The College of Optometrists

Hi all!

My current routine on a presbyope takes about 40-50mins and it consists of the following:

History and Symptoms Unaided distance vision with cover test Unaided near vision with cover test pd motility pupil reactions ophthalmoscopy ret subjective (monocular refraction) distance cover test near add range near cover test convergence

I would really appreciate it if someone could give some hints/tips on how to speed up as my supervisior would like me to run 30-40min clinics soon. Many thanks

Hi irukhsana

you're doing good. I tend t odo the same as you - but do monoc push ups to get the near add range. Its as a final check on distance balancing.

To speed it up :

Try to enter into your routine more and stick to it. Having a routine will help you not to miss anything out and also keep momentum.

Try to write the notes as you go along - I use a clip board and write my notes while doing the subjective - while hey are deciding if its one or two, etc.

Area's where speed up is easiest is

Subjective : don't duplicate - if they say its blurry - then never try that lens again!

They can decide the outcome ofa lens if they are looking at a line they just CAN'T read. -It increases sensitivity (and so is easier).

If you are getting confused - drop that eye - and go to the other. - or - drop that technique and try another. (You can always come back to it again).

Check your questions are clear and the px knows what to do or say.

Know when to stop subjective : don't fiddle back and forwards on 0.25's - save that for the very end. If you do monoc near push ups - then they should give the same result - if one eye pushes up closer to the face - try +0.25 to the other eye and repeat distance balance.

Ret:

Practice makes perfect here - but make sure the room is dark enough and take time to get the trial frame set properly. Going from big powers to smaller powers is easier than creeping up in power.

Get central to them - block one of their eyes with your head.

If you can't decide - or feel 'lost' - double the last lens - and try that : it should give reversal.

You can see cataract best on ret : so if you see it - plan slit lamp to have a better look - and don't forget to chec kanterior angles then as well.

Ophthalmoscopy.

Be very methodical,

use your green filter alot!!

Keep to smaller stops will keep the pupil open - as will a very dark room.

Explain what you are seeing as you go: if you see any pathology - explain it as you go - this will speed up your 'judgement' at the end. But at this stage, be gentle (you have not got all your facts - and you may need to modify your care plan.

Eg: "hmm, you may have a little cataract developing in that eye. Later I will have a better look and we can then chat about it."

-You have prepared them, and not shocked them.

At the end you can then carry on without sounding too much.

Practice saying/ talking one thing - while writing another (as you write your notes). For me, it was the notes that took my time, so I worked out that if I could do the eye test 'one handed'

I could write with the other and so speed myself up. Now, with yonks of practice, the notes are usually nearly finished just before the final summing up and dispensing / wearing advice.

I never talk to the patients very much - but I try to give them space : my job is to get the eye test done to time and without stress, so its all carefully planned!

Search this site for other tips, please - I wrote things a few months ago on speed up techniques.

- hope it helps = steve

Hi Stephen

Many thanks for your reply, the tips are a great help! I will also search the site for other speed up techniques.

Which book would you recommend for reading up on the mononc near push up technique?

Many thanks again.

Hi again,

you can look it up in Pickwell's Binocular Vision Anomalies. Page 24ish depending on edition you have.

Basically, with a presbyope you are simply finding the near point with their reading add in place. (Use a card with small print, - you will find it gets clear and then just blurs again - as you bring it closer = that's the near point)

Do it for each eye seperately. That way you can be sure of the binocular balancing.

Good luck to you - just try to be methodical and come back to anything that is not working out properly.

Over the years, my subjective technique has got more simple. I tried hard to reduce the number of lens changes - and found I could reduce these changes right down if I always thought ahead. That made things quicker for me.

Equally, I do tend to be directive on history. I don't let them ramble. I am looking for pertinant history : so I may not ask a kid about family history of degenerative ocular diseases, but I will ask about history of squints etc.

- I will help more if I can : always ask. stven

Hi

Thanks for your reply.

I will read up on it and let you know if I need any more help.

Kind Regards