Complete Patient Work Up – Junior TechnicianAn outline of the detailed examinations, scans, and tests that are to be completed by the Jervey Eye Group intern or junior technician prior to the doctor’s visitation.

Outline of the Procedures• Preparation of patients’ files

and past appointments• Collection of patient history• Completion necessary scans• EPIC Refractions• OCT• SDP

• Chief complaint• Visual acuity• Manifest refraction• Confirmation of glasses

prescription• Examination of pupils

• Measuring intraocular pressure• Applanation tonometry

• Check visual fields• Check ocular motility• Complete external

examination• Apply dilation drops• Slit lap examination• Examine fundus• Indirect method through 90D

• Justify assessments• Scribe

Preparation of Patient Files• Prior to each examination, the

patient’s file is retrieved from its designated, alphabetized section.

• The folder contains information about the patient’s past medical history, past appointments, past scans, and chronic symptoms/diseases of the eyes.

• It is the technician’s responsibility to transfer pertinent material and information from the previous documentation on to a new file designated for that day’s appointment

Sample work up sheet

utilized by Jervey Eye

Group

Top Half of the Work Up SheetThe more prominent steps of the examination are labeled above

Reviewing Patient History• Prior to examination, the technician must review the

patient’s medical history with them.• The history must be updated at least every year.• This includes reviewing family history, listing current

medications, noting any hospitalizations/surgeries, and their past eye history.

• The technician must also check if the patient’s mental status is in good condition.

• Additionally, if the patient is new to Jervey Eye Group, or it is required as such, the technician will complete an EPIC scan prior to examination. • The EPIC scan gives a rough estimate of the dimensions of the eye,

the curvature of the lens, and characteristics of the cornea

Chief Complaint & Vision Check

• CC/HPI• In this section, the technician will write any previously noted

problems with the eye and take down the patients’ main reason for the visit

• Additionally, it is the technicians responsibility to ask what the problem is, how long it has bothered the patient, the severity of the problem, what the problem is causing, and why this might be a problem?

• V• In this section, you will be testing the patient’s visual acuity (VA):

the sharpness of vision, measured by the ability to discern letters or numbers at a given distance according to a fixed standard.• V(s) – the patient’s visual acuity without glasses of contact lenses• V(c) – the patient’s visual acuity with glasses or contact lenses

Vision Check

• The technician will ask the patient to take the guard and hold it over one eye• On the work up sheet, the VA for the right eye (OD) is written above

the VA of the left eye (OD)• Based on the line that the patient can clearly read in its entirety,

that distance will be recorded for each eye

Reading Prescriptions• W• This portion of the work up sheet is where the technician will write out

the prescription for the patient’s glasses (as needed)• The prescription is read using a machine that is adjusted using dials until

the sphere, cylinder, and axis are perfectly aligned. These numbers are written in this format: [+/-] sphere # [+/-] cylinder # x axis #• Prism is read by the optical shop only if necessary and then “Add” is

determined by the physician.

Refraction• Refraction - Manifest• A manifest refraction is the manual way of determining the best

suited lenses for a patient’s eyes• The technician will place the phoropter in front of the patient and

place a block in front of one eye • The same will later be repeated for the other eye

• The technician will single out a line mirrored on the wall. • Then, the tech will adjust the sphere on the phoropter, giving the

patient two different options; asking them to pick which one they like better• The tech will move their adjustment of the sphere in the direction of

the favored option. This will be continued until the patient sees no notable difference between the options.

• Next, the tech moves on to the adjustment of the cylinder, and carries this out in the exact same manner

Refraction• Lastly, the tech moves on to the

axis• The cross-cylinder is placed in front

of the eye. The tech will flip the cross-cylinder lens and adjust to axis based on the chosen option.

• The axis is turned in the direction of the colored dots

• This is repeat until there is no noticeable difference

• The manifest refraction is written in the same format as a prescription for glasses.

• An important point that must be emphasized is that the patient must not analyze the options with too much depth. They should answer as soon as possible.• “If you think during the test, then you

are going to get glasses that you will have to think in” – Dr. Myers

Excerpt of the Work Up Sheet (cont.)The more prominent steps of the examination are labeled above

PUPILS• In this section, the technician

dims the light and has the patient focus on an object straight ahead.

• The tech shines a light briefly in to the patient’s eyes to see the reaction of the pupil• Under normal circumstances, the

pupil will constrict once the light hits it

• The tech will write down the change in the pupil’s size

• If the pupil enlarges, or only one constricts, the patient likely has an afferent pupillary defect (APD) • This could be due to damage to the

nervous/muscular tissue of the eye

Measuring Intraocular Pressure• TA - Applanation Tonometry:

Goldman• The first step in this process

involves the tech applying a fluorescein-anesthetic drop into the eye(s) that the pressure is to be measured in.• It is important to warn patients that

there will be a yellow hue over their eye and in their vision, but it will fade within minutes.

• The tech will adjust the patient so that he/she can comfortably place his/her forehead and chin in the slit lamp’s holsters.

Measuring Intraocular Pressure• TA - Applanation Tonometry: Goldman• The tech will adjust the piece, the light and the filter so that a large range of blue

light is cast on the tip of the tonometer.• Instructing the patient to open both eyes wide (tech may lift lids as needed), the

tech will move the slit lamp towards one of the eyes and gently rest the tonometer on the center of the cornea

• Simultaneously looking through the slit lamp, the tech will adjust the calibrated dial of the tonometer until the two fluorescent semi-circles seen through the lenses form a horizontal “S” shape• The number that the dial is adjusted to will be the intraocular pressure (mmHg)

Measuring Intraocular Pressure• TA - Applanation Tonometry: Perkins• The Perkins method determines

intraocular pressure in a different process.• Different process are performed based

on variables including medication, sensitivity and characteristics of the eyes

• For this procedure, a hand-held tonometer is used to collect the data.• The tech applies an anesthetic drop in

the desired eye.• Zeroes out the device• And in the same manner, brings the tip

of the tonometer to gently touch the cornea of the eye. It is held there until the device displays the pressure.

Motility• For this portion of the exam, the

tech has the patients keep their head facing forward, and instructs them to follow the light with just their eyes.

• The light is moved in the shape of a box and then across from corner to corner in front of the patient.• If there is no noticeable strain or

inability, all boxes are checked• If the patient is unable to follow the

light in a certain direction, this could be caused by damage to muscle tissue.

Additional Motility Tests:• If the tech notices that the patient is constantly adjust his/her eyes, it is the tech’s responsibility to

check for things like diplopia or confusion• This is done by having the patient focus on a single letter on the mirrored wall. The tech will

place a hand in front of one eye and move over to the other, back and forth.• If the eyes move to refocus, the direction is noted and the diagnosis is written in this section.

Visual Fields• VF• For this portion of the

examination, the tech is determining if there is any defect to the patient’s peripheral vision.

• Asking the patients to look straight ahead while covering one of their eyes, the tech will hold up numbers in the four corners of the patients’ peripheral vision• It is advised that the tech hold up

either a 1, 2 or 5 for the sake of clarity.

• If all four numbers are correctly read, the exam sheet is marked “Full OU”• Inability to correctly call the

number presented will be noted on the sheet by drawing the eyes and shading in the quadrant that the number was missed

External Examination• EXTERNAL• For this portion of the examination, the tech will comfortably place

the patient in the holsters of the slit lamp and use varying filters and intensities of light to observe any abnormalities in exterior portions of the eye.• If there is something abnormal about these parts of the eye, the box is

circled and a description is place beside• Otherwise, all boxes would be checked

Slit lamp beam shot across eye

Source – OcuQuest

Bottom Half of the Work Up SheetThe more prominent steps of the examination are labeled above

Slit Lamp Examination • SLE• Similar to the external

examination, the tech will bring the slit lamp up to the patient and utilize different powers, filters and ranges of light to analyze more characteristics of the eyes

• In this sections, commonly observed abnormalities include some of the following:• Scratches on the cornea• Thick lenses (cataracts)• Defect in the iris• Tear film dysfunction

• Any additional notes will be specified under the eye that it pertains to

Slit Lamp Examination

A variety of different defects seen through the slit lamp. Source linked to

picture

Fundus Examination• FUNDUS• During this portion of the examination, the tech will dilate the

patient’s eyes, as needed.• There are important requirements and restrictions with regards to

dilation that all techs must be aware of. • The tech must be conscious of the patient’s history, medications, and

diagnoses prior to dilating

Effects of dilation, source

linked in picture

Fundus Examination• Examination with 10D Lens• Combining the 10D lens with

the lights and the magnification of the slit lamp, the examiner will be able to get a more detailed look at the optic nerve within the eye.

• The lens’s distance is adjusted to create clear images.

• The purpose of this examination is to observe the cup-disc ratio of the optic nerve

Examination with 10D LensThe cup [blue, inner circle] is measured in comparison to the disc [green, outer circle]

The normal ratio is 0.3

Fundus Examination• Examination with 90D Lens• Using the light and

magnification of the headlamp in combination with the 90D lens, the examiner will be able to explore more areas of the retina

• The lens is held above the patient’s eye and creates an inverted, opposite image of the interior of the eye

• The patient will be told to look in different directions• This allows the tech to observe

the components of the retina more in depth

Mechanism of the 90D lens with the headlamp

Refracted image of the retina in the lens

Scribe: Assessment & Plan• Following the complete work up of the patient, the tech also

has the responsibility of serving as a scribe for the specialist upon entering the room.

• These responsibilities include writing any additional notes that the physician deems necessary. Based on the context of the observation, it is the tech’s job to correctly write this description in the correct area of the exam sheet.

• For each assessment that is made in the examination and listed at the bottom of the exam sheet, the tech must ensure that there is some comment written next to it.

• Regarding the plan, the tech must mare certain that each assessment is addressed in this section.• Tasks following the completion of the visit include writing

prescriptions, completing scans, validating ICD-10-CM codes, and double checking for missed sign-offs or dictations.

Complete ScansOCT : Optical Coherence Tomography

• This diagnostic technique employs light waves through the anatomy of the eye to achieve high resolution pictures of the structural layers located in the back of the eye.

• Physicians analyze these images to determine if there is an underlying determinant that is affecting a patient’s vision

SDP: Stereo Disc Photos

• Stereo disc photography enhances the evaluation of the fundus examination.

• This photography allows for a more in depth analysis of the optic nerve.

• The technique used at Jervey involves taking two pictures from different angles and using a stereoscope viewer to superimpose the images, giving it a 3D effect

Jervey Eye group uses a machine that takes both OCT’s and SDP’s when the

system preferences are reset

Standard OCT Data Layout

Standard images printed from SDP