Cae gaye" We a ae Ate) ae David B ElliCONTENTS Preface ix Acknowledgements xi Tables and boxes xiti Figures xv 1. Introduction to the primary eye care examination 1 What constitutes a primary eye care examination? 1 How to use the research literature to inform you about the usefulness of clinical tests 11 Obtaining normal data 16 Recording 16 Recording, diagnoses and treatment suggestions 17 Referral letters and reports 18 Testorder 21 The case history 21 2 Assessment of visual function 29 Case history 29 Distance visual acuity 29 Near visual acuity (near vision adequacy) 37 Colour vision testing 41 ‘Central visual field screening 48 Central visual field analysis 57 Peripheral visual field screening 63 Macular testing 64 Photostress recovery time 67 Esterman test for visual field screening 68 ‘Confrontation field testing 70 Potential vision assessment 73 Contrast sensitivity 75 Disability glare 77 3 Assessment of binocular vision 81 Classification of ocular deviations 81 Case history 84 Bahan dengBUTTERWORTH-HEINEMANN An imprint of Elsevier Limited © 1997, Elsevier Limited. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, ‘without either the prior permission of the publishers or a licence permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP. Permissions may be sought directly trom Elsevier's Health Sciences Rights Department in Philadelphia, USA: phone: (+1) 215 238 7869, fax: (+1) 215 238 2239, ‘e-mail; healthpermissions@elsevier.com. You may also complate your request on-line via the Elsevier homepage (http2/www.elsevier.com), by selecting ‘Customer Support’ and then “Obtaining Permissions’. First edition 1997 Second edition 2003. Reprinted 2004, 2005 ISBN 0 7506 5527 5 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A.catalog record for this book is. available from the Library of Congress Notice Medical knowledge is constantly changing. Standard safety precautions. must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check tha most current product information provided by the manufacturer of each drug to be administered to verity the recommended dose, the method and duration of administration and contraindications. It is the responsibility of the practitioner, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual Patient. Neither the Publisher nor the authors assume any liability for any injury and/or damage to parsons of property arising from this publication. The Publisher ‘Where illustrations have been borrowed trom other sources, every effort has been made to contact the copyright owners to get their permission. However, should any copyright owners ‘come forward and claim that permission was not granted far the use of their material, we will arrange for acknowledgement ta be made. your source for books, journals and multimedia Inthe health sciences: www.elsevierhealth.com aT Working together to grow libraries in developing countries wnnecheviercom | wwwbooksidorg | wews Printed in ChinaPREFACE This manual is a guideline to clinical procedures in primary eye care, and was written primarily as a teaching aid for undergraduate optometry students and for practitioners wishing to review their clinical practice. Although it is not intended to be inclusive of all techniques that can be performed in pri- mary eye care examinations, most of the most popular procedures are covered. For the majority of functions or states that can be tested in an eye examin ation, some background information is provided, then a recommended test is indicated and described in detail. For each recommended test, the following aspects are discussed: the rationale behind choosing the test recommended; the measurement procedure; how to record the results of the test; how to interpret the results; a list of errors most commonly made by students (with an attempt to put the most common first); key references and an indication of which books or book chapters provide useful further reading, References from dif- ferent sections have been combined where appropriate (e.g. for central visual field screening and analysis). References have been kept to a minimum, with the most recently published references being chosen when possible — these usually cite earlier published reports. The manual is divided into five chapters. In summary, Chapter 1 is an intro- ductory chapter. It includes a review of how clinical tests and procedures are assessed in the research literature and how such reports should be critiqued. In addition, the chapter includes a discussion of what constitutes an opto- metric examination and reviews how screening tests are used in the primary eye care exam. A discussion of the case history and how it should be per- formed complete the chapter. Chapters 2,3, 4 and 5 discuss the assessments of functional vision, binocular vision, refractive correction and ocular health respectively. The second edition differs from the first in several ways: @ The recommended tests and procedures are based explicitly on evidence from the research literature whenever possible, rather than just clinical experience. @ It includes many procedures not covered in the first edition, including those procedures particularly associated with the use of a phoropter. @ Significantly more diagrams and photographs have been included. @ The format of the chapters has altered from one where the procedures were given in approximately the order they appear in an eye examination (a ‘database’ examination approach), to chapters based on the assessment of systems.TABLES AND BOXES Table 1.1 Table 1.2 Table 1.3 Box 1.1 Box 1.2 Box 1.3 Box 1.4 Table 2.1 Table 2.2 Table 2.3 Table 2.4 Table 2.5 Table 3.1 Table 3.2 Table 3.3 Table 3.4 Table 3.5 Table 3.6 Table 3.7 Table 4.1 Table 4.2 Table 4.3 Table 4.4 Classification of tests / procedures into one of four clinical oculovisual systems 2 Possible outcomes of a screening test 7 Two examples of problem-plan lists 18 Example of a referral letter 20 Example of a report 20 Approximate order of testing for performing various procedures in a routine optometric examination of an adult patient 21 Abbreviations that could be used during the recording of a case history 26 Distance visual acuity conversion table 33 Normal age-matched visual acuity data for various notations 34 Near visual acuity conversion table 38 The Ishihara 24-plates edition scoring sheet 46 The SPP-2 scoring sheet 47 Information required to classify comitant heterotropia 83 Examples of recordings from the cover test 91 Examples of recordings of the near point of convergence 97 Signs and symptoms that can differentiate between an cold and new ocular motor palsy 99 Approximate range of normal fusional reserves 129 Monocular expected accommodation levels as a function ofage 140 Park’s three-step method for identifying the paretic muscle when the deviation is vertical 148 Estimated rotation of the cylinder axis for different cylinder powers when using the Jackson cross-cylinder 177 An indication of the changes made to the clearer eye and the interocular difference when either +0.25DS or -0.25DS is used in the Humphriss immediate contrast technique 184 Tentative near additions estimates asa function of age 190 Calculations of the range of clear vision with different working distances and subjective measurements of amplitudes of accommodation 196Contents Binocular visual acuity 85 Binocular status in the primary position 85 Convergence ability 95 Comitance of the ocular deviation 99 Pursuiteye movements 104 Assessment of sensory status 106. Stereoacuity 109 Subjective assessment of heterophoria 115 Accommodative convergence /accommodation (AC/A) ratio 123 Fusional vergence reserves 126 Associated heterophoria or aligning prism 131 Fixation disparity curves 134 Assessment of accommodative status (pre-presbyopes) 137 Amplitude of accommodation 138 Accommodative lag or lead 141 Accommodative facility 142 Degree of incomitancy 145: Assessment of microtropia 150 Saccadic eye movements 151 Determination of the refractive correction 155 Spectacle lens identification 155 Case history 159 Visual acuity 159 Phoropter or trial frame? 160 Measurement of interpupillary distance 162 Objective measurement of refractive error 165 Subjective refraction 172 Monocular refraction 173 Binocular balance of accommodation 181 Binocular refraction 185 Cyeloplegic refraction 188 Near addition determination 190 Prescribing 197 Counselling 202 Corneal topography 203 Ocular health assessment 211 Case history 211 Visual function 211