12 Point Eye Examination
At Occhiali, we perform a 12 Step Eye Examination which gives a holistic diagnosis for Vision Correction.
Recording of Patient History in our Network Software helps our qualified and well trained optometrist to access patient’s information in any of our Yateem Group’s branches.
Besides performing Computerized refraction, Retinoscopy remains a key technique to obtain an objective measurement of the refractive error of a patient's eyes. This technique is to is used determine the refractive error of the eye (farsighted, nearsighted, astigmatism) and the need for glasses. The test can be quick, easy, reliably accurate and requires minimal cooperation from the patient. Years of practice by our Optometrists, help them to arrive at near accurate prescriptions for our patients. This has been key to our success.
In addition to this, our Optometrist include tests on Confrontation Visual Field, Extra Ocular Motility and slit lamp examination for Ocular Health. Patient’s suitability to wear contact lenses is a routine part of the assessment.
Contact Lens Education and
Insertion and removal training
Insertion and removal training for staff and patient education.
These instructions will help you learn how to insert and remove your contact lenses.
Place the wet, clean “right” lens on the tip of the index or middle finger of your dominant hand (if you're right-handed this would be your right hand), and pull down the lower lid with the middle or ring finger of the same hand. Use your other hand to hold the upper lid firmly open.
Look directly at the lens or look directly into a mirror and place the lens directly on the cornea (the large coloured circle in the centre of your eye).
Slowly release your hold on the lid. If there are any air bubbles beneath the lens, close your eye, and with the eye closed, roll the eye gently. Another way of getting rid of air bubbles is to massage the lids very lightly. Under no condition, however, should your rub your eyes.
Removing the lens:
Look up. With middle finger, hold down lower lid. Use forefinger to slide lens to lower part of eye. Pinch lens with thumb and forefinger and remove without excessively folding the lens.
Appropriate referrals to Specialists
Medicare requires that all patients seeing a specialist must have a current referral to receive a Medicare refund for their treatment. A referral to an eye specialist may come from your General Practitioner (G.P.) or an optometrist and these referrals are generally valid for 12 months. Another specialist doctor (i.e. endocrinologist or heart surgeon) may refer you also but their referral is only valid for three months.
Remember, the best way to protect your vision is to schedule regular, thorough, dilated eye exams to check for hidden signs of sight-threatening conditions. Ask yourself and your family members—"When was your last eye exam?" If it was more than two years ago, it's time to pick up the phone.
When to Schedule A Routine Eye Exam
Vision screening is one of the most important parts of your family's health care. Many serious eye disorders can be prevented or treated if detected soon enough. Eye Care Specialists ophthalmology practice in Milwaukee recommends that people have their eyes checked at the following stages:
A pediatrician should check your baby's eyes as part of a comprehensive newborn exam. "An ophthalmologist will be called if the eyes are cloudy, infected, or appear abnormal. A thorough eye exam is also required if the baby was born premature, has a low birth weight, or required oxygen treatment. Babies who have been exposed to maternal rubella, venereal diseases or AIDS-related infections, or those with a family history of retinoblastoma (a form of eye cancer), unusual metabolic disorders (e.g. galactosemia), or infantile cataracts should also be promptly evaluated," reports Dr. Norman Cohen, co-founder of Eye Care Specialists.
Six months of age
Your infant's doctor should check that your child's eyes are straight (not crossed in or out as with "strabismus") and that each eye can fix and follow a light or toy (unlike children with a "lazy eye" or "amblyopia"). The doctor will also make certain that light reflects and passes through the eye normally and that the tear ducts work properly.
3 1/2 years of age
"Your doctor should confirm proper development and alignment of the eyes and lids, as well as examine the internal structures of the eye with a hand-held instrument called an ophthalmoscope. They should test your child's exact visual acuity (e.g. 20/20) using charts with tumbling Es, pictures or letters. As before, any unusual findings by your pediatrician or family physician should prompt an immediate referral to an eye care specialist," says Dr. Robert Sucher, an eye surgeon with 33 years of experience.
Most schools provide annual visual screenings. The most common eye problem found during these tests is "nearsightedness" (inability to see letters or objects at a distance). Some authorities feel that the start of school is an appropriate time for the first visit to an eye doctor. He or she can then recommend the frequency of follow-up examinations based on your child's condition.
The teen years
"Most young people have healthy eyes, but they still need to take care of their vision with an eye exam before age 20. Teenagers should be cautioned to use appropriate eye protection in chemistry, woodworking, shop and other classes, as well as when playing sports. People in this age group should also be advised of the dangers of inappropriate contact lens wear and care," notes ophthalmologist Dr. Daniel Ferguson, who sees patients of all ages and walks of life at three locations in the metropolitan Milwaukee area.
Ages 20 to 39
Even people in this group can be affected by eye problems. "As always, eye protection should be worn for sports, yard work, tasks involving chemicals, and any other activities that could cause eye injury. A complete eye exam is recommended at least once between the ages of 20 and 29, and at least twice between the ages of 30 and 39," says Dr. Brett Rhode, Head of Ophthalmology at Aurora Sinai Medical Center. If you have any of the risk factors listed later in this article, you may need to be seen more often.
Ages 40 to 64
Besides scheduling a thorough dilated eye exam every two to four years, you should be aware of symptoms that may indicate a problem as listed below.
Age 65 and older
Leading laser eye surgeon Dr. Mark Freedman advises, "Seniors should have complete eye exams every one to two years to check for cataracts, glaucoma, age-related macular degeneration, diabetic retinopathy, and other conditions. Time is crucial, since some conditions have no warning signs and early treatment is needed to protect and preserve vision."
Personalized After Care
Today, people want more from health care. They want the best high-tech treatments available today, but they also want the personal attention and care of yesteryear … and at the same time, they want a way to reduce health care costs. What’s the answer? Ministry's approach to personalized care. This model helps patients achieve that level of care. But what does personalized care actually mean? It is modeled after the health care delivery model, Patient Centered Medical Home. But it's not a physical “home.” Rather, it is a relationship developed with your primary care provider and his or her staff at one of our outpatient facilities. It is a place where people know you, know your needs and preferences, and know the best way to care for you. Click on the video below to learn more about Patient Centered Medical Home and how this more personalized approach benefits you as a patient.
The visual acuity test is used to determine the smallest letters you can read on a standardized chart (Snellen chart) or a card held 20 feet away. Special charts are used when testing at distances shorter than 20 feet.
How the Test is Performed
This test may be done in a health care provider's office, a school, a workplace, or elsewhere.
You will be asked to remove your glasses or contact lenses and stand or sit 20 feet from the eye chart. You will keep both eyes open.
You will be asked to cover one eye with the palm of your hand, a piece of paper, or a small paddle while you read out loud the smallest line of letters you can see on the chart. Numbers or pictures are used for people who cannot read, especially children.
If you are not sure of the letter, you may guess. This test is done on each eye, one at a time. If needed, it is repeated while you wear your glasses or contacts. You may also be asked to read letters or numbers from a card held 14 inches from your face. This will test your near vision.
How to Prepare for the Test
No special preparation is necessary for this test.
How the Test Will Feel
There is no discomfort.
Why the Test is Performed
The visual acuity test is a routine part of an eye examination or general physical examination, particularly if there is a change in vision or a problem with vision.
In children, the test is performed to screen for vision problems. Vision problems in young children can often be corrected or improved. Undetected or untreated problems may lead to permanent vision damage.
There are other ways to check vision in very young children, or in people who do not know their letters or numbers.
Confrontation Visual Fields
The visual fields of both eyes overlap; therefore each eye is tested independently. The patient should cover their right eye with their right hand (vice versa when testing the opposite eye). With the examiner seated directly across from the patient, the patient should direct their gaze to the corresponding eye of the examiner. The testing itself can be performed using stationary or moving targets (disk mounted on a stick or examiner's fingers).
A moving target should start outside the usual 180 º visual field, then move slowly to a more central position until the patient confirms visualization of the target. To perform stationary testing, the examiner holds up a certain number of fingers peripherally, equidistant between themself and the patient. The patient is asked to correctly identify the number of fingers . All 4 quadrants (upper and lower, temporal and nasal) should be tested. Stationary targets are more precise because they present a finer stimulus to the retina and are less easily identifiable relative to a moving target. In addition, for unknown reasons, colored targets such as red or green discs are more sensitive in detecting deficits when compared to a white test object (cotton disc mounted on a stick).
Extra ocular Movements
Normally, the eyes move in concert (e.g. when the left eye moves left, the right eye moves left to a similar degree). The brain takes the input from each eye and puts it together to form a single image. This coordinated movement depends on 6 extraocular muscles that insert around the eye balls, allowing them to move in all directions. Each muscle is innervated by one of 3 Cranial Nerves (CNs): CNs 3 (Oculomotor), 4 (Trochlear) and 6 (Abducens). Movements are described as: elevation (pupil directed upwards), depression (pupil directed downwards), adbduction (pupil directed laterally), adduction (pupil directed medially), extorsion (top of eye rotating away from the nose), and intorsion (top of eye rotating towards the nose). We'll first review the individual Extraocular Muscles (EOMs), then the CNs which innervate them, and lastly functional testing and pathology.
Start by a general observation, noting the shape and size of the pupil in ambient bright light. Size is measured in millimetres and the normal pupil ranges from 1-8 mm. Next, dim the light and have the patient fixate on the far wall. You can then observe the pupils closely by shining a bright light on the patient's face from below (minimise the shadow cast by the nose by placing the light in the midline). If you think there is size asymmetry, a good trick is to stand back and observe the red reflex of both eyes simultaneously with the ophthalmoscope. A slight difference will then become more apparent. If you have access to a slit lamp, use it as a lot of more detailed information can be gauged about the abnormally shaped pupil.
Assessing pupillary reflexes
There are essentially three reflexes to specifically test for
Light reflex test
- What it assesses - the integrity of the pupillary light reflex pathway.
- How to perform it - dim the ambient light and ask the patient to fixate a distant target. Illuminate the right eye from the right side and the left from the left side. (Make sure you do not stand in front of the patient, as their pupils will accommodate to focus on you.) Record whether there is a direct pupillary response (the pupil constricts when the light is shone on it) and a consensual response (the fellow pupil constricts too).
- Normal test - there should be a brisk, simultaneous, equal response of both pupils in response to light shone in one or the other eye.
Swinging flashlight test
- What it assesses - compares direct and consensual responses of each eye (as opposed to seeing whether they are there or not).
- How to perform it - use the same conditions as for the light reflex test and check this reflex first. Then, move the beam swiftly and rhythmically from one eye to the other, making sure that you allow the same amount of light exposure on each eye and that each is illuminated from the same angle. You should note the pupillary constriction of both eyes when the beam is maintained. However, when it is swung, look at what happens to the pupil of the eye you are concerned about and compare this with what is happening to the fellow eye.
- Normal test - the pupil should constrict or stay the same size. If it dilates when light is shone on it, then this means that the light reflex is weaker than the consensual reflex (produced by withdrawing light from the unaffected eye), suggesting optic nerve pathology. This abnormal response is known as a relative afferent pupillary defect (RAPD) and is a very important sign. Note that this is a comparative test: you cannot have a bilateral RAPD.
Near reflex test
- What it assesses - this assesses the miosis component of near fixation, otherwise known as accommodation. (The other two components of accommodation are increased lens thickness and curvature, and convergence of the eyes.)
- How to perform it - in a normally lit room, instruct the patient to look at a distant target. Bring an object (a toy, the patient's thumb) into their near point (about an arm's length away) and observe the pupillary reflex when their fixation shifts to the near target.
- Normal test - there should be a brisk constriction. A near-light dissociation describes the situation where the patient has a significantly better pupillary near reflex than light reflex.
This refers to unequal pupils. This is physiological in about 20% of people. However, if this is a new complaint, the steps to the underlying diagnosis lie in determining which of the pupils is abnormal and then looking for associated signs. The first step is to compare the pupils in light and dim conditions:
- If there is a poor reaction to light in one eye and the anisocoria is more evident in a well lit room, the affected pupil is abnormally large.
- If there is a good reaction to light in both eyes but a poor dilation in the dark (ie the anisocoria is enhanced), the affected pupil is abnormally small.
The large pupil
- Features - there is poor constriction in a well lit room.
- Differential diagnosis - traumatic iris damage, third cranial nerve palsy, pharmacological dilation (ie dilating drops), Adie's pupil, iris rubeosis.
The small pupil
- Features - there is poor dilation in a dim room.
- Differential diagnosis - physiologically small pupil, pilocarpine drops, uveitis with synaechiae, Horner's syndrome.
The abnormally shaped pupil
- Features - a pupil should be round. Deviation from this suggests abnormalities.
- Differential diagnosis - congenital defects (eg, coloboma), iris inflammation or trauma, Argyll Robertson pupils. A fixed oval pupil in association with severe pain, a red eye, a cloudy cornea and systemic malaise suggests acute angle-closure glaucoma which warrants immediate referral.
The abnormally reacting pupil
- Light reflex test - abnormalities arise as a result of severe optic nerve damage (eg, transection) - the patient will be blind in that eye, neither pupil reacts when the affected side is stimulated but both pupils react normally when the fellow eye is stimulated.
- Swinging flashlight test - when the pupil exhibits an RAPD, it is described as a Marcus Gunn pupil. It suggests optic nerve disease, central retinal artery or vein occlusions (see the separate article on Non-diabetic Retinal Vascular Disease. A mild RAPD may also occur in amblyopia, with vitreous haemorrhage, retinal detachment or advanced macular degeneration
- Near reflex test - there are several causes of light-near dissociation which can be grouped according to whether the problem is unilateral or bilateral.
- Unilateral light-near dissociation - afferent conduction defect, Adie pupil, herpes zoster ophthalmicus, aberrant regeneration of the third cranial nerve.
- Bilateral - neurosyphilis, diabetes, myotonic dystrophy, Parinaud's dorsal midbrain syndrome, familial amyloidosis, encephalitis, chronic alcoholism.
The cover test is the part of a comprehensive eye examination in which your eye doctor checks for a deviation or misalignment of your eyes. The cover test usually involves two parts, the unilateral cover test and the alternating cover test.
During the first part of the cover test, the unilateral cover test, you will be asked to focus on a distant object, such as a single letter on an eye chart. (You will be instructed to keep your glasses on, if you have them.) The practitioner will cover your right eye with an occluder while watching for movement from the left, then do the same by covering your left eye. If your uncovered eye moves in order to fixate on the letter or object, then you may have strabismus or an eye turn.
The second part of the cover test is the alternating cover test. The occluder will be switched from one of your eyes to the other. The practitioner will be watching to see if your eye moves after it is uncovered, known as a phoria. Although some amount of phoria is normal, large amounts can cause eye strain, blurry vision or double vision, as you must make an effort to fixate both eyes on a target.
Your eye care practitioner can measure the amount of strabismus or phoria you have by holding prisms in front of your eyes while performing the cover test. These measurements will help determine how much power or prism is needed to help you see your best.
The autorefractor reading provides a useful guide to the optometrist when refining your prescription.
It enables faster refraction times and greater accuracy in determining your prescription.
Reliable results can sometimes be difficult to obtain the following subset of patients and the Autorefractor is of particular benefit to them:
- People who struggle to differentiate small differences in what they see
- Advanced Eye Disease (e.g. Macula Degeneration)
- Children in general
- Amblyopia/Lazy Eye
- Stabismus/ Eye Turn
- High Prescriptions (short sighted, long sighted and astigmatism)
- Acquired Brain Injuries
- Language Difficulties
- Deafess/Poor Hearing
- Mute/Struggles to talk
Retinoscopy (Ret) is a technique to obtain an objective measurement of the refractive error of a patient's eyes. The examiner uses a retinoscope to shine light into the patient's eye and observes the reflection (reflex) off the patient's retina. While moving the streak or spot of light across the pupil the examiner observes the relative movement of the reflex then uses a phoropter or manually places lenses over the eye (using a trial frame and trial lenses) to "neutralize" the reflex.
Static retinoscopy is a type of retinoscopy used in determining a patient's refractive error. It relies on Foucault's principle, which states that the examiner should simulate optical infinity to obtain the correct refractive power. Hence, a power corresponding to the working distance is subtracted from the gross retinoscopy value to give the patient's refractive condition, the working distance lens being one which has a focal length of the examiner's distance from the patient (e.g. +2.00 dioptre lens for a 50 cm working distance). Myopes display an "against" reflex, which means that the direction of movement of light observed from the retina is a different direction to that in which the light beam is swept. Hyperopes, on the other hand, display a "with" movement, which means that the direction of movement of light observed from the retina is the same as that in which the light beam is swept.
Static retinoscopy is performed when the patient has relaxed accommodative status. This can be obtained by the patient viewing a distance target or by the use of cycloplegic drugs(where, for example, a child's lack of reliable fixation of the target can lead to fluctuations in accommodation and thus the results obtained). Dynamic retinoscopy is performed when the patient has active accommodation from viewing a near target.
Retinoscopy is particularly useful in prescribing corrective lenses for patients who are unable to undergo a subjective refraction that requires a judgement and response from the patient (such as children or those with severe intellectual disabilities or communication problems). In most tests however, it is used as a basis for further refinement by subjective refraction. It is also used to evaluate accommodative ability of the eye and detect latent hyperopia.
Slit Lamp Examination
The slit-lamp is a low-power microscope combined with a high-intensity light source that can be focused to shine in a thin beam.
You will sit in a chair with the instrument placed in front of you. You will be asked to rest your chin and forehead on a support to keep your head steady.
The health care provider will examine your eyes, especially the eyelids, cornea, conjunctiva, sclera, and iris. Often a yellow dye (fluorescein) is used to help examine the cornea and tear layer. The dye is either added as a drop, or the health care provider may touch a fine strip of paper stained with the dye to the white of your eye. The dye rinses out of the eye with tears as you blink.
Next, drops may be placed in your eyes to widen (dilate) your pupils. The drops take about 15 to 20 minutes to work. The slit-lamp examination is then repeated using another small lens held close to the eye, so the back of the eye can be examined.
Tonometry is a test to measure the pressure inside your eyes. The test is used to screen for glaucoma.
How the Test is Performed
There are several methods of testing for glaucoma.
The most accurate method measures the force needed to flatten a certain area of the cornea.
The surface of the eye is numbed with eye drops. A fine strip of paper stained with orange dye is touched to the side of the eye. The dye stains the front of the eye to help with the examination.
The slit-lamp is placed in front of you, and you rest your chin and forehead on a support that keeps your head steady. The lamp is moved forward until the tip of the tonometer just touches the cornea.
The health care provider looks through the eyepiece on the lamp and the machine gives a pressure reading. There is no discomfort with the test.
A slightly different method uses a handheld device similar in shape to a pencil. Again, you are given numbing eye drops to prevent any discomfort. The device touches the outside of the eye and instantly records eye pressure.
The last method is the noncontact method (air puff). In this method, your chin rests on a padded stand.
You stare straight into the examining device. The eye doctor shines a light into your eye to properly line up the instrument, and then delivers a brief puff of air at your eye.
The machine measures eye pressure by looking at how the light reflections change as the air hits the eye.
Dilated Fundus Examination
A comprehensive dilated eye exam is a painless procedure in which an eye care professional examines your eyes to look for common vision problems and eye diseases, many of which have no early warning signs. Regular comprehensive eye exams can help you protect your sight and make sure that you are seeing your best.
Drops are placed in your eyes to dilate, or widen, the pupils. Your eye care professional uses a special magnifying lens to examine your retina to look for signs of damage and other eye problems, such as diabetic retinopathy or age-related macular degeneration. A dilated eye exam also allows your doctor to check for damage to the optic nerve that occurs when a person has glaucoma. After the examination, your close-up vision may remain blurred for several hours.
Contact Lens Eligibility
The Optometry Department provides a specialist contact lens service for patients who have a medical need or 'clinical necessity' for contact lenses.
For example, those with:
- keratoconus and other corneal irregularities or scarring where lenses are necessary for
- visual rehabilitation
- post corneal graft
- complex spectacle prescriptions e.g. more than 12.00 DS of either myopia (short sightedness) or hypermetropia (long sightedness)
- therapeutic (bandage) lenses e.g. for pain relief or to aid healing
- cosmetic lenses e.g. to improve the appearance of an eye following injury or infection
- paediatric lenses e.g. following cataract surgery.
The decision to fit contact lenses is made in agreement with a hospital contact lens practitioner or consultant ophthalmologist.
Contact lenses are charged at a cost set by the NHS each year on 1 April. Some groups of patients are eligible for a voucher which covers the cost of the contact lens/es.
General Eye Health
To maintain good vision and to keep your eyes healthy, it is important to have routine eye exams. For those with stable vision and without any eye disease having routine eye exams every two years is important. At this exam your eyes will be dilated so the doctor can see into your retina, your vision will be checked and you will be screened for eye diseases or disorders. If further testing is required a more comprehensive exam and testing will be scheduled.
If you experience any changes in your vision between regularly scheduled visits with your eye specialist, you should schedule an appointment as soon as possible. Early detection of problems and treatment of problems can be the key to preventing loss of vision.
Preparing for Your Eye Exam
When a person calls to make an eye appointment, he or she should be prepared to describe any current vision problems. In addition, patients should ask if the eye examination will affect their vision temporarily and if they will need someone to drive them home. They may also want to ask about the cost of the exam, if their insurance plan will cover any of the cost, and how payment is handled.
Before going to the appointment, patients should gather the following information to help answer questions the eye care professional may ask:
- Symptoms of current eye problems (flashes of light, difficulty seeing at night, temporary double vision, loss of vision, etc.).
- Eye injuries or eye surgeries (approximate dates, where treated)
- Family history of eye problems (glaucoma, macular degeneration, cataracts, etc.)
- Any questions about their vision, glasses, contacts, laser surgery, etc.
- A list of all prescriptions and over-the-counter drugs currently being used
- Their general health condition (allergies, chronic health problems, operations, etc.)
Patients should also bring the following items with them to their eye appointment:
- Glasses, contact lenses or both
- A list of all prescriptions and over-the-counter drugs currently being taken
- Medical or health insurance card
- Photo ID
Signs that an Eye Exam May be Needed:
- Holding a book too close to their eyes
- Difficulty reading the blackboard in school
- Complaints of blurry eyesight
- Squinting a lot
- Closing or covering one eye in order to see
If your child is experiencing any of these symptoms, schedule your appointment today.