Transcript Low Vision Exams: Is 20/20 the status quo?

How to Read an Eye
Report
(Interpreting Regular and Low
Vision Eye Reports)
BJ LeJeune, CVRT, CRC
Garry M. Griswold, OD
Mississippi State University
Learn the Jargon

Resources include:
– Cassin & Solomon, Dictionary of Eye
Terminology
– Vaughan & Asbury’s General
Ophthalmology
– Google
The goal of a regular eye
exam
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Check general eye health
To diagnose any eye problems
To develop a treatment plan to
address disease and refraction errors
To maximize vision using traditional
glasses or contact lenses or refer for
lasik surgery
What constitutes a
“regular” eye exam?

SOAP format
– S = subjective
– O = objective
– A = assessment
– P = plan
WHY?
Subjective

Patient History
“What’s going on?”
“Where is problem?” – (Which eye?)
“When did it start?”
“Why?” – (Did something cause
problem?)
– Modifiers
–
–
–
–
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Severity?, How often?, Does anything help?
Subjective (cont.)
– Medical History –
Health history
 Meds - Rx, OTC, vitamins/supplements
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– Previous eye care
– Brief Psychological evaluation

O X 3 = oriented to person, place and time
(date, year, etc.) – Medicare requires this for
a comprehensive exam
Objective Testing

Visual acuity = VA
s = without correction, c = with correction
 DVA = distance, NVA = near
 OD = right eye, OS = left eye, OU = both
eyes
 BVA = Best Corrected Visual Acuity
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– Charts
Snellen (or POC = “Project-o-Chart)
 = standard chart – gives 20/XX #’s - 1st 20
= test distance (20 feet). 2nd number = size
of letter seen.
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Snellen Chart
Objective Testing (cont.)
– Pupils
PERRLA = Pupils equally round and reactive
to light and accommodation
 +/- APD (or MG) = positive/negative afferent
pupillary reaction (or Marcus-Gunn pupils)

– EOM = Extra Ocular Muscles or Eye
movements
S & F = Smooth and Full
 Restricted – Which eye in which quadrant of
gaze (up, down, left, right or combinations)

Objective (cont.)
– Eye alignment
Tropia = constant eye turn
 Phoria = intermittent eye turn
 Eso =in, Exo = out
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– Visual Fields – show field loss

Confrontations = peripheral
– FTFC = Full to Finger Counting in all quadrants
– Can be used to map central or peripheral loss
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Amsler grid = central
Amslar Grid
Objective (cont.)
– Automated Fields (Humphrey, Dicon,
Octopus, etc.)
Gives a more detailed view of loss
 Can be used for central or peripheral loss
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– Refraction
Manifest = traditional
 Cycloplegic = dilated
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– Jaegar Near Vision chart
– Intraocular pressures (IOP) or tonometry
Humphrey Visual Field
Test
Results of Field tests
Objective (cont.)
– SLE = Slit Lamp Exam (Biomicroscopy)
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Examination of external structures of eye
Lids/lashes, conjunctiva, cornea, anterior chamber, iris.
Lens
– DFE =Dilated Fundus Exam
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internal eye exam
–
–
–
–
–
C/D = cup to disc ratio of optic nerve
V V = blood vessels
Vitreous
M/PP = Macula/Posterior Pole
Periphery
Slit Lamp
Dilated Fundus Exam
Fundus View of Diseased
Retina
Jaegar near vision
Assessment

Also called Impression
– What the doctor thinks is going on
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Examples = AMD (macular degeneration),
GLC (glaucoma), BDR (non-proliferative or
background diabetic retinopathy), PDR
(proliferative diabetic retinopathy), Cataracts
(NS = nuclear sclerosis), Myopia (nearsighted), Hyperopia (far-sighted), Presbyopia
(you need bifocals)
Plan (Treatment Plan)
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How is patient to be treated
– Medical management
Drug therapy
 Surgery
 Observation
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– Optical management
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Glasses or contacts
– Referral – need to be sure they know
about Rehabilitation Services and Low
Vision services
The goal of a Low Vision
Evaluation
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To confirm findings of eye report
To maximize functional vision through
low vision aids, therapies,
environmental modifications and
patient strategies
Make the Low Vision
Exam Practical
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Bring samples of what the person
wants to see (nutrition facts on a soup
can, page from the phone book, etc.)
Think about the environment where
the person will be – lighting, glare,
distance, etc.
The more information you bring to the
exam, the better the results
Low Vision Eval
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History
– What is pt having trouble doing?
– Be specific – i.e. “How far are you sitting from
the TV? What type of reading light do you use?
How much reading do you need to do? Glare?
Vocation? Hobbies? Computer use?, etc.”
– Glasses? (How old?) Contacts? What magnifiers
do you use now? (Look for “buzz words” – i.e.
“reading machine” = CCTV)
– What is the one thing you want to do
most?
Low Vision Evaluation
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Similarities to standard exam
– Most often will check the same areas, but
with some differences.
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Differences
– History
Most Important = functionality
 Most patients are referrals so Dx (diagnosis) is
known
 Current Medications – eye drops, orals,
supplements
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Low Vision Eval
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History (cont.)
– Include social info - living arrangements,
transportation issues (Are they still
driving?!?), smoking, alcohol/drug use
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VA – most often use different charts
– Distance - Feinbloom #, EDTRS, Lea, etc.
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Why? – gradations between lines, test
distances
–.
– High contrast vs. low contrast
Feinbloom chart
Common Near Vision
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Bailey–Lovie
Hoeft
Mnread
Low Vision Eval
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Visual fields
– Confrontations - but can use to map
scotomas and field restrictions
– Amsler grid – use for quality of macular
loss
Scotoma density
 Metamorphopsia (distortion)
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Low Vision Eval
– Automated fields – sometimes less
effective – difficulties with fixation, etc.
Nidek MP-1 – maps central scotomas
 Scanning laser ophthalmoscope
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– Pupils/Eye movements = same but can
give info on undetected brain issues
(stroke, etc.)
– Eye health eval = seldom dilate – creates
artificial VA problems
Low Vision Eval
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Low Vision Aid evaluation
– Start with what they want most
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Most often = READING!!
– Prescriptive process - Not just throwing
magnifiers at them!
– May take more than one visit to determine
best aids for that person. Good to let them
try before purchase if possible.
– Training on use of aids is critical.
Low Vision Eval
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Assessment and Plan
– Diagnosis for billing purposes
– Aids may or may not be Rx’d at first visit
– May need additional visits
– May include referral to other agencies for
services – O&M, home visits, OT/CVRT
services, VR services, Social Service
agencies
– Overall exam should be at least an hour,
often 2.
Reading Reports
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Who is it from?
– Primary eye care provider (ECP =
OD/MD)
– Low Vision Specialist (OD/MD,
OT/CLVT/CVRT)
– Interagency/Intra-agency
– Neurologist or NeuroOptometrist/Ophthalmologist
(Remember providers have their own “Lingo”)
Reports
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Primary ECP (OD/MD)
– Objective findings
– Medical Dx and Medical/Optical treatment
– When/how often they will see patient
– Most often geared toward other medical
professionals
– Do not expect opinions on low vision aids
– You may only get “chart notes”
Report Format
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May get a letter or have a form your
agency has the physician fill out.
Look for:
– Diagnosis
– Level/severity of vision loss (legally
blind?)
– Prognosis
– Treatment Plan
Eye Exam Letter Example
Dear XXX,
I had the pleasure of seeing XXX, a very pleasant XX year old female for a comprehensive
eye exam on XX/XX/XX. Chief complaint was blurred vision. She has a history of macular
degeneration, worse in the right eye than the left. Medical history includes hypertension
and hypothyroid, both controlled by medication,
Following is a summary of XX’s exam:
Best Corrected Visual acuities: OD 20/200, OS 20/80
Pupils: PERRLA, (-) APD
EOM: Smooth and Full
Visual Fields: Full to Finger Counting
IOP’s: OD 18mmHG, OS 17mmHg
Biomicroscopy: Nuclear cataracts – OD & OS, otherwise unremarkable
DFE: Macular drusen and RPE changes, otherwise unremarkable
Diagnosis: Age-related Macular Degeneration - OU
My plan is to see XX in 6 months for continued care. If there are questions, please do not
hesitate to call me.
Best Regards,
XXX XXX, OD
Reports
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Low Vision Specialist
– Visual acuities
– Other pertinent findings
– Diagnosis
– Should include advice on low vision aids
or at least preliminary results and that
there is on-going evaluation
– May include information on environmental
adaptations, aids, and devices
LV Letter Example
Dear XXXXX.
I had the pleasure of seeing your patient (client), XXX XXXX, for a low
vision evaluation on xx/xx/xx. As you know, XXX is a very nice XX year
old woman, who suffers from macular degeneration. As you are familiar
with her medical history, I will not recount that here. XXX lives at home
with her husband.
XXX’s main concern is reading. She also has difficulty with personal
hygiene and other daily tasks. Following is a brief summary of her
evaluation:
With her current eyeglasses, XXX’s vision measured at OD 10/100
(20/200) and OS 10/40 (20/80). Reading measured at 2.5 M (large print
material size). Pupil reactions were minimal and eye movements were
full. Visual fields by confrontations/Amsler grid showed a large dense
central scotoma in the right eye and a smaller area of metamorphopsia
centrally in the left eye, with periphery full to finger counting in both
eyes. Additional findings were consistent with the diagnosis.
LV Letter part 2
Various low vision aids were demonstrated. We also
demonstrated and instituted a course of eccentric viewing
training. Best response to low vision aids were: 4.0X
(brand) LED lighted stand magnifier for reading which
allowed 1.0 M print (newsprint). We also demonstrated a
4.0X LED hand mag for portability. For glare issues, a
medium plum sun filter (NoIR U81) was recommended.
We plan to see XXX for additional evaluation and training,
at which time we will demonstrate CCTV’s and other low
vision aids.
Thank you for allowing us to share in the care of this
delightful woman. If there are questions, please feel free
to contact us.
Best Regards,
What do those Numbers
Mean?
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Visual acuity
– 20/XX
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1st 20 = test distance (20 feet)
2nd number = Letter size – based on angle subtended
in seconds of arc
The larger the 2nd number, the worse the vision
– Many low vision doctors work in shorter
distances (ex. 10 feet) so may look like 10/40 –
this equates to 20/80 (7/40 = 20/125, 5/40 =
20/160, etc.)
Legal Blindness – Social
Security 1934
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Best Corrected (!!) vision of 20/200
or worse in the better eye OR
Visual field of 20 degrees or less
YOU CANNOT BE LEGALLY BLIND
IN ONE EYE !!! (I wish I could
convince eye doctors of this fact!)
The Numbers
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Magnification
– D (diopters) to X (magnification) =
D/4 (or in Europe D/4 + 1)
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12 D = 3X (European = 4 X)
Results should be
functional and informed
Contact Info
Garry M. Griswold,
OD
Rest in Peace
BJ LeJeune, CVRT,
CRC
P. O. Box 6189
Mississippi State, MS
39762
(662) 325-2001