Routine eye examination (C7655)

This article is best viewed in a PDF Format.    

View PDF 

It is a safe assumption that a patient will attend for an eye examination for a reason. This reason may range from simple response to a posted reminder from a practice to the reporting of a specific visual or ocular symptom. It is often stated that the first question an optometrist might ask is "Why are you here?" If the reason for attendance is not addressed then it cannot be deemed a successful examination. If the reason for attendance is to be investigated properly, then the optometrist must ask pertinent questions to place the patient requirement in its appropriate context. It is this process of gathering information which will be discussed. A thorough initial interview with a patient has the following advantages:    

• Baseline data may be recorded which aids accuracy and efficiency in future examinations of a patient. It allows for monitoring of any changes in a patient over time and provides clues as to the success or relevance of any previous interventions

 

• Careful questioning allows the optometrist to discover the nature of any problem relating to a patient's vision or ocular health

 

• It allows a good rapport between the optometrist and the patient to be established

 

• Allied information may be gained which may allow the optometrist to offer advice beyond the presenting needs of the patient. For example, if it is discovered that a patient with glaucoma has a brother, or that a high myope has had a child recently, the practitioner may be able to offer sensible eye care advice

 

• The information gained at the beginning of the examination allows the optometrist to adapt the clinical assessment to meet the needs of the patient. Often the decision to omit certain tests as irrelevant is based upon information gained from the patient, for example not measuring amplitude of accommodation in a patient once they have disclosed their date of birth. The patient information may also impact on the use of further investigations, for example a patient with asthenopic symptoms and a cover test showing a poorly controlled phoria may warrant further investigation of fusional reserves or fixation disparity. The adaptation of the clinical procedures to meet the requirements of the patient has been described as a problem-oriented examination as opposed to a 'checklist' examination where a set number of techniques are applied to every patient. It may be argued that basing the design of the examination to meet the needs of a patient as gleaned from a thorough initial interview allows the optometrist to use their time more efficiently and to reach an accurate conclusion without the need for carrying out unnecessary tests. On the other hand, this must be tempered by the practitioner's skill in inferring when the patient has given adequate or accurate information. As will become clear from the forthcoming case examples, one may not always be given the full, or even the true, picture by the patient. Furthermore, there are many examples where a condition may be detected in a patient with no pre-disposing symptoms or history, such as open-angle glaucoma, and an approached based purely on the presenting problem may overshadow this consideration

 

• The recording of accurate data based upon a history and symptoms may have legal implications in that, if a problem occurs subsequent to an examination, then clear recorded evidence that the optometrist asked questions relating to a condition at the time of the examination is important. Asking about systemic medications with a patient who subsequently suffered an adverse ocular reaction, or about the nature of perceived flashing lights in a high myope who developed a retinal detachment some years later, may prove crucial in any litigation surrounding the role of the optometrist.

  The nature of the history and symptoms Interview There are arguments against describing the history and symptoms interview under separate headings relating to the different aspects of a patient, such as their ocular history or their family ocular history and so on. A purely problem-oriented approach would lead the optometrist to ascertain any symptom or reason for attendance and then to ask further questions to shed light on this particular need. A checklist approach, where one simply asks a set list of questions relating to each of the categories mentioned below has the advantage of establishing potentially useful baseline data even if some of this is not relevant on the day. For example, to discover a strong family history of glaucoma in the family of a 16-year-old may prove more important later on in the patient's life. A disadvantage, apart from the risk of using time less than efficiently, is the possibility that the optometrist, by dwelling on a fact of no immediate relevance to the matter in hand, such as a patient's medication history may fail to grasp that they have attended to ask about the advantages of varifocals. Careful explanation by the optometrist of the need to ask certain facts should prevent this happening. A sensible approach would appear to be a combination of the two. All relevant baseline information should be established even if not of immediate relevance to the particular problem presenting on the day, but any specific problem needs more probing to elicit its exact nature. In occasional cases where a patient is apparently reluctant to offer information or questions the relevance of certain questions (typically those about general health issues), it is most useful for the optometrist to explain that, in order to assess the health of the eyes adequately, a bigger picture of the patient's well-being needs to be gained. Eyes are affected by many general health factors. The questioning is necessarily going to be different for every patient, but a systematic approach helps the optometrist to remember to ask all relevant questions. This should be recorded carefully and clearly so providing important personal details together with what may be described as a subjective problem list. One suggested structure to areas to be investigated during the history and symptoms interview now follows. Reason for attendance It is generally considered that an appreciation of why the patient has attended for an eye examination should be gained from the outset. Whether it is a routine two-yearly recall or a specific concern regarding a particular problem, all subsequent questions and actions by the practitioner may follow on from this premise. An initial question is usually an open one, that is, one for which there is not a simple yes/no or single statement answer. 'Tell me why you've come to see me today' may elicit more immediate information from the patient than 'Do you have a particular problem with your eyes?', though the latter may be appropriate as a follow-up question in some circumstances or in cases of poor response from the patient. Ocular and optical status Details about the patient's current vision, correction, any symptoms and so on. As this is a more specific line of questioning where some essential facts need to be established, closed questions with one specific answer may be appropriate. Furthermore, while the practitioner should be aware of the pitfall of sounding as though they are reading a list of pre-written questions, it is often important to ask questions of a patient to rule out certain possibilities. For example, it is common practice to establish that the patient has not experienced photopsia, but unless this is asked, the patient who has reported no particular symptom cannot be assumed to have not experienced photopsia. A typical list of initial questions might include the following, most of which may then lead on to more specific questions:    

• Do you see well in the distance? (examples may be given, such as driving, television and so on)

 

• Do you see near objects well? (usually reference to reading ability is made)

  Any blur should be qualified further in terms of distance, near or both, which eye (or both), onset and duration and so on.    

• Do you currently wear any correction? (what type, standard of vision with correction, condition of correction and so on)

 

• Do you experience any?

  This last question may allow one to find out whether a patient has experience of a whole range of symptoms. To reproduce a list invites the criticism that it is encouraging a practitioner to read out automaton-like a list of potential symptoms and that a better approach would be to adapt one's individual questioning to the specific needs of the patient. However, relevant symptoms might include the following. Headaches Further questioning here might ascertain:    

• Which part of the head?

 

• Both sides or one?

 

• Nature of the pain (sharp, throbbing, dull, cluster and so on)

 

• Associated nausea and vomiting

 

• Associated visual disturbance (migraine as opposed to possible ischaemic incident)

 

• Medication being taken for headache

 

• Association with any task, visual or possibly other activity.

  Eyepain    

• Constant or intermittent

 

• Nature of the pain (severe or otherwise)

 

• Associated with eye movement.

  Floaters    

• Location in view

 

• Size

 

• Moves with the eye

 

• Solid or web-like

 

• Associations, such as trauma.

  Flashes of light    

• Persistent or transient

 

• Associated with onset of floaters (see list above)

 

• One or both eyes.

  Itching, redness, soreness, tearing, burning and so on    

• One or both eyes

 

• Any associations (outdoors, light, season and so on)

 

• Nature of any discharge.

  Double vision    

• Double as opposed to blurred (many patients may be confused by the difference, so the practitioner must be careful to help in the distinction)

 

• Monocular or binocular

 

• Vertical or horizontal.

  This list, for the reasons outlined, is not exhaustive and each patient should be taken individually. The follow-up questions usefully allow the practitioner to qualify individual symptoms. So the general pattern so far has been of an initial open questioning followed by more specific possibly closed questions about presenting symptoms, affirmative responses being further probed to gain more specific detail. The overall pattern of initial open questioning followed by successive increasingly closed questions is sometimes called a funnel approach. A list of questions of similar form or depth is sometimes called a tunnel approach or technique. The probing questions appropriate for symptoms are summarised in Table 1. Patient ocular history details regarding any history of:    

• Last eye examination

 

• Optical correction (type, when and how long worn, condition)

 

• Injury or trauma

 

• Surgery, orthoptic or refractive treatment

 

• Known eye disease or 'squint'.

  The term 'squint' should always be qualified as, together with astigmatism and 'lazy eye', it is open to misinterpretation. Family ocular history Details regarding any family members with:    

• Visual problems (high myopia, amblyopia and so on)

 

• Squints

 

• Eye diseases (glaucoma, nystagmus and many others).

  Patient general medical history This is one particular area where the use of a leading question may confuse the issue. To ask of a patient 'Is your health good at the moment?' may elicit a definite 'Yes, thank you' from a patient who has just been through a period of poor health which has just recently stabilised. An insulin dependent diabetic may feel in the best of health. More useful approaches might include:    

• How is your health at the moment?

 

• Do you have to visit your doctor for any reason?

 

• Are you taking any medication at present (or have been recently)?

 

• Are you being treated for diabetes or hypertension.

  With regard to medication the more detail the better, and it is often considered good practice to look at drug bottles, prescriptions or any literature the patient may posses. Some indication as to patient compliance, for example use of glaucoma drops or control of sugar levels in diabetes, may be obtained through careful questioning here. With some conditions, such as hypertension, further questioning may be appropriate to ensure that the patient is being monitored regularly and that they are aware of the importance of adequate control of their condition. With diabetes in particular some more detail may be of direct relevance to the optometrist and may influence the nature of the subsequent correspondence with the general practitioner. Follow-up questions might include:    

• Duration of the disease

 

• Nature of the disease (Type 1 or 2)

 

• Nature of the control and whether this has changed, and whether it is stable

 

• Who monitors the disease and if other eye examinations are included

 

• When was the last medical check and when will the next one be?

  Family medical history Any family history of hypertension, stroke or diabetes (and type) may be of importance. Lifestyle and occupation details This information may arise during the above questioning and our placing this item at the end of a list does not relegate it to an afterthought. Indeed the presenting problem in many eye examinations may be directly related to problems in the workplace or driving or carrying out a hobby. Asking about the nature of a patient's work is more useful than just knowing a job title, which may be misleading. Use of a VDU may lead onto a whole host of further questions. The need to drive may influence one's final consideration of results and there are obvious legal implications here. The practitioner may be able to infer the possible requirement for safety spectacles or advice relating to eye health and safety. A good concluding question might be 'Is there anything else about your eyes or vision which concern you?' or 'Is there anything else about your eyes or health that I should know?' This should fill in any missing detail so that the practical examination may begin with a detailed knowledge of the patient's ocular state. The problem with drafting a list such as this, on top of tempting a wholesale reading out of a checklist to a patient, is that any comprehensive list seems to be quite daunting. The fact that a skilled practitioner may be able to elicit all the relevant information mentioned above in a perfectly acceptable time is partly due to correct sequencing of questions and the appropriate combination of open and closed and other types of questioning. This is generally done without conscious thought and is certainly a skill that improves with practice. Further Reading Harvey W, Franklin A. Eye Essentials Routine Eye Examination, Elsevier Science 2005. ? Andy Franklin is an optometrist in private practice and professional programme tutor with Boots Opticians