What I Do at Work part 2

There are 2 things that make the patient believe that the technician does all the work (and to that I tell them I deserve a raise). The first is the manifest refraction I described in the last post - "which is better 1 or 2?" The second is when I check the pressure in the eyes with a tonometer.

Not me, but you get the idea (source)

To do this I give the patient a drop of flucaine in each eye. It is a bright yellow numbing drop. Ironically, the drops sting when they first go in. I then hold the patient's lids open and  place the tip of the Perkins tonometer on the cornea. When I look through my tool, I am looking for a green line that I will align and use to obtain the measurement.

My View (source)

Can you see the faint green semicircles? Now imagine if the patient is sensitive and is squeezing their eyes shut. To get a good view, one must get up close and personal. Short fingernails and good breath are a must. When I have to give this test to prisoners, I get scared. Usually the patient is unaware that the instrument is touching the eye. Pressures between 10 and 20 are normal. Savvy patients, usually those with glaucoma will be very curious as to knowing their measurement. This method of measurement has replaced the need for the "puff of air" test in our office.

After checking pressure, I will instill the dilating drops. We use two types phenelyephrine 2.5% and tropicamide 1%. Because we usually instill these after the numbing drops, no pain is felt. This is different than when I worked in pediatrics and we just had to tell the kids that it would feel like soap is in their eyes. The dilating drops are important so that the doctor will be able to look into the back of the eye where the nerves and blood vessels are. To look inside, he will need to shine a light in. The dilation drops keeps the muscles of the eye from contracting and gives the doctor a more complete view. The drops can last anywhere from 4 to 24 hours depending on the individual. This will make it especially hard to read and the sunlight will seem very bright. We encourage our patients to bring a driver with them, however, if you've had them before and are comfortable driving then it may not be a problem.

In my next post I'll discuss testing like visual fields, OCTS and pachymetry.

What I Do At Work part 1

Have you had an eye exam recently? Then maybe some of this will ring a bell. I wanted to explain a bit more about what I do all day.

I call the patient back (sometimes seriously embarrassing myself with mispronouncing names). Some common techniques to deal with this are to
- make eye contact and ask "are you ready? come with me"
- call the patient by just their first name, or Mr. or Mrs. (last name) based on which is easier to pronounce

When I bring the patient back to the room I introduce myself as the technician. I still feel awkward calling myself a technician. I feel like I should be repairing a car or computer or something...

My job is to find out why the patients are here and get some basic measurements. To get a chief complaint I will always ask about blurry vision, pain, flashes, floaters and double vision and whether or not you use any eye drops. General medical history is also important - medications, chronic conditions, etc... This is when you get to find out how talkative the patient is. As they talk I fill out this worksheet:

And don't worry, electronic medical records are coming this year. I'm excited!

As a healthcare professional I deal with people all day long. As an introvert, this is a very tiring thing! But, the patients always keep things interesting and the majority are friendly. I am always amazed when I find myself telling my life story to random strangers - some people just know how to ask the right questions! 

I use a lot of equipment when I do my initial patient work-up. The first thing I will hand the patient is the occulder.

Me, back in the Doc Plot days (source)

Source

Every time we will start by checking your vision, Believe it or not people will complain that we have to do this. I'm sorry but even if you were just here yesterday we HAVE to make sure you can see, you're at the eye doctor!! I turn on the projector and have the patient read lines off the Snellen eye chart. When they can't got any further I have them use the pinholes which can sometimes help (like squinting). Up close, we use a Jaeger reading card:

Source

For patients who see an MD, I manifest refract the patient. That's when you look through the phoropter and I ask "which is better, one or two?" Patients get so nervous about making the right choice! In this post, an optometrist gives advice for refracting. I like his advice to call certain lines of letters "teeny tiny" or "for bonus points." This really works well for kids. Speaking of kids and babies, this video explains how pediatric eye exams are done (surprisingly entertaining).

Then I go on and check your pupils, by shining a light in your eyes and watching to make sure they are round and react equally. By shining my light from the side, I can check angles. Closed angles create shadows and that is part of a check for glaucoma. Then I will have you follow my light to check motility of the eyes. Your eyes should be able to move in all the directions. Finally we do a peripheral vision test. I have the patient cover one eye and look at my nose. Without looking at my fingers, I ask the patient to tell me how many fingers I am holding up in each of the 4 quadrants. 

Source

For older patients we check for cataracts by performing a test called the BAT (brightness acuity test) using a "big flashlight." I perform the glare test by having the patient look through the light and read the letters on the wall. If a patient has cataracts and they are advanced enough, the light shining in their eyes will cause a glare that decreases their acuity. For more information about cataracts, check out this site.

To be continued....

Love Your Eyes

Infographic by Ultralase