1. Advanced Pre-Testing Lynn E. Konkel, MS, CPOT Heart of American – February 2013

2. Introduction Will discuss the procedures and common results of the following pre-testing skills: o pupillary reflexes o eye movements o cover test & maddox rod o near point of accommodation o confrontation visual fields

3. Overview Patient pre-testing is used to gather information regarding the patient’s visual system. Pre-testing is not used to diagnose conditions of the eye or visual system. This course is for the technician who is performing basic pre-testing skills. This is an advanced course and may be useful for technician level certification examination prep.

4. Overview Prior to performing pre-testing the technician should o Wash hands o clean equipment with specialized antiseptic agent o Briefly explain test to patient prior or as starting to perform

5. Pupillary Responses Pupil Facts o Normal size varies 3-7mm o Smaller than normal as we age, infant o Myopes have larger pupil size o Pupils dilated when surprised o Some medications cause miosis or mydriasis Why test pupil responses? o Important test of neurological integrity o Objective evaluation of 2 nd cranial nerve o Pupils important sign of ocular disease

6. When to evaluate pupil reflexes? All primary eye examinations All cases of vision loss/reduced vision Prior to dilation Prior to contact lens fits, vision training, low vision evaluations

7. Five steps in pupil evaluation Step 1 o Explain test o Evaluate for anisocoria Step 2 o Evaluate lid position

8. Steps to Pupil Testing Step 3 o Evaluate light responses Direct Consensual Step 4 o Evaluate for afferent pupil defect Swinging flashlight test Step 5 o Evaluate near response o Record findings

9. Video of Pupil Testing

10. Abnormalities Marcus Gunn Argyll Robertson Adie’s Pupil Horner’s Syndrome

11. Eye Movements Ductions - movement of a single eye Versions - conjugate movements of both eyes together Rotations/Pursuits - following movements Saccades/Fixations - jumping movements

12. Eye Movements Explanation - test your eye movements Instructions - follow my light with your eyes, do not move your head Evaluate muscles in primary position, up/down, 6 cardinal positions of gaze - see handout

14. Eye Movement Procedure Testing is performed at 30-40 centimeters Move target in an exaggerated H pattern Observe both eyes together & separately Record lag, limits, paralysis, smooth, accurate versus jerky movements. If eye movements are normal may record SAFE (smooth, accurate, full, extensive)

15. Cover Test Equipment - occluder and small letter Heterophorias - tendency for the eye to deviate Heterotropias - fixed deviation of the eye the patient cannot overcome. Specified as to the position of the eye: eso = inward, exo = outward, hyper = upward, hypo = downward. The movement the eye will make when performing the cover test is the opposite motion to the above listed direction of deviation

16. Cover Test Explanation - test to determine the position of your eyes Instructions - I will be simply swinging the occluder in front of your eyes, look at the letter at all times, ignoring the occluder. Feel free to blink your eyes.

17. Cover Test Cover/Uncover

18. Cover Test Alternating Cover

19. Maddox Rod Equipment - maddox rod and light source Will detect position of eye; eso, exo, hyper or hypo will not differentiate from a phoria or tropia Rods of maddox rod placed vertically will detect hyper/hypo Rods of maddox rod placed horizontally will detect eso/exo

20. Maddox Rod Explanation - test to determine the position of your eyes Instructions - hold the red lens in front of your right eye (technician positions the rods correctly). Keeping both eyes open look at the light. Do you see a red line and white dot of light? Where is the red line in relationship to the light? o record position of eyes; eso, exo hyper or ortho

21. Maddox Rod Procedure o place maddox rod in front of one eye, shine light at midline of patient o instruct patient to keep both eyes open o verify that patient sees the red line and white light Ask patient to give position of red line o rod placed vertically red line will be above, below or directly on the red line o rod placed horizontally red line will be in towards nose, out towards ear or directly on red line

22. Near Point of Accommodation (NPA) Equipment - occluder, small letters and PD stick NPA is the measurement of the ability of the crystalline lens to add plus power for near focus. Explanation - test to measure the eyes ability to change focus Instructions - look at the smallest line of letters you can see. I will move the chart in towards your nose, tell me when the line blurs.

23. NPA – Cont. Procedure o Perform monocularly and with full distance Rx o Move small letter target smoothly in towards eye and have patient report when the letter blurs. o Measure in centimeters and convert to diopters. Convert centimeters to meters D = 1/ f (meters) Example you measure NPA of 40 cm (40/100 = 0.4 meters). Diopters of accommodation = 1/0.4 = +2.50 D Expected outcome o Donder’s amplitude of accommodation — 10 yr. old = 14.00 D, 40 yr. old = 4.50 D o Hofstetter’s average = 18.5 – (0.3 x age)

24. Near Point of Convergence (NPC) Equipment - small letter target and PD stick NPC is the measurement of the ability of the eyes to converge (move in toward midline) while maintaining single binocular vision.

25. NPC Explanation - test to measure how well your eyes move in together. Instructions - look at the smallest line of letters you can see. I will be moving the letters in toward your nose. Tell me if the line of letters doubles, if it does, keep looking at the letters, I will move the target away and tell me when the line is single again.

26. Procedure Perform with near Rx Move the target smoothly toward the nose and stop when the patient reports double or you see one of their eyes move out

27. NPC - Measurement Measure the distance, in centimeters, the patient reported double or their eye turned out. Also note which eye turned out. If the patient reported double, smoothly pull the target away and stop when the patient reports single Measure the distance, in centimeters the distance at which the patient reported single.

28. NPC - Expected Results NPC of 5.5 cm or less except in presbyopia where normal is 8 or 9 cm or less Recovery should be no more than 8 cm in people less than 40 yr. of age

29. Confrontation Visual Field Gross Screening Equipment - fingers, white target, or penlight Explanation - this is a test to evaluate your peripheral vision Instructions - cover your left eye and look at the bridge of my nose. Keep looking at my nose at all time.

30. Confrontation Procedure Face patient at eye level - 60 - 80 centimeters apart Illuminate area between patient and technician. Dark background behind technician if possible Ask patient if they can see all your face as they look at the bridge of your nose. Is there any part of your face missing? Any part of your face blurry or distorted

31. Confrontation Part 2 Have patient remain looking at your nose, tell them you are going to hold up fingers in their side vision. They are to tell you how many fingers you are holding up. Hold up 1,2, or 5 fingers in the four quadrants of their peripheral vision. If patient incorrectly identifies number of fingers, redo area at least once. If it is a true visual field defect it will be repeatable Record any deficiencies, note eye and which areas

32. Summary We have covered a number of advanced pretesting techniques. Recommend you take this information back to the office, discuss the techniques with your doctor, adjust procedures to fit your particular office situation. Please complete the course evaluation form. Note your comments regarding this course as well as topics you would like to see addressed in the future. Thank you for coming.

33. Where to get more information For additional reading: o AOA Paraoptometric Section, Self-Study Course for Paraoptometric Assistants and Technicians, Revised 3 rd Edition. Butterworth-Heinemann. 1997 o Stein, Stein, Freeman, The ophthalmic assistant 8 th edition Mosby 2006 o Cassin, Rubin, Dictionary of eye terminology 6 th edition Traid 2011 Websites: o http://www.richmondeye.com/apd.asp - has interactive pupil responses http://www.richmondeye.com/apd.asp o http://cim.ucdavis.edu/eyes/version15/eyesim.html - interactive muscle testing simulator. http://cim.ucdavis.edu/eyes/version15/eyesim.html o http://cim.ucdavis.edu/EyeRelease/Interface/TopFrame.htm - pupil reflex testing simulator. http://cim.ucdavis.edu/EyeRelease/Interface/TopFrame.htm o http://www.kellogg.umich.edu/theeyeshaveit/index.html - the University of Michigan, Kellog Eye Center http://www.kellogg.umich.edu/theeyeshaveit/index.html