Download Visual field testing

SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel
Page 1
Dr. Matchinski Started on Page 4 and ended with this packet on page 34
Statistics will NOT be part of the final exam
APPROACHING GERIATRIC EYE CARE

Aging
o
Aging is NOT a disease process  physiological, psychological, sociological, and visual changes with
time
o
Several Biological changes with aging
o
It is a natural process that happens which has many aspects: psychosocial, ocular, etc.
o
With aging, there are some very significant things that happen medically!
o

Reduction of water within the cells

Reduction in the elasticity of the skin

Increase in fatty connective tissue

Loss of muscle fibers

Thinning of bone structure

Lowering of hormone levels

Changes in digestion which affects nutrition

Our bodies slow down

Muscles do not move as fast

Short term memory isn’t as efficient

Digesting, nutrition and medications will change with age due to less body effectivity

Cardiovascular system is not as strong in older people (even in those that are very fit)
When you are treating an older person (especially with anterior segment disease) they are not going
to heal as fast as a young person.

Ex: Corneal abrasions on an elder patient will NOT heal the same way it heals on a younger
patient.

Intelligence and Learning Ability
o
Impairment of short term memory and lengthening of response time

Remember that these people are intelligent and are still good at forming ideas, it is just that
their response time may be a bit slower!
o
Intelligence in older patients is always underestimated because the testing scenarios are set up for
middle-aged/younger people—but elderly will do just as well if given more time  GO SLOW for
them!
o
When you are examining these patients, you must give them ample time to answer 1 or 2 during
refraction – give them blinks in between and let them have time to process
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel
o
Page 2
Two important factors

Adults form a number of structures or outlines in which to fit new information. New stimuli
to previous learning will be more easily retained.

Time is important, the longer the exposure to the new stimuli, the greater the opportunity
for memory storage.
o
When all time pressures are removed from older learners, there is no significant difference in
problem solving ability between age groups.
o
The slides before page 4 had to do with demographics of geriatric patients. If you want to practice
optometry with a focus on geriatrics, Arizona or Florida are great locations!

Characteristics of the Aging Experience  important because you can learn how to communicate and better
understand where the patients are coming from
o
Change in the Sense of Time

Shortened Perspective: The life in front of them is shorter than the life you have in front of
you  they may tend to live more in the past or live in the moment
o
Sense of Life Cycle

Experiencing a personal sense of the entire life cycle  bring up things they could’ve done
and should’ve done etc

o
o
o
Accumulation of factual knowledge, broadening perspective and personal growth.
Tendency Toward Life Review

Promoted by realization of approaching death

Consciousness of past experiences, taking stock of one’s self
Reparation and Resolution

Constantly writing and rewriting scenarios of their lives

Coming to terms with regretted actions of commission and of omissions of the past
Attachment to the familiar

Nostalgic attachment to familiar objects  grocery stores etc.

These attachments facilitate the life review and provide continuity, comfort, security and
satisfaction
o
Conservatism of Continuity

Passing on that which is of worth of one’s life  important for us to listen because we can
learn from them
o
Desire to Leave A Legacy  example: Dr. Rosenboom

To leave something behind when someone dies

Preserving a heritage for the future is a common desire
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel
o
Page 3
Transmission of Power

Psychological issue is when to give one’s power and authority to another


o
o
Spouse, or child  can be a struggle
Still continuing a counseling role and a sense of continuity
Sense of Consumation or Fulfillment in Life

Serenity and wisdom derived from resolving personal conflicts

Reviewing one’s life and finding it acceptable and gratifying

Viewing death with equanimity
Capacity for growth

Capacity for curiosity, creativity, and continued learning does not necessarily decrease with
age

Secrets to successful aging  Won’t be asked

New Blood pressure norms: 120/80 or lower

New fasting blood sugar norm: below 100

Maintain cholesterol levels at or: below 100 (LDL below 70)

Weight control, CV exercise, Diet control, no smoking, limited alcohol, socialization
with friends and family
o
Transition of power is difficult – it is hard for people to let go of control (whether that is driving, not
shopping for yourself, etc.)
o
Older patients can be incredibly curious, we just need to engage them – ask them questions, just talk
to them!

Goals of Geriatric Eye Care
o
Everyone gets really caught up in the overall health of the person (ex: maintaining diabetes) that eye
care gets pushed to the side even when there is known pathology
o
Prevention/Preservation
o
Maintenance/Restoration
o
Rehabilitation/Enrich
o
HUGE PRACTICE BUILDER!
o
Goals are to prevent problems before they stop, maintain health of the eyes, and to attempt to
restore or provide rehabilitation vision if it is lost

VOSH 2007 – Mexico
o
Dr. Matchinski was on this trip in her 30’s and all the other doctors were in their mid 80’s – students
were also on this trip
o
Older people are still able to engage with their community and stay active!
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel

Page 4
Geriatric Optometry
o
Understanding the aging process of a person as a whole and the physiological and functional change
of the aging eye
o

Quality of life
o

Understanding that aging is not a disease  also having insight in what is going on in their lives.
Education, Prevention, maintenance, Treatment/Management, Rehab
Ocular Aging
o
Physiological changes  Visual Perceptual changes  Functional Ramifications

Why do people fall?

When you go from light to dark or light to dark we don’t adapt well to the change
when we are older!
o
In the absence of ocular disease, the eye undergoes normal physiological aging

This helps us understand how to communicate with a patient

Ex: 20/20- patient was super symptomatic because she wasn’t contrast sensitive

At the end of the day, we had to educate her on we don’t process vision efficiently
and it is just part of life
o
These changes contribute to a decline in visual function
o
Vision depends on eye structures and on visual pathways/visual cortex
o
The aging process affects all of these
o
Visual world involves many components beyond visual acuity…

Contrast

Spatial frequency

Temporal frequency

Spatial location

Color

Visual field

Glare

Light-dark adaptation
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel
Page 5
-
Great Summary slide. There will be 2ish questions on “what changes in the eye as you age”
-
Hint: Everything gets worse

Eyelids

These get floppier with age

Poor blink reflex

Dehydration of Dermis

Decreased elasticity and vascularity

Atrophy of subcutaneous fat

Orbital fat prolapses to form bulge at inner 1/2 of upper lid
o

Ectropion, entropion, senile ptosis

Increased lid lesion: papillomas, xanthelasma and keratoses

More lid lesions in the elderly  might be something we can refer out

Manage patient’s Dry Eyes and maybe manage with blepharoplasys.
Tear Layer

Important for health and comfort of the eye

These patients may complain of epiphora, burning, FBS, etc.
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel
Page 6

Poor lid structures and poor tear films in the elderly sets them up to be more
prone to eye infections and ulcers which also take longer to treat in these
populations!

Decreased tear production (at the age of 80,
our tear production is ¼ to 1/5 of what we
had as kids!)
o

Lubrication is important!
Decreased corneal sensitivity (may not
present with an abrasion or infection as soon
as they should because they don’t feel it!)


Look and try to treat the dry eye!
Cornea

Thickens and clouds with age

Things are changing in each layer (from the epithelium to the endothelium)

Pumps aren’t as efficient – cornea swells easily

Stroma has decreased transparency
o
Light is being scattered and isn’t reaching the back of the eye as it
should

Refractive index decreases with age affecting transparency by 67% by age of 80
 yellow appearance

Arcus increases with age

Hudson-Stahli lines are the buildup of ferretin in the epithelium

Because the epithelium and endothelium are both changing, we see an
increase in corneal degenerations and dystrophies with age  stippling of
Bowman’s, Crocodile Shagreen

Steepening of horizontal corneal meridian WTR to ATR

Decreased corneal sensitivity


o
Declines most rapidly after the age of 50
o
80 year olds have 1/2 to 2/3 of sensitivity that you do at a younger age
Endothelial  more gutatta as the pumps become less efficient
Conjunctiva

Thinner and yellow with age

Increase in lumps and bumps  pinguecula and ptergiums due to degenerated
collagen fibers
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel
Page 7

Sclera

Dehydrates with age

Yellow appearance due to fat deposition

Lose of elasticity, becomes thinner, denser and more permeable to light

Hyaline plaques seen at the insertion of recti muscles

Because of the thin-ness, some light may diffuse into the globe and degrade
the image on the retina

Between the conj and sclera thinning, light can also enter through the tissue
causing some light scattering

Aqueous Humor/Anterior Chamber

Overall production of aqueous slows down with age—this may make you think
that IOP would decrease, BUT the lens thickens with age (narrows the angle)
and the trabecular meshwork isn’t as efficient at draining the eye (the pressure
actually INCREASES with age)


Trabecular Meshwork

Changes with age cause it to be less effective at draining the eye

Remember the IOP increases with age even though aqueous production slows!

Don’t need to memorize the 7 ways TM changes etc.
Iris/Pupil

Iris is thinner and less pigmented with age
o
Iris atrophies (white flecks!) – lets more light into the eye and
degrades the image at the retina

Sphincter muscle gets stronger than the dilator—we get a pinhole pupil
o
This can cause problems for older patients at night or in dark
atmospheres

Don’t dilate as well!

Atrophy of dilator muscle and increase in rigidity of iris and the iris blood
vessels resulting in senile miosis

Senile miosis results in increased depth of focus which limits spherical
aberration

Pinhole affect during refraction

Fails to dilate in dim illumination to same degree as those of younger patients

Refractions: more challenging because JND is not as easy to determine even if
they are 20/20
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel
Page 8
o
Due to the changes on the eye such as depth of field, depth of focus
etc


It decreases retinal illuminance  can lead to more falling
Ocular Motility

Our EOM’s are not as
effective/coordinated

Our gaze ranges DECREASE—
especially UP GAZE!!! Image on
the right shows the results of the
Chamberlain study: (with age our
ability to rotate our eye upward
decreases)

At our age: 37 degrees of upgaze

In 80s: it will become almost half

Ocular motility and sensory motor
fusion will have an increase in diplopia in older patients
o
Do a better job of doing cover test and fusion vergences etc to make
sure the SRx released will not cause diplopia in elders

Crystalline Lens

CATARACTS  progressive yellowing due to metabolic activity and hydration

Increase in cataracts which degrades the image coming into the eye – cataract
surgery to treat!

Remember the lens thickens with age and increases the IOP

Would expect changes in refractive error as thickness increases, expect myopic
shift in older patients
o
Does not happen because the axial length of the eye decreases with
age
o
Lens has variable index of refraction from center to periphery,
therefore the gradient undergoes a change with age to compensate
for increased thickness
o

 HYPEROPIC SHIFT AND ATR ASTIGMATISM!
Vitreous Humor

When we are young, the vitreous is a firm, jelly-like material

As we get older it thins out and becomes much more liquefied  PVD
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel
Page 9

Increase in floaters that move through the eye at a faster rate
o

More bothersome
Retina  skips a lot of the slides

Loses cells as we get older

Some cells will die; some will become disorganized (this also happens with
photoreceptors)



Lipofusion accumulation

Breaks in Bruch’s leads to non-normal aging changes such as CNVM or AMD

Decrease in the connections from the eye to the brain

Cells change and become less efficient
Optic Nerve

5500 axons lost per year

Total of approximately 1,200,000 nerve fibers in an average optic nerve

By 100, almost half of nerve fibers are lost
Visual Cortex

Image processing becomes less efficient  It takes a long time for patients to
process and understand what they are seeing.  BE SLOW when you are
communicating and examining them

o

Decreased neuron density

Increased glial cell density

Cell loss

neurofibrillary degeneration

dendritic atrophy

neurotransmitter depletion

lipofusin accumulation in striate cortex
Vision Tests

Standard battery of vision tests

Special attention to: contrast, color, visual field, glare, stereopsis
Studies:

First Study: Tested a population to see what the standard of vision is as we age

Tested: Acuity, Contrast, Near Acuity

They took acuities using high and low contrast

On average, in the absence of ocular disease you do expect about 1 line loss of
VA per decade!
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel
Page 10

Second Study: They looked at standardized testing and how to apply it to elderly
patients

Low contrast acuity will be lost the fastest

They found that if they can adjust the tests to allow for a longer response time,
the elderly are very good test takers
o
Poses a scheduling conflict in the real world though. Might be
beneficial for you to have techs that do some of the things and
schedule less patients per hour
o
Visual Acuity

Patients do well until they reach about 65-70 years old –this is when they begin to lose
about 1 line on the VA chart per decade!


Just remember that if you have an elderly patient free of any ocular disease and they
aren’t getting down to 20/20

Loss of visual acuity without ocular disease is hypothesized to be attributed to the rate
of neuronal loss in the brain with age
o
Study: Haegerstrom-Portnoy, et al  won’t put these studies on the test

This is a very popular study due to the large elderly population and the wide variety of
tests they used

The Bailey-Lovie chart has five letters per line

What this study found was that patients lost about 1 line of high contrast per
decade of life (5.5 letters lost/decade)

Low contrast acuity was lost even faster (8.0 letters lost/decade)

Low illumination and low contrast (9.0 letters lost/decade)

10.5 letters lost/decade with low contrast acuity with glare

Remember this won’t be true for EVERY patient! This is just the general trend!
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel
Page 11

Patient’s measureable vision was significantly decreased if the contrast was
decreased, if the illumination was decreased, or if there was increased glare


These relate to real life situations

It is important to communicate these things to family members and caretakers
Contrast Sensitivity

This is VERY important

Always use the Mars test
o

Found 4.6 letters/decade decrease in CS through MARS test
These findings can be indicative of how these patients see in day to day
situations (facial recognition, reading, etc.)

o
Measured low contrast, low illumination near VA with the SKILL card
o
loss of 9 letters/decade with low luminance/low contras
o
loss of 5.5 letters/decade with high contrast/high luminance

In this study, they found that they lost almost TWO lines with low luminance

Why do we lose Contrast Sensitivity?

o
Haegerstrom-Portnoy, et al., cont.
o
Optical (eye)
o
Neurosensory (brain)
Driving can become difficult with age due to the contrast changes
Dr. Morgan: Older OD that writes what it feels like to be an elder patient

Glare Recovery

Time to recover sensitivity after exposure to a bright glare source
o

Sometimes referred to as photostress

Increases significantly with age

Glare discomfort is discomfort or fatigue of the eyes caused by the intensity,
direction and exposure to light

Glare disability is glare that disrupts vision by ‘blinding, veiling or dazzling’ and
results in decrease of visual ability

Aging changes of the eye that reduce recovery time are:
o
Pupillary miosis
o
Reduced retinal illumination
o
Yellowing of lens
o
Light scatter by ocular tissues
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel
Page 12

Median letters lost with glare was about 5 letters/decade

Also found that with 1 minute glare exposure, 25% of oldest group took more
than 3 minutes to recover


Can pose danger coming indoors on bright day  Fall risk
Refractive Changes

Sphere
o
o
increase in hyperopia (ALSO more ATR)

between 50’s-70’s

+0.25 to +0.50 diopter/decade
Reason is unsure

shortening of eye?

Changing index of refraction of ocular structures?

Cataracts can cause myopic shift

Higher levels of anisometropia

Uncontrolled systemic disease cause refractive shift


Diabetes Mellitus
Systemic medications causing refractive shift

diuretics, carbonic anhydrase inhibitors,
sulfonamides, corticosteroids

Astigmatism
o
Increase in ATR astigmatism  steepened in horizontal corneal
meridian
o

Reasons: Eyelid pressure reduces with age
Presbyopia  skipped
o
Loss of eye’s ability to focus on near objects
o
Loss of flexibility of lens capsule and matrix leading to loss of
accommodation

o
Greatest reduction occurs between the ages of 45- 55
o
Reduced to zero diopters around the age of 70 Duane
o
Monocular amplitude of accommodation from the spectacle plane
o
4000 eyes
o
8-72 years old
Nearpoint of Convergence
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel
Page 13

Because we don’t accommodate as well with age, we may have problems
turning our eyes inwards  PRISMS more helpful because VT might be too
challenging


This is another area where older patients may experience more double vision
Stereopsis

Reduced even without any problems/disease

Mainly due to the decrease in visual processing efficacy (cortical problem)

This also has a hand in causing problems with day to day tasks such as driving,
walking, etc.


With age there is a significant decline in stereopsis, reasons may include:
o
different acuity in each eye
o
retinal and pre-retinal changes
o
cortical stereo processing
Studies have also found decreased stereopsis even with maintained foveal
function in each eye

From 65 to 75 years old, the percentage of people without stereo jumped from
5% to 35% according to the Haegerstrom-Portnoy study (again won’t test us on
findings)

Color Vision

Decreased ability to discriminate colors with increasing age

due to light absorption by lens

decrease in short wavelength light transmitted

decreased sensitivity at receptor/postreceptor levels along the visual pathway
o
Three classes of cones: Short-wavelengthsensitive, Mediumwavelength-sensitive and Long-wavelength sensitive
o
Short-wavelength-sensitive is more affected by age related changes
than Medium or Longwavelength sensitive cones 1/29/2016 22
o
Blue, green and violet colors are most affected due to the yellowing of
the crystalline lens

Mimic tritan (blue-yellow) defect
o
Whites look yellow
o
Trouble distinguishing between dark grays and browns
o
Trouble with desatured pink and purple
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel
Page 14

Haegerstrom-Portnoy, et al., found that 1/3 of their subjects over 70 failed the
D15  Subjects had no previous color deficits

Color changes due to cataracts --> Monet paintings changed

Have you ever seen an old lady walking around with Purple-Blue hair?
o
When an old lady is dying someone’s hair and she is trying to bleach it
white, the hair may still look brown to her if she has cataracts—
because of this she will leave the bleach on the hair for an extended
period of time which can cause the hair to turn a purple/blue color

Visual Field

Physiologically there is only a slight change, but there is a huge change in the
attentional

They found that the “useful” field of vision dramatically decreases over our
lifetime
-
Patient symptoms
o
Some of the most common problems with these aging ocular changes include driving, and
locating objects in a complex/busy dynamic field (they would have troubles trying to find their
grandchild at the mall)
o
Remember that physiologically there is hardly any change to the field, but attentionally it gets
dramatically smaller with age

They also have holes or pockets in their visual field that they may decide to ignore/not
pay attention to

Healthy, young people have a visual field of 140 degrees—when they tested an 80-yearold group they were found to have a median visual field of 41 degrees (ATTENTIONALLY
NOT PHYSIOLOGICAL)

Useful Visual Field is where they engage the patient centrally and things are happening
constantly peripherally. Because they are concentrating on something centrally, their
brain does not pay attention to the things happening in the periphery. (we don’t have
one of these at ICO)

VF tested that is not centered right in the middle will have a decrease  patients are
less prone to detecting something coming from the side
o
Remember: light scatter, smaller pupil, less things getting into the eye, less efficient visual
processing
o
Eye Movements

Changes occur in eye movement control and efficiency
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel
Page 15

Fixation maintenance doesn’t show aging change  fixation unaffected

Disparity Vergence Ranges have not been found to change significantly with age

Saccades and pursuits will change

Pursuits
o
increased initiation latency, lower pursuit gain (accuracy), decreased
velocity, increase in frequency of catch-up saccades

Saccades
o
decrease peak velocity (especially with longer saccades), increase
latency of saccade, slight decrease in duration, possible slight decrease
in gain (accuracy)

Less effective at reading—will need more fixations

There aren’t a lot of concrete studies on elderly patients and horizontal/vertical
deviations—there’s only a lot of generalizations

We are unsure if the general trend is to more exo or more eso

It would make sense that elderly patients become more exo because they lose
accommodation

Horizontal deviations

Different studies have different results for distance… increasing exophoria or
esophoria??

Studies agree that there is an increase in exophoria at near with age

some reasons include:

o
decreased accommodative amplitude
o
decreased near point of convergence
o
decrease in accommodative- convergence
Some success show with visual therapy
o


To eliminate asthenopia
Vertical deviations  quicker then horizontal

Most restriction of vertical version movements with age

increase in vertical deviations due to decreased fusional abilities

Prism effective to eliminate diplopia
Vision therapy is effective in this group, but not as effective as in younger patients only
because they don’t have the same potentials as younger patients

o
Prism also helps these patients attain comfort
Brightness Sensitivity
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel


Page 16
Ability to detect and discriminate differences in amount (intensity) of light entering the eye
o
Rods (scotopic)
o
Cones (photopic)
reduction of cone and rod luminance efficiency function-need more light to produce same
visual response
-
Due to normal physiological ocular changes 1/3 of the light that reaches the retina of a 20
year old would fall on the retina of a 60 year old
-
It takes 3x the amount of illumination for a 60 year old individual compared to a 20 year old
to complete the same visual task comfortably

-
o
 Need more light with age
o
Less light makes it onto the retina
Light-dark adaptation
o
Both light-dark and dark-light adaptation times are significantly slowed with age
o
Decrease in both rod and cone adaptation rates
o
Increased time needed to adapt

o
-
20/20 patient may still need a lot of light just to see clearly
More common reason why falls after coming indoors after a sunny day outside occur
Thought to be due to changes in:

Retinal metabolism

Miotic pupils

Decreased central nervous system function
Temporal Processing Critical Flick Frequency
o
Processing/separating visual events that occur in rapid succession
o
Patient symptom
o

Can’t see quick enough

Separate visual events appear ‘smeared’ together

Decreased image processing
Action movies for an elder patient might not effectively stimulate his/her vision as it would a
younger patient
-
Visual Processing Skills  trouble with them
o
Difficulties with:

figure-ground, cluttered scenes, crowding

dynamic visual scenes

visual search
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel
Page 17

visual attention

spatial orientation/interaction

Visual illusions
-
Dr. Matchinski started zooming through this part
-
Figure-Ground Organization
-
o
Ability to distinguish and perceive figures from the surrounding background
o
Decreased ability with age and more affected by irrelevant stimuli
o
Can the patient see the stoplights in the trees, people, traffic lights at an intersection?
Spatial orientation/interaction
-
Ability of vision as it relates to the perception of the relationship of objects using environmental cues
o
Relative size
o
Shadows
o
Highlights
o
Interposition
o
Reduction in binocular depth perception reduces spatial orientation skills
o
It is also thought that different object sizes and spaces are perceived by different neurons, as
we age there is neuronal loss
-
Visual Illusions -> More susceptible to them
-
Summary of consequences of age related vision loss
o
Ask patients what is difficult for them
-
Reduces mobility
-
↓ “Activities of Daily Living”
-
↑ Likelihood of falls and hip fracture(s)
-
Associated with ↑ physical ailments and ↓ appetite
-
Impacts success of restorative programs
-
↓ morale; ↑ depression; ↑ social isolation; ↓ self worth and emotional security
-
Best prism glasses, task lights etc
-
EDUCATE EDUCATE EDUCATE!
EXAM TECHNIQUES AND MODIFICATIONS
o
Exam time best scheduled in midmorning
o
More than one visit may be required
o
Longer exam time may have to be scheduled
o
May have to take short breaks during the exam
o
Encourage patient to bring in material they are experiencing problems with
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel
-
Page 18
Greeting and observation of patient
o
In the waiting room

Decreases patient apprehension

Provides information to visual status

-
-
-
Shaking hands – VA and localization
o
Observe interaction of patient with individuals who may have brought patient to office
o
Observe patient appearance
o
Observe speech pattern
Observe postural abnormalities
o
Head or eye tilt or turn
o
Hats or sunglasses being worn
Observe mobility to exam room
o
Steadiness of gait
o
Note any paralytic movement disorders
o
Note pauses when entering room of different illumination
Establish effective communication
o
Hearing loss is more common in elderly population, loss of ability to hear high frequency noise
o
Up to 30% of people over the age of 65 have hearing loss
o
Increase volume decrease pitch
o
Speak in a deep voice, do not shout
o
Look directly at patients when you speak, so they can also read your lips
o
Speak at normal pace
o
Do not speak directly into patient’s ear
o
Eliminate background noise such as overhead music
o
Use of assistive listening device
o
Encourage family members to accompany patient into exam room, however address the patient,
not the family member
-
Case History
-
May be more complicated and take more time
-
Try to obtain as much information as possible before the appointment via telephone or mail
-
If information in advance is not possible, use forms in the office prior to the examination
-
communication/hearing problems  don’t ignore patient
-
complicated health problems and medications  can be online to help skip that part
o
systemic conditions with ocular complications
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel
-
-
-
Page 19
o
psychiatric illness
o
polypharmacy, side effects and adverse drug interactions
-
Psychosocial factors
-
Increased prevalence of ocular disease
Investigate:
o
Health status
o
Activities of daily living
o
Cognition
o
Mobility
o
Care-giving arrangements
o
Life events
o
Personality
o
Physical environment
o
Ask if they can manage bills, pills, driving, fallen, bright light issues etc
Systemic history  important
o
Diagnosis
o
Onset
o
Management
o
Patient’s understanding of condition and prognosis
o
Effect on vision
o
Effect on lifestyle
Areas of questioning should include  SKIPPED
o
o
Visual demands

transitioning from work to retirement

interests and priorities are changing
Activities of Daily Living

o
activities with visual demands that are essential to personal independence
Areas of visual difficulties

glare, blur, mobility, visual crowding, visual search, ability to adapt to changes in
illumination, near functioning, etc...
-
Sample Questions  SKIPPED
o
What do you do during a typical day?
o
What would you like to do?
o
What is your vision preventing you from performing?
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel
-
Page 20
o
Are you able to manage your own medications? Can you read the labels?
o
Do you read your own mail, write your own checks?
US Health Department Report:  SKIPPED
-
Less than 1/3 of people 85 and older require assistance in activities of daily living
-
Assistance with home management activities such as housework, meal preparation, shopping, etc…
o
16% of 65-74 age group needed help
o
51% of 85 + age group needed help
Short Portable Mental Status Questionaire (SPMSQ)
-
Questions asked to estimate cognitive ability
-
MoCA (montreal cognitive assessment) also works
o
Patients can be good at covering up
Examination:  SKIMMED SUPER FAST
Visual Acuity
-
-
-
Visual acuity charts  SLOWER. Trail frame work better than phoropter
o
Number of optotypes per line
o
Spacing between optotypes and rows of optotypes
o
Configuration of optotypes
o
Contrast of charts
o
Projected vs. printed
Distance Acuity
o
Monocular and Binocular
o
Uncorrected and best-corrected
Near acuity
o
Visual acuity vs. reading acuity
o
Monocular and Binocular
o
Uncorrected and best-corrected
Refraction
-
Objective measurements
o
Keratometry
o
Retinoscopy

Radical retinoscopy

Off-axis retinosocpy
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel
Page 21

Changing sleeve position

Plane mirror (sleeve down)

Concave mirror (sleeve up)
o
Large lens changes
o
Autorefraction

More difficult because of pinhole pupil w/ age
Retinoscopy
-
More difficult due to miosis, media opacities
-
Autorefraction, retinoscopy (radical/off axis) and keratometry
Subjective Measurements
-
-
Trial Frame
o
More habitual situation than phoropter
o
Allows Doctor to observe patient’s head and eye turns
o
Allows for a comparison of lenses more quickly and easily
o
Vertex distance more constant and closer to spectacle plane
o
Allows doctor to incorporate other lenses to demonstrate to patient (tint, A/R, microscope, etc…)
Subjective
o
JND may be larger due to decrease sensitivity to blur, ocular changes and increased depth of
focus
o
use bigger lens steps +or - 0.50, 0.75 or 1.00
o
go slower, repeat lens choices
o
Use of trial frame, trial lens clips
Entrance Testing
-
Color vision
-
Ocular alignment
-
Stereopsis
-
Accommodation
EOMs
-
Watch eyes and eyelids move
SOP 367 — Vision Rehabilitation
Date: 2/9/17 1st hour
Note taker: Jay Patel
Binocularity
-
-
Advantages
o
Larger field of view
o
Greater depth of focus
o
Improved acuity
o
sychological factor
Tests
o
Cover Test – important because as age, decrease convergence = can become diplopic
o
Worth 4-Dot
o
Stereo Fly, Randot E
o
Red Maddox Rod
o
Vertical Prism
Ocular health assessment
-
Pupils
-
Extraocular muscles
-
External examination
-
Biomicroscopy
-
Tonometry
-
Central and peripheral fundus examination
Supplemental testing
-
Contrast sensitivity
-
Glare testing
-
Potential Acuity Meter (PAM)
-
Laser Interefrometry
-
Brightness acuity test (BAT)
-
Electrodiagnostic testing
-
B-Scan ultrasonography
Visual field testing
-
Amsler
-
Confrontation
-
Tangent
Page 22
SOP 367 — Vision Rehabilitation
Note taker: Jay Patel
-
Goldmann
-
Automated
Vision tests
-
Standard battery of vision tests
-
Special attention to
o
contrast sensitivity
o
color vision
o
Visual field
o
Glare sensitivity/recovery
o
Stereopsis
Quality of life
-
Education what’s normal vs not normal
-
Prevention (of preventable vision loss)
-
Maintenance
-
Treatment/Management
-
Rehabilitation
-
Date: 2/9/17 1st hour
Page 23