Interpreting Regular and Low Vision Eye Reports BJ LeJeune, CVRT, CRC Mississippi State University...

Interpreting Regular and Low Vision Eye Reports

BJ LeJeune, CVRT, CRC

Mississippi State University

November 1, 2012

TACE Center: Region IV, a project of the Burton Blatt Institute.Funded by RSA Grant # H264A080021. © 2012

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Resources that Help

• Dictionary of Eye Terminology

www.eyeglossary.net

• Riordan P. & Whitcher, J.P. (2008).Vaughn & Asbury’s General Ophthalmology

http://www.eyeglossary.net/


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Two Types of Eye Exams

Low Vision ExamRegular Eye Exam


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The goal of a regular eye exam

• 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


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What constitutes a “regular” eye exam?

SOAP format

• S = subjective

• O = objective

• A = assessment

• P = plan


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Subjective

• Patient History “What’s going on?” “Where is problem?” – (Which eye?) “When did it start?” “Why?” – (Did something cause problem?) Modifiers

Severity?, How often?, Does anything help?


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Subjective (cont.)

Medical History – Health history Meds - Rx, OTC, vitamins/supplements

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


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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

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


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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) relative afferent pupillary defect (RAPD)

• 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)


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Objective (cont.)

• Eye alignment Tropia = constant eye turn Phoria = intermittent eye turn Eso =in, Exo = out

• 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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Objective (cont.)

• Perimetry – measurement of the visual fields – Patient must be able to fix on an object

• Automated Fields (Humphrey, Dicon, Octopus, etc.) Static perimetry Gives detailed view of loss Can be used for central or peripheral loss

• Manual Fields (Goldmann) Kinetic (moving) Evaluates the entire visual field


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Humphrey Visual Field Test


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Results of Field tests


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Amslar Grid

Objective Continued• Refraction

Manifest = traditional Cycloplegic = dilated

• Jaegar Near Vision chart

• Intraocular pressures (IOP) or tonometry Combined with dilated fundus exam to test for

glaucoma Normal pressures 14-20


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Objective (cont.)

• SLE = Slit Lamp Exam (Biomicroscopy) Examination of external structures of eye Lids/lashes, conjunctiva, cornea, anterior chamber,

iris. Lens


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Slit Lamp


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Dilated Fundus Exam

• DFE =Dilated Fundus Exam -internal eye exam• C/D = cup to disc ratio of optic nerve• V V = blood vessels• Vitreous• Periphery


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Dilated Fundus Exam


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Fundus View of Diseased Retina


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Jaegar Near Vision Test


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Intra Ocular Pressure

• IOP 10-21 normal

• Glaucoma is now diagnosed by changes in the disk to ratio, not simply intra-ocular pressure readings


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The Numbers

• IOP = intraocular pressure – measured by tonometry – applanation, non-contact (“air puff”), old style = Schiotz Expressed in mmHg (millimeters of mercury – just like

a barometer) Glaucoma – pressure in the eye too high for the eye

to handle. Normal range = 10 – 21 mmHg. Can have normal pressure and still have glaucoma (GLC). Can have higher than normal pressures and NOT have glaucoma.


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Assessment

• Also called Impression What the doctor thinks is going on

Examples = AMD (macular degeneration), GLC (glaucoma), BDR (non-proliferative or background diabetic retinopathy), PDR (proliferative diabetic retinopathy), Cataracts (NS = nuclear sclerosis), Myopia (near-sighted), Hyperopia (far-sighted), Presbyopia (you need bifocals)


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If there is Eye Condition, it is noted…

• Most common abbreviations: Age-related Macular Degeneration ARMD or AMD Retinitis Pigmentosa – RP Retinopathy of Prematurity – ROP Background Diabetic Retinopathy – BDR Proliferative Diabetic Retinopathy - PDR Cataracts – lens removed (aphakia) Leber’s Congenital Amaurosis - LCA


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Plan

• How is patient to be treated Medical management

Drug therapy Surgery Observation

Optical management Glasses or contacts

Referral – need to be sure they know about Rehabilitation Services and Low Vision services


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Low Vision Evaluation


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The goal of a Low Vision Evaluation

• To confirm findings of eye report

• To maximize functional vision through low vision aids, therapies, environmental modifications and patient strategies


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Low Vision Evaluation - 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?


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• Similarities to standard exam Most often will check the same areas, but with some

differences.• 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 Evaluation History (cont.)

• Include social info - living arrangements, transportation issues (Are they still driving?!?), smoking, alcohol/drug use

• VA – most often use different charts Distance - Feinbloom #, EDTRS, Lea, etc.

Why? – gradations between lines, test distances High contrast vs. low contrast


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Feinbloom chart


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Common Near Vision

• Bailey–Lovie

• Hoeft

• Mnread


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Low Vision Evaluation – 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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• Automated fields – sometimes less effective – difficulties with fixation, etc. Nidek MP-1 – maps central scotomas Scanning laser ophthalmoscope

• Pupils/Eye movements = same but can give info on undetected brain issues (stroke, etc.)

• Eye health eval = seldom dilate – creates artificial VA problems


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Bi-Optic Driving Assessment


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Bioptic Driving

• Check fields

• Ability to quickly find and track

• Ability to anticipate

• Accuracy of interpretation (VA)

• Light issues

• Eye Dominance

• Contrast sensitivity

• Motivation and Enthusiasm


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Low Vision Aid Evaluation

• Start with what they want most 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.


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Helpful Hint

• If you have difficulty seeing in

different situations, bring

samples.


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Low Vision Evaluation – 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


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Causes of Low Vision Aid Abandonment

• Inability to use aid correctly

• Wrong Aid for situation

• Poor lighting

• Aid too strong or not strong enough


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Reading Reports

• Who is it from? Primary eye care provider (ECP = OD/MD) Low Vision Specialist (OD/MD, OT/CLVT/CVRT) Interagency/Intra-agency Neurologist or Neuro-Optometrist/Ophthalmologist

(Remember providers have their own “Lingo”)


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Reports – 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”


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Regular 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,


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Regular Exam Letter Example (cont.)Following is a summary of XX’s exam:Best Corrected Visual acuities: OD 20/200, OS 20/80Pupils: PERRLA, (-) APDEOM: Smooth and FullVisual Fields: Full to Finger CountingIOP’s: OD 18mmHG, OS 17mmHgBiomicroscopy: Nuclear cataracts – OD & OS, otherwise unremarkableDFE: Macular drusen and RPE changes, otherwise unremarkableDiagnosis: Age-related Macular Degeneration - OUMy 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


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Reports – 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


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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:


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LV Letter Example 2 (cont. 2)

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 Example (cont. 3)

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 magnifer 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.

RegardsXXXX, OD


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One Other Type of Assessment: Functional Vision Assessment

• Field based – home, school, work

• Submitted by a LVT, TVI, VRT, O&M or CRC

• Friends and Family can assist with observations

• Variety of factors beyond just eyes – fatigue, environmental cues, experiences, glare, contrast, etc.


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What do those Numbers Mean?

• Visual acuity 20/XX

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.)


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Legal Blindness – Social Security 1934

• 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 !!!

• YOU CANNOT BE LEGALLY BLIND IF YOU VISION IS CORRECTED BY GLASSES OR CONTACTS TO BETTER THAN 20/200.


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Eccentric viewing

• Eccentric viewing forces the use of alternate areas of retina with lower resolution that are often located outside of the affected foveal/macular area.


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Preferred Retinal Locus


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Refraction


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Filters (Sunglasses)


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The Numbers

• Magnification D (diopters) to X (magnification) =D/4

(or in Europe D/4 + 1) 12 D = 3X (European = 4 X)


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Results should be functional and informed


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Comments & Questions


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Thank You


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Contact Information

BJ LeJeune, CVRT, CRCP. O. Box 6189Mississippi State, MS 39762(662) [email protected]

Special thanks to Dr. Garry M. Griswold, Low Vision Clinician

mailto:[email protected]


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Education CreditsCRCC Credit - (1.5)Approved by Commission on Rehabilitation Counselor

Certification (CRCC) • By November 11, 2012, participants must score 80%

or better on a online Post Test and submit an online CRCC Request Form via the MyTACE Portal.

My TACE Portal: TACEsoutheast.org/myportal


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Southeast TACE Region IV

Toll-free: (866) 518-7750 [voice/tty]

Fax: (404) 541-9002

Web: TACEsoutheast.org

My TACE Portal: TACEsoutheast.org/myportal

Email: [email protected]


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Disclaimer

This presentation was developed by the Southeast TACE Center: Region IV ©2012 with funds from the U.S. Department of Education, Rehabilitation Services Administration (RSA) under the priority of Technical Assistance and Continuing Education Projects (TACE) – Grant #H264A080021. However, the contents of this presentation do not necessarily represent the policy of the RSA and you should not assume endorsement by the Federal Government [34 CFR 75.620 (b)].

Interpreting Regular and Low Vision Eye Reports BJ LeJeune, CVRT, CRC Mississippi State University...

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