The date of their next appointment. Leaflet and information given to patient
• Advice Given To Patient Clinical decision making.
• The card should remain neat and legible.
Emphasising the importance of aftercare
• The card must be filled-in in ink.
The date of their next appointment.
• Only Anglia Ruskin approved abbreviations should be used.
Record Card Keeping • The card should remain neat and legible. • The card must be filled-in in ink. • Only Anglia Ruskin approved abbreviations should be used. • Please ensure that the clinical record shows clearly the full specification of lenses being worn by the patient.
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Record Card Keeping
Advice to patient on the health of their eyes, prescription changes
• Please ensure that the clinical record shows clearly the full specification of lenses being worn by the patient.
Aftercare Visit • History and Lens-Related Symptoms Reason for visit/Chief complaint Contact lens history Habitual wearing schedule Number of hours wear today • Technical Skills Slit lamp Keratometry Tear tests Lens verification Lens handling Ophthalmoscopy (if needed) • Recognition of Clinical Signs • Communication with Patient Advice Given To Patient Clinical decision making. Advice to patient on the health of their eyes, prescription changes Advice regarding any modification to their lens wearing pattern or care procedures. Emphasising the importance of further aftercare The date of their next appointment.
Record Card Keeping • The card should remain neat and legible. • The card must be filled-in in ink. • Please ensure that the clinical record shows clearly the full specification of lenses being worn by the patient.
Department of Optometry and Ophthalmic Dispensing 11
STUDENT ASSESSMENT FORM (This is just an example to illustrate the sections on the actual clinic form) STUDENT NAME
DATE
PATIENT NAME HISTORY AND SYMPTOMS Comments
RETINOSCOPY Comments
OPHTHALMOSCOPY + EXTERNAL EYE Comments
SUBJECTIVE Comments
OCULAR MOTOR BALANCE Comments
FURTHER TESTS Comments
INVESTIGATIVE TECHNIQUES Comments
COMMUNICATION & ADVICE GIVEN TO PX Comments
RECORD CARD KEEPING Comments
PROFESSIONALISM
FINAL MARK Comments SUPERVISORS NAME + SIGNATURE EASY PX
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MODERATE PX
DIFFICULT PX
PRELIMINARY & FITTING VISIT (This is just an example to illustrate the sections on the actual clinic form) STUDENT NAME
DATE
PATIENT NAME HISTORY AND LENS-RELATED SYMPTOMS
TECHNICAL SKILLS
RECOGNITION OF CLINICAL SIGNS
CHOICE OF LENS
FITTING PROCEDURE
COMMUNICATION WITH PATIENT
ADVICE GIVEN TO PATIENT
RECORD KEEPING
FINAL MARK SUPERVISORS NAME & SIGNATURE EASY PX
MODERATE PX
DIFFICULT PX
Department of Optometry and Ophthalmic Dispensing 13
LENS COLLECTION VISIT (This is just an example to illustrate the sections on the actual clinic form) STUDENT NAME
DATE
PATIENT NAME
HISTORY AND LENS-RELATED SYMPTOMS
TECHNICAL SKILLS
RECOGNITION OF CLINICAL SIGNS
COMMUNICATION WITH PATIENT
ADVICE GIVEN TO PATIENT
RECORD KEEPING
FINAL MARK Comments SUPERVISORS NAME + SIGNATURE EASY PX
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MODERATE PX
DIFFICULT PX
ONE TO ONE STUDENT ASSESSMENT FORM (This is just an example to illustrate the sections on the actual clinic form) STUDENT NAME
DATE
PATIENT NAME
EXAMINER
Routine Checklist Salient clinical details of patient:
TEST
SEQUENCE OF TEST
WAS TEST APPROPRIATE?
WAS THE TECHNIQUE ADEQUATE?
WAS THE RESULT “ACCURATE”?
Symptoms and History
Unaided visions
Cover test
Motility
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ONE TO ONE STUDENT ASSESSMENT FORM (contd) (This is just an example to illustrate the sections on the actual clinic form) Pupils
NPC
Peripheral field check
External examination
Internal examination
PD measurement
Trial frame/phoroptor fit
Retinoscopy
Subjective
Distance VA
Binocular balancing
Ocular motor balance
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ONE TO ONE STUDENT ASSESSMENT FORM (contd) (This is just an example to illustrate the sections on the actual clinic form) Compensation/FD
Accommodation
Reading addition
Near VA
Range of near VA
Near ocular motor balance
Compensation/FD
Further tests
Rx
Advice and communication with patient
FINAL MARK Comments SUPERVISORS NAME + SIGNATURE EASY PX
MODERATE PX
DIFFICULT PX
Department of Optometry and Ophthalmic Dispensing 17
Clinic Marking Scheme 70% - 100%
Accurate results Finished in 1 hr 30 mins (incl supp tests) No significant findings missed Good communication throughout, retaining full control of the test Good technique with all procedures Full understanding of all procedures Able to sum up and present findings to patient independent of supervisor
60-70%
Accurate results No significant findings missed Finished in reasonable time Good communication and reasonable control of test Technique of most of procedures good Understanding shown of most of procedures Able to do at least some of the presentation of findings to patient
50-60%
Final Rx within 0.50 dioptre any meridian No significant findings missed Communication could be improved Some time wasted Some techniques of non-critical procedures need brushing up Shows lack of understanding of significant number of procedures Supervisorâ&#x20AC;&#x2122;s help needed in decision making and presentation of findings
40-50%
Final Rx within 1 dioptre any meridian No significant findings missed Communication adequate such that patient does not lose faith in practitioner Poor timekeeping Significant brushing-up of non-critical procedures needed Shows lack of understanding of significant number of procedures Supervisorâ&#x20AC;&#x2122;s help needed in decision making and presentation of findings
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30-40%
Any significant findings missed Or Final Rx outside 1 dioptre in any meridian and/or some of the following: Inadequate communication Poor timekeeping Poor techniques in critical or non-critical procedures Lack of understanding of significant number of procedures Supervisorâ&#x20AC;&#x2122;s help needed in decision making and presentation of findings
<30%
Any significant findings missed Or Final Rx outside 1 dioptre in any meridian and, in addition, most of the following: Inadequate communication Poor timekeeping Poor techniques in critical or non-critical procedures Lack of understanding of significant number of procedures Supervisorâ&#x20AC;&#x2122;s help needed in decision making and presentation of findings
Department of Optometry and Ophthalmic Dispensing 19
Anglia Ruskin Abbreviations
Alt XOT
Alternate Exotropia
ARC
Anomalous Retinal Correspondence
ARMD
Age-Related Macular Degeneration
A/V
Arteriole/Venule ratio
BDR
Background Diabetic Retinopathy
BE
Both Eyes
AACG
Acute angle closure glaucoma
bd/b.i.d
Twice a day
AC
Anterior Chamber
BIO
Binocular Indirect Ophthalmoscopy
AC 4/4
Grade 4 Anterior Chamber angle
BP
Blood Pressure
AC 3/4
Grade 3 Anterior Chamber angle
BRAO
Branch Retinal Artery Occlusion
AC 2/4
Grade 2 Anterior Chamber angle
BRVO
Branch Retinal Vein Occlusion
AC 1/4
Grade 1 Anterior Chamber angle
Cat
Cataract
AC 0/4
Grade 0 Anterior Chamber angle (closed)
CD
Centration Distance
AC/A
Accommodative Convergence/ Accommodation ratio
C/D
(Vertical) Cup/Disc ratio
CF
Count Fingers Vision - State Distance
ACG
Angle closure glaucoma
CLO
Cortical lens opacities
Acc
Accommodation
C/O
Complains of
Add.
Addition
CRAO
Central Retinal Artery Occlusion
ALT
Alternating
CRVO
Central Retinal Vein Occlusion
Alt SOT
Alternate Esotropia
CT
Cover Test
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CVA
Cerebral Vascular Accident
MS
Multiple Sclerosis
CW
Close Work
M.Wing
Maddox Wing
CWS
Cotton-wool spot
MR
Maddox rod
Prism dioptre
NCT
Non Contact Tonometry or Near cover Test
D
Dioptres
ND
Neutral Density filter
DOB
Date of Birth
NIDDM
Type 2 diabetes
DR
Diabetic Retinopathy
NPL
No Perception Light
DS
Dioptre sphere
NPC
DV
Distance Vision
Near Point of Convergence, or No Previous Correction
DVD
Dissociated Vertical Deviation
NRC
Normal Retinal Correspondence
EF
Eccentric Fixation
NS
Nuclear Sclerosis
FB
Foreign Body
NTG
Normotensive Glaucoma
FD
Fixation Disparity
NV
Near Vision
FF
Foveal Fixation
NWT
Normal Wearing Time
FOH
Family Ocular History
F/U
Follow Up appointment
GH
General Health
GP
General Practitioner
GPC
Giant Papillary Conjunctivitis
gtt, Gutt.
Guttae (drops)
HA
Headaches(s)
HARC
Harmonious Anomalous Retinal Correspondence
HES
Hospital Eye Service
HM
Hand Motion vision -
IDDM
Type 1 diabetes
IOL
Intra Ocular Lens implant
IOP
Intra-Ocular Pressure
IRMA
Intraretinal Microvascular Abnormality
K
Keratometry
KCS
KeratoConjunctivitis Sicca
KP
Keratic Precipitate
LE
Left Eye
LHyperT
Left Hypertropia
LHypoT
Left Hypotropia
LO’s
Lens Opacities
L/RFD
L/R Fixation Disparity
L/R
Left Hyperphoria
LSOT
Left Esotropia
LVA
Left Visual Acuity, or Low Vision Appliance or Low Vision Assessment
Meds
Medications
Horizontal Orthophoria Vertical Orthophoria Horizontal & Vertical Orthophoria
State Distance
Oc
Ointment
OC’s
Optical Centres
Occ.
Occupation
o.d
Once a day
OH
Ocular Hypertension
OMB
Ocular Motor Balance
ONH
Optic Nerve Head
Oph
Ophthalmoscopy
PD
Pupillary Distance
PDR
Proliferative Diabetic Retinopathy
PERRLA
Pupils Equal, Round, Reactive to light and Accommodation
PH
Pinhole
PL
Light Perception
POH
Previous Ocular History
PPA
Peri-Papillary Atrophy
PPDR
Preproliferative Diabetic Retinopathy
POAG
Primary Open Angle Glaucoma
PRK
Photorefractive Keratotomy
p.r.n
When required
PSCC
Posterior Subcapsular Cataract
Px
Patient
PVD
Posterior Vitreous Detachment
Department of Optometry and Ophthalmic Dispensing 21
q.d.s/q.i.d.
four times a daily
RAPD
Relative Afferent Pupillary Defect
RD
Retinal Detachment
RE
Right Eye
Ret.
Retinoscopy
RHyperT
Right Hypertropia
RHypoT
Right Hypotropia
BC
Base curve
RK
Radial Keratotomy
BOZD
Back optic zone diameter
RNFL
Retinal Nerve Fibre Layer
BOZR
Back optic zone radius
RP
Retinitis Pigmentosa
WT
Wearing time
RPE
Retinal Pigment Epithelium
MWT
Maximum wearing time
RSOT
Right Esotropia
PMMA
Polymethyl Methacrylate
RVA
Right Visual Acuity
SCL
Soft contact lenses
Rx
Prescription
OS
Overall size
SEAL
Superior Epithelial Arcuate Lesion
OZD
Optic Zone Diameter
SLE
Slit Lamp Examination
TBUT
Tear break up time
SOP
Esophoria
HVID
Horizontal visible iris diameter
SOT
Esotropia
VPA
Vertical palpepral aperture
SPE
Superficial Punctate Epitheliopathy
RGP
Rigid Gas Permeable
Supp.
Suppression
t.d.s/ t.i.d
Three times daily
TIA
Transient Ischaemic Attack
TWT
Today Wearing Time
V
Vision (unaided)
VA
Visual Acuity (corrected V)
VDU
Visual Display Unit
VD
Vertex Distance
VF
Visual Field
WD
Working Distance
x/12
X months
x/52
X weeks
x/7
X days
x/24
X hours
XOP
Exophoria
XOT
Exotropia
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Contact Lens abbreviations
Health and Safety
The following guidelines on hand washing (taken from ‘Practical guidelines for infection control in health care facilities’) should be adhered to. Please ensure the student washes their hands after they have taken the patient into the consulting room.
Hand Washing Appropriate hand washing can minimize micro-organisms acquired on the hands by contact with body fluids and contaminated surfaces. Hand washing breaks the chain of infection transmission and reduces person-toperson transmission.
Hand washing is the simplest and most cost-effective way of preventing the transmission of infection and thus reducing the incidence of health-careassociated infections. All health care personnel and family caregivers of patients must practise effective hand washing. Patients and
primary care givers need to be instructed in proper techniques and situations for hand washing. Compliance with hand washing is, however, frequently sub-optimal. Reasons for this include: lack of appropriate equipment; low staff to patient ratios; allergies to hand washing products; insufficient knowledge among staff about risks and procedures; the time required, and casual attitudes among staff towards bio-safety.
Hand washing helps to remove microorganisms that might cause disease.
·
Hand washing Hand washing is usually limited to hands and wrists; the hands are washed for a minimum of 10 – 15 seconds with soap (plain or antimicrobial) and water.
Hand antisepsis /decontamination
Purpose
·
Types of hand washing
Washing with soap and water kills many transient micro-organisms and allows them to be mechanically removed by rinsing. Washing with antimicrobial products kills or inhibits the growth of microorganisms in deep layers of the skin
Hand antisepsis removes or destroys transient micro-organisms and confers a prolonged effect. It may be carried out in one of the following two ways: Wash hands and forearms with antimicrobial soap and water, for 15-30 seconds (following manufacturer’s instructions). Decontaminate hands with a waterless, alcohol-based hand gel or hand rub for 15-30 seconds. This is appropriate for hands that are not soiled with protein matter or fat. Immersion of hands in bowls of antiseptics is not recommended.
Department of Optometry and Ophthalmic Dispensing 23
Surgical hand antisepsis Surgical hand antisepsis removes or destroys transient micro-organisms and confers a prolonged effect. The hands and forearms are washed thoroughly with an antiseptic soap for a minimum of 2-3 minutes. The hands are dried using a sterile towel. Surgical hand antisepsis is required before performing invasive procedures.
Facilities and materials required for hand washing
Materials used for hand washing/hand antisepsis Soap: Plain or antimicrobial soap depending on the procedure.
Running water
Plain soap: Used for routine hand washing, available in bar, powder or liquid form.
Access to clean water is essential. It is preferable to have running water:
Antimicrobial soap: Used for hand washing as well as hand antisepsis.
large washbasins with hand-free controls, which require little maintenance and have antisplash devices.
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If bar soaps are used, use small bars and soap racks, which drain.
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Do not allow bar soap to sit in a pool of water as it encourages the growth of some micro-organisms such as pseudomonas.
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Clean dispensers of liquid soap thoroughly every day.
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When liquid soap containers are empty they must be discarded, not refilled with soap solution.
When no running water is available use either a bucket with a tap, which can be turned on and off, a bucket and pitcher, or 60%-90 % alcohol hand rub.
Specific antiseptics: recommended for hand antisepsis: ·
2%-4% chlorhexidine,
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5%-7.5% povidone iodine,
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1% triclosan, or
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70% alcoholic hand rubs.
Waterless, alcohol-based hand rubs: with antiseptic and emollient gel and alcohol swabs, which can be applied to clean hands.
Alcohol hand-rubs are appropriate for rapid decontamination between patient contacts. They are not a substitiute for hand washing if hands are soiled. Dispensers should be placed outside each patient room.
Facilities for drying hands Disposable towels, reusable single use towels or roller towels, which are suitably maintained, should be available. If there is no clean dry towel, it is best to air-dry hands
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Equipment and products are not equally accessible in all countries, or health care facilities. Flexibility in products and procedures, and sensitivity to local needs will improve compliance. In all cases, the best procedure possible should be instituted.
Common towels must not be used as they facilitate transmission of infection.
Steps in hand washing Preparing for hand washing: ·
Remove jewellery (rings, bracelets) and watches before washing hands,
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ensure that the nails are clipped short (do not wear artificial nails),
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roll the sleeves up to the elbow.
Wet the hands and wrists, keeping hands and wrists lower than the elbows (permits the water to flow to the fingertips, avoiding arm contamination). Apply soap (plain or antimicrobial) and lather thoroughly. Use firm, circular motions to wash the hands and arms up to the wrists, covering all areas including palms, back of the hands, fingers, between fingers and lateral side of fifth finger, knuckles, and wrists. Rub for minimum of 10-15 seconds. Repeat the process if the hands are very soiled. Clean under the fingernails. Rinse hands thoroughly, keeping the hands lower than the forearms. If running water is not available, use a bucket and pitcher. Do no dip your hands into a bowl to rinse, as this re contaminates them. Collect used water in a basin and discard in a sink, drain or toilet. Dry hands thoroughly with disposable paper towel or napkins, clean dry towel, or air-dry them.
Discard the towel if used, in an appropriate container without touching the bin lids with hand. Use a paper towel, clean towel or your elbow/foot to turn off the faucet to prevent recontamination.
Using antiseptics, hand rubs, gels or alcohol swabs for hand antisepsis
If soap and water are unavailable, hands should first be cleansed with detergent-containing towellettes, before using the alcohol-based hand rub, gel or swab.
Clinical waste All clinic rooms now have clinical waste bins which are for the following waste only: • Fluorets • Soft contact lenses
Apply the product to the palm of one hand. The volume needed to apply varies by product. Rub hands together, covering all surfaces of hands and fingers, until hands are dry. Do not rinse. Note: When there is visible soiling of hands, they should first be washed with soap and water before using waterless hand rubs, gels or alcohol swabs.
• Minims • Cotton buds • Tonosafe heads
Periodically the bins will be collected and autoclaved on site. After this they can be emptied and reused. Your help in seeing that these are correctly used would be appreciated.
Department of Optometry and Ophthalmic Dispensing 25
Certificate of Clinical Competence All third year students are required by the GOC to be assessed on and pass a range of clinical competencies before entering the pre-registration period. These competencies are set by the GOC, not by Anglia Ruskin University. They are assessed in the clinic modules. Below is an outline for the skills that each student should demonstrate in order to be â&#x20AC;&#x2DC;signed offâ&#x20AC;&#x2122; on a particular competency. The competencies are based on practical skills rather than theoretical knowledge, which is assessed elsewhere in the syllabus. The criteria for assessing each competency is therefore focussed on the ability to do a task, instructions given and recording of results rather than the theory behind a test or understanding of the results, therefore the students do not need to be questioned on these competencies in order to be signed off. This does not however mean that the students should not be questioned in more detail during the clinic module (as they obviously gain a lot from this), only that deeper questioning is not a specific requirement to demonstrate clinical competency. Remember the final signing off is at your discretion and common sense should always prevail.
Taking case history
Cover test
i. Adequately evaluates primary and secondary complaints using open, closed and follow-up questioning
i. Provides appropriate room illumination for distance vision
ii. Adequately assesses ocular and general health history as above iii. Adequately assesses family ocular and general health history as above iv. Communicates with the patient adequately v. Records findings legibly and in adequate detail
Vision and visual acuity
ii. Instructs the patient to view a distance fixation target iii. Accurately assesses the oculomotor balance using a cover test for near vision iv. Chooses an appropriate near fixation target and working distance v. Accurately assesses the oculomotor balance using a cover test at near vi. Records findings for distance and near including type of deviation, direction and magnitude
i. Provides appropriate room illumination
Motility
ii. Uses appropriate charts and targets to measure distance and near acuity for both eyes and binocularly
i. Provides appropriate room illumination
iii. Records the results at distance and near for both eyes and binocularly, using appropriate notation
ii. Uses an appropriate fixation target at the correct distance iii. Moves the target at an appropriate speed iv. Moves the target in relevant diagnostic directions v. Asks if the patient experiences diplopia or discomfort during the test vi. Records findings
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Pupil actions
Ophthalmoscopy â&#x20AC;&#x201C; indirect
i. Assesses the direct pupil response adequately
i. Adequately prepares the instrument
ii. Assesses the consensual pupil reflex adequately
ii. Selects appropriate illumination and magnification
iii. Performs the swinging flashlight test adequately to screen for a RAPD
iii. Selects and positions the fundus viewing lens correctly
iv. Records all findings appropriately.
iv. Performs a systematic examination of all four quadrants v. Adequately assesses and records the A/V ratio
Retinoscopy
vi. Adequately assesses and records the optic nerve head appearance
i. Provides appropriate room illumination
vii. Adequately assesses and records the appearance of the macular area
ii. Measures and records the distance PD iii. Adjusts the trail frame or phoropter properly
viii.Adequately assesses and records the appearance of the peripheral retina
iv. Chooses an appropriate fixation target for the patient v. Records the results for both eyes vi. Achieves an appropriate level of accuracy (within +/- 1D in any meridian)
Ophthalmoscopy â&#x20AC;&#x201C; direct i. Uses logical progression of focussing to examine anterior segment, media and fundus
Subjective refraction i. Provides appropriate room illumination ii. Records results for both eyes including sphere, cylinder, axis, visual acuity iii. Achieves an appropriate level of accuracy iv. Records the final subjective result following balancing procedures as appropriate
ii. Maintains a satisfactory working distance from the patient iii. Performs a systematic examination of all four quadrants iv. Adequately assesses and records the A/V ratio v. Adequately assesses and records the optic nerve head appearance vi. Adequately assesses and records the appearance of the macular area Department of Optometry and Ophthalmic Dispensing 27
Cycloplegic refraction
Measurement of heterophoria
i. Is able to explain the procedure and potential side effects to the patient (or parent).
Dissociated distance phoria
ii. Selects appropriate drug for the procedure iii. Instills the drug safely and records all the details of the drug instilled iv. Records results for both eyes including sphere, cylinder, axis, visual acuity v. Achieves an appropriate level of accuracy
i. Aligns and levels the phoropter or trial frame appropriately ii. Selects an appropriate target iii. Provides appropriate illumination for the test type iv. Accurately assesses the horizontal and vertical phorias using a test other than cover test v. Records the findings including direction and magnitude of deviation
vi. Records the final result appropriate for prescribing.
Low vision assessment
Dissociated near phoria vi. Sets the near PD
The student has examined a patient whose best corrected vision with spectacles or contact lenses is not sufficient for their needs, and has:
vii. Provides appropriate illumination for the test type viii. Selects and appropriate near target and working distance(s)
i. Take a case history appropriate to identifying the needs of the patient.
ix. Accurately assesses the horizontal and vertical phorias using a test other than cover test
ii. Assess visual function appropriately, using specialist test charts where necessary.
x. Records the findings including direction and magnitude of deviation
iii. Where necessary adapt routine refraction to compensate for the patientâ&#x20AC;&#x2122;s reduced vision. iv. Where necessary assess the patientâ&#x20AC;&#x2122;s need for simple optical magnifiers and trial these with the patient showing the patient how to use the aids to best effect.
Associated distance phorias xi. Use the appropriate polarising filters xii. Accurately assess the associated horizontal and vertical phoria xiii. Record the findings including direction and magnitude of deviation
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Associated near phorias
Colour vision assessment
xiv. Use the appropriate polarising filters
i. Instructs the patient
xv. Accurately assess the associated horizontal and vertical phoria at the appropriate working distance(s)
ii. Provides correct room illumination
xvi.Record the findings including direction and magnitude of deviation
iii. Selects an appropriate test (congenital vs. acquired defects and screening vs. extent of the defect) iv. Uses appropriate spectacles v. Uses the appropriate working distance for the test type
Tonometry â&#x20AC;&#x201C; non-contact Instructs the patient appropriately
vi. Performs the test adequately vii. Records the results including the type of defect when applicable
Checks the calibration of the instrument Correctly positions the patient
Contact lens specifications
Put the safety lock in place (if available) Obtains appropriate number of readings and records valid readings including time
i. Adequately prepares the radiuscope ii. Positions lens appropriately using supporting fluid iii. Identifies both target positions
Tonometry â&#x20AC;&#x201C; contact i. Checks drug labelling ii. Washes hands iii. Sets up the tonometer and slit lamp (if applicable)
iv. Records BOZR to within 0.05mm v. Measures lens BVP with focimeter to within ISO tolerances vi. Uses V-gauge to measure TD to within 0.1mm vii. Sets up centre thickness gauge adequately - measures to within 0.02mm
iv. Instructs the patient appropriately v. Cleans and disinfects the probe or prepares a disposable probe vi. Instills anaesthetic and fluorescein correctly vii. Applanates the cornea in a safe and efficient manner viii. Retracts the tonometer safely
Keratometry i. Correctly identifies the type of keratometer being used ii. Focuses eyepiece
ix. Obtains and records a valid reading
iii. Takes measurements of patientâ&#x20AC;&#x2122;s cornea in 2 principally opposed meridians
x. Checks the cornea for staining
iv. Takes average of three readings v. Records findings, accurate to within 0.05mm each eye.
Visual fields i. Prepares the instrument adequately ii. Positions patient satisfactorily iii. Instructs the patient appropriately iv. Adjusts room illumination v. Uses appropriate spectacles or supplementary lenses vi. Obtains a valid result and records relevant details
Insertion and removal RGP lenses i. Demonstrates suitable hygiene procedures ii. Prepares lens for insertion iii. Gives appropriate instruction to patient iv. Holds lids appropriately v. Inserts lens directly onto cornea vi. Takes suitable care of patient to control foreign body reflex vii. Holds lids correctly to remove lens viii. Removes lens safely ix. Is aware of the need to check corneal integrity prior to lens insertion and after lens removal Department of Optometry and Ophthalmic Dispensing 29
Insertion and removal soft lenses
Aftercare
i. Demonstrates suitable hygiene procedures
i. Elicits full contact lens history and symptoms
ii. Prepares lens for insertion
ii. Demonstrates suitable hygiene procedures
iii. Gives appropriate instruction to patient
iii. Correctly asses fit and condition of patientâ&#x20AC;&#x2122;s lenses
iv. Holds lids appropriately
iv. Examines the patientâ&#x20AC;&#x2122;s eye with white light and fluorescein, including lid eversion
v. Inserts lens directly onto bulbar conjunctiva vi. Takes appropriate measures to centre the lens vii. Gives patient adequate instruction for lens removal viii. Moves lens onto bulbar conjunctiva ix. Removes lens safely x. Is aware of the need to check corneal integrity prior to lens insertion and after lens removal
v. Identifies significant response of the eye to contact lens wear vi. Records observations clearly vii. Makes appropriate recommendations to the patient taking into account significant signs and symptoms
Slit lamp
RGP lens fit
i. Explains the aim of the test to the patient.
i. Demonstrates suitable hygiene procedures
ii. Adequately prepares the instrument (should have been cleaned and already focused before use)
ii. Selects appropriate first lens for trial iii. Examines the lens in situ using white light iv. Inserts fluorescein and examines fluorescein pattern v. Makes correct judgement as to lens fitting vi. Records observations in clear and logical manner vii. Performs spherical over-refraction viii. Selects appropriate material and care regime ix. Completes lens order
iii. Demonstrates the use of various illumination systems including diffuse, direct, indirect, retroillumination, sclerotic scatter and specular iv. Is able to demonstrate appropriate techniques to assess lids and adnexa v. Uses the correct illumination techniques and magnification to assess the anterior chamber angle vi. Uses the correct illumination techniques and magnification to assess the cornea and tears vii. Uses the correct illumination techniques and magnification to assess the conjunctiva and sclera
Soft lens fit
viii. Uses the correct illumination techniques and magnification to assess the lens
i. Demonstrates suitable hygiene procedures
ix. Throughout the procedure maintains patient safety
ii. Selects appropriate first lens for trial iii. Examines lens in situ
Facial measurements
iv. Makes correct judgement as to lens fitting v. Performs spherical over-refraction vi. Records observations clearly vii. Selects appropriate care regime viii. Completes lens order
i. Accurate taking and recording of distance interpupillary distance, mono pupillary distances and near centration distances for orthophoric and heterophoric patients ii. Accurate taking of bridge measurements to allow for a hand made frame to provide a smooth continuous contact around the bearing surface of the nose iii. Accurate taking of bridge measurements to allow for a fixed pad plastics frame to provide a smooth continuous contact along the pads only iv. Accurate taking of the measurements of the head to allow sides to be made so that there is sufficient grip to hold the frame in place
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Spectacle fitting
Focimetry
i. To align the spectacle frame so that the load is bourn equally at the points of the fitting triangle.
i. To accurately, within the tolerances stipulated in the BSEN standards, determine the correction supplied (BVP) in the main viewing area of the lens including any prismatic effect
ii. To balance the frame so that the front is symmetrical and the optical centres and lens type/style is not compromised iii. Ensure that there will be no slippage of the frame iv. Ensure that the vertex distance is not compromised with the fitting position v. Ensure that the fitting and the position of the frame will not cause or potentially cause discomfort and/or areas of pain. vi. Demonstrate an ability to identify and rectify the need for readjustments vii. Show an ability to reassemble and repair (minor) spectacle frames viii. Recognise frame materials and the necessary amounts of heat needed to carry out the adjustments
ii. To accurately determine the intermediate/near addition in the segment of a bifocal/trifocal lens iii. To accurately locate and mark the major reference point on a Progressive Powered Lens and to measure the prism at this point iv. To determine the amount of prism present in a Progressive Powered Lens once the thinning prism has been compensated v. Record any prismatic effect at the near visual point on a pair of spectacles vi. Check the position of the bifocal segment vii. Check the position of the fitting cross in Progressive Powered Lenses viii. Check the positionings of all optical centres
Frame measurements These should all be related to the facial measurements i. Accurate assessment of the bridge measurements to allow for the frame to match the facial measurements for a hand made frame so that the smooth continuous contact around the bearing surface of the nose is maintained iii. Accurate assessment of the bridge measurements to allow for the frame to provide a smooth continuous contact along the pads only
Neutralisation i. Mark the Optical Centre ii. Mark the principle axis iii. Determine the principle powers iv. Convert to spherocylindrical form
iv. Accurate assessment of the sides to ensure that the sides comply to the measurements specified on the order form
Department of Optometry and Ophthalmic Dispensing 31
Notes
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Notes
Department of Optometry and Ophthalmic Dispensing 33
Further information Department of Optometry and Ophthalmic Dispensing Optometry Clinic/Cambridge Campus East Road Cambridge CB1 1PT
Optometry Clinic General Enquiries Tel: 0845 196 2070 Email: arueyeclinic@anglia.ac.uk
Web links Anglia Ruskin University www.anglia.ac.uk
Department of Optometry and Ophthalmic Dispensing
www.anglia.ac.uk
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