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    V551#9 prac#2review2010 [autosaved] V551#9 prac#2review2010 [autosaved] Presentation Transcript

    • V551 Practical Review Richard E. Meetz, OD, MS 2010
    • The Practical: Patients
    • The Patients
      • What to expect?
        • The AIs will NOT be sitting as your patients
          • Will be grading as outside observer with minimum interaction with you
        • Patients will be 2 nd and 3 rd years
          • Will be myopes of varying degrees
            • Range -0.50 to -9.00
          • All will have cylinder to some degree,
            • May only see on ret and patient may run you or kick it all out
          • Good VAs & No suppression
    • The Patients
      • What to expect?
        • Scenarios
          • If the patient’s Rx is under -3.00
            • You will be told they have lost their glasses
            • You will only be able to take unaided VAs
          • If the patient’s Rx is over -3.00
            • You will be told they have lost their current glasses and are wearing a old pair of -#.## power
            • You will take the aided acuities
              • May also take take unaided VAs if you like
          • The patients will give you the VA correlating to the approx. error they are portraying
    • Timing
      • Set up & VAs?
      • Ks
      • Ret
      • Refraction
      • A&P
      • Auxiliary tests
    • Timing
      • Set up & VAs?
        • Not timed for points but will be observed and scored for efficiency
      • Ks
        • Same time as the 1 st practical
        • Starts with cleaning if not done as part set-up or focusing the eye piece
        • Stops after you have recorded
        • Predicting the cylinder on “set-up” time
    • Timing
      • Ret
        • Starts with the Fog step
          • If fogging is not needed MUST state to grader
        • Will be paused for the VA check
          • If 20/40 time will hold as you do the quarter and axis rock
          • If 2 nd ret is needed, time is not reset but continues
          • if 2 nd ret is indicated it must be done
            • Can not skip to R-G
            • But only need be done on the eye >20/30
          • If 2 nd ret >20/30 no 3 rd try, record & go to aux Sph ck
    • Timing
      • Ret time points
        • Ret time ends with recording the findings & VA
        • Notice 2x points at 1 st cut-off: 4min
          • Gives you two min / eye
          • The time now matters on a real patient!
        • At 10 min penalized -1 / min over!
        • No pause between recording the ret and the start of the refraction time
          • Only long enough to record your time and re-set the stop watch
    • Timing
      • Refraction time
        • Starts with the Fogging step
        • Refraction time ends with recording the BVA findings & the VAs
        • Will be given extra time for a difficult patient
    • Timing
      • A&P
        • Not timed
          • But they are NOT going to give you all day
      • Auxiliary tests
        • Not timed for points but will be observed and scored for efficiency
      • Total time should be < 45 min each
        • Wait time < 1 hour
    • Trouble Shooting the Practical: What do I do when things go wrong?
    • Trouble Shooting the Practical: What do I do when things go wrong?
      • Patient’s vision is >20/200! Do I PinHole?
      • - No they are all refractive cases
      • Do I need to take both distance and near VAs!
      • - Yes, std testing
      • - The near can tell you if a sig or large cylinder is present
      • - 20/80 DVA & 20/15 NVA = little to no cyl
      • - 20/80 DVA & 20/25 NVA = sig cyl
    • Trouble Shooting the Practical: What do I do when things go wrong?
      • Can’t focus the Keratometer!
      • - Check the eyepiece
      • - Check the headrest
      • Can’t find the meridians!
      • - Check the focus?
      • - Place the mires tip to tip? Try slightly over lapped.
      • - Suppressing an eye? Try switching to dominate.
      • - Check the powers are they the same or close?
    • Trouble Shooting the Practical: What do I do when things go wrong?
      • Can’t see the ret reflex!
      • - Is patient centered? Patient Awake?
      • - Refractor tipped? Re-align refractor?
      • - Flip out the ret lens; it may be fogged or dirty
      • - Suppressing an eye? Or using non-dominate? Try closing or occluding dominate. Try switching to dominate .
      • - Reflections? Re-align refractor. Try using R-G Filter in projector? Cuts glare but increases pupil size.
    • Trouble Shooting the Practical:
      • Can’t tell the movement!
      • - “Make it move” add +/- 1.00DS.
      • Can’t tell which is the sphere/cylinder meridian on the ret reflex!
      • - Use your K prediction as a starting meridian.
        • - However do not dial in your prediction and try to ret, remember the cross-cyl issue!
    • Trouble Shooting the Practical:
      • Still can’t tell which is the sphere/cylinder meridian on the ret reflex!
      • - Just start neutralizing one meridian and as you get closer the difference will become more obvious.
      • - Watch out for the 45° reflex shift
    • Trouble Shooting the Practical:
      • I’m dialing in power and nothing changes!
      • - Are you on the correct knob or wheel?
        • - on cyl knob but sweeping the sphere
      • - Are you sweeping the correct meridian?
        • -From arrow to arrow for Sphere,
        • -align with both arrows for cyl?
    • Trouble Shooting the Practical:
      • I’m dialing in cyl power and can’t find neutral!
      • - Are you sweeping the correct meridian?
        • -Aligned with both arrows for cyl?
        • - Watch the K’ prediction,
          • - The cyl power is usually within +/- 0.50 DC
        • -Watch out for the center with reflex shift
        • - Watch out for the 45° reflex shift
          • - Usually within +/- 0.50 DC
    • Trouble Shooting the Practical:
      • I’m seeing a scissor reflex
      • - Is it a 45° reflex shift?
          • Are you sweeping in line with the meridian?
          • Aligned with both arrows for cyl?
        • Does the patient have large pupils?
          • Watch out for the center with reflex shift
          • Make the pupil smaller
            • - Flip out the R-G to a white chart
            • - Turn stand light on “dim”
    • Trouble Shooting the Practical:
      • Got 20/30 after the ret!
      • - Did you take the WD lenses out? Correctly?
      • - Click -0.25 DS, if the VA improves start step down, if not redo ret.
        • - If > -1.00 cylinder in refractor, rock +/- 10 ° check for VA improvement. If not redo ret.
    • Trouble Shooting the Practical:
      • Still over 20/30 after the 2 nd ret!!
      • - Go to R-G sphere check and clock dial.
      • Patient not able to read 20/20 after sphere check!
      • - If < 20/30 Use VA line 2 lines larger then sphere check VA for JCC.
      • - If > 20/30 go to Clock Dial.
    • Trouble Shooting the Practical:
      • Patient not able to see JCC choices!
      • - Do you still have them fogged?
      • - Remove fog!
      • - Can they see the target?
      • Patient not able to make JCC choices!
      • - Move off ret axis by 15 ° & move back.
      • - Change line or Isolate a single letter target
        • - Drop back to clock dial
    • Trouble Shooting the Practical:
      • Patient still not able to make JCC choices!
      • - If small cyl; Go to eliciting cylinder procedure.
      • - If large cyl; redo Ks and set at predicted then check clock dial.
      • Patient runs me around dial on JCC!
      • - Following correct dots?
          • -Either side of flip knob. Same side of cyl bank?
      • - Go to eliciting cylinder procedure.
    • Trouble Shooting the Practical:
      • Patient can’t pin down axis on JCC!
      • - You pick axis to nearest 5 °.
      • Patient can’t pin down power on JCC!
      • - Pick smaller power.
    • Trouble Shooting the Practical:
      • Patient calls “white” on the power check when I’m at zero in the cyl bank. Am I done?
      • - NO. Your axis is 90 ° off!
      • - Change 90 ° or Go to eliciting cylinder procedure.
    • Trouble Shooting the Practical:
      • Patient already blurred for MPMA at end of JCC!
      • - Did you remove JCCs? Remove.
      • - Maintain sphere check during JCC? Redo sphere ck & JCC.
      • - Patient accommodating?
      • Go to Humphriss.
    • Trouble Shooting the Practical:
      • Patient can’t see two charts on balance!
      • - Both eyes open?
      • - Fogged too much? Reduce fog.
      • - Prisms set correctly? Reset/Increase.
      • Patient can’t be balanced!
      • - Too fogged? Reduce fog.
      • - Step down to 20/30.
    • Trouble Shooting the Practical:
      • Still patient can’t be balanced!
      • - Do alternate occlusion balance.
        • Leave dominate eye clearer.
      • On final step down patient sees 20/15 right after prism removed!
      • - Fog back up to +0.75 and step down.
    • Trouble Shooting the Practical:
      • Patient keeps calling better!
      • - Stop with the lens of no “letter” improvement.
      • The BVA’s monocular VAs are not the same!
      • - Return to balance.
      • - Start from MPMA. Or Recheck JCC.
      • - Do MPMA balance.
      • - Do alternate occlusion balance if still off.
    • The A & P
      • What to expect?
        • On both the practical and the 2nd written expect both trouble shooting problems and prescribing scenarios
          • Know now to do K predictions
          • Recognize when a procedure has been done incorrectly
            • Missed step, wrong steps, lighting, instructions
          • Be able to ID the most likely error source or bad data
            • VA, Ks, Ret, Subjective
            • VA rules
    • The A & P
      • What to expect?
        • -You will be asked if all your data makes sense
          • -do the K’ predict the cylinder found on either the ret or refraction?
          • -+/- 0.50? Axis?
        • -Did the K’s & ret predict the final refraction?
          • -+/- 0.50? Axis?
        • -If not be able to come up with a why not?
          • - Over minus ret, ΔK too small, etc
    • The A & P
      • What to expect?
        • -You will then be given 2 senarios either
        • Where the patient should have their Rx changed and why
        • One where you should not change the Rx and why by giving the general guideline rule that best applies
        • Know the rules
    • The A & P
      • What to expect?
        • Example: Hab Rx none 20/25-1
          • Ks predict -0.25 x015
          • Retinoscopy gives -0.50- 0.50x030 20/20
          • Subjective gets -0.25-0.25x060 20/20+2
        • Error? Ks? Ret? Or patient?
        • Rx give or not?
    • The A & P
      • What to expect?
        • Example: Hab Rx -2.00DS 20/20-2
          • Ks predict -1.00 x180
          • Retinoscopy gives -1.75 - 0.50x030 20/20+1
          • Subjective gets -1.50-0.75x010 20/15-1
        • Error? Ks? Ret? Or patient?
        • Rx give or not?
    • The A & P
      • What to expect?
        • You will then be given a blank Rx slip will write out what you think the patient should have.
          • Be able to give the rational for giving or not an Rx
            • Know the rules
          • Know how to correctly write a prescription
    • The Alternate Procedures
      • What to expect?
        • You will be given a alternate procedure to perform of the AI’s choosing
        • 1 st You need to give them 2 indications for the procedure
        • Next you will conduct the step with the AI playing the part of the patient
          • You will give all patient instructions and test steps as if there is a patient behind the refractor, do NOT simply say “I would do this then this…” you must actually do the steps.
    • Lastly
      • What to expect?
        • You will be given a briefing after you have completed the practical by both the AI and the patient
        • You will be notified of scores with in three days
        • There will be no section redos
        • Retakes for scores <75% will be the last week in class during the normal scheduled lab
          • If your score >75% you do not have lab the last week.
    • Lastly
      • Monday lecture class will not meet next Monday
        • I will be in my office for questions
          • It is best that you email ahead to check
      • Monday the 26th we will have a Review session for the final exam
    •