The "Right Hand CoIumn"

PMH (past medicaI history):

Past medical history should include the usual health
questions, but with the main emphasis on conditions
directly contributing to ocular pathology such as diabetes,
hypertension, and coronary artery disease. Also, ask
about thyroid problems and asthma (you might need to
prescribe a beta-blocker and you don't want to set off
bronchospasm).

POH (past ocuIar history):
Ocular history should inquire about past clinic visits and
surgeries. Specifically ask about cataract surgeries, eye
trauma, and glaucoma. You can often piece together
your patient's ocular history by examining their eyedrops.

FamiIy History:
Focus on history of glaucoma and blindness. Patients will
often confuse glaucoma with cataracts, so be sure to ask.
AIIergies:
List basic allergies and their reaction. Fortunately, there aren't many drug-
drug interactions in our field. We sometimes give Diamox to control eye
pressure so make sure your glaucoma patient isn't allergic to sulfa drugs.

Medications:
Find out what eyedrops your patient is taking, and why. Are they using a
regular eyedrop? How about vasoconstricting Visine? Did they bring their
drops with them? f your patient can't remember their medications, it often
helps to ask about the bottlecap-color of their drops (ex: all dilating drops
have red caps). Also, it's nice to know if your patient is taking an oral beta-
blocker already, in case you want to start a beta-blocking eyedrop (which
usually have yellow caps).

Vision, PupiI, and
Pressure . oh my!
Vision, pupil, and
pressure are the "vital
signs of ophthalmology. After a brief history, always check these
measurements before dilating the eyes. This is because dilating drops will
effect these measurements - the vision gets blurry, pupils enlarge, and eye
pressure goes up. f you ever consult ophthalmology, we will always ask you
.
What's the vision, pupil, and pressure?


t's kind of a mantra. don't know how many times during my training 've
been asked to "get the vision, pupil, and pressure, then dilate them.
VisuaI Acuity:
You measure visual acuity with a standard
Snellen letter chart (the chart with the BG E on
it). f your patient can't read the E on the top line,
see if they can count fingers at different
distances. Failing this, try hand motion and light.
Poor distance vision usually occurs from
refractive error (your patient needs better
glasses).
The only vision that matters is the "best corrected vision so have your
patients wear their glasses. You're going to be amazed at the number of
people complaining of "blurry vision who leave their glasses in their car.
You'll also be impressed by the number of consults you'll get where the
consulting doctor hasn't bothered to check the patient's vision. Remember: "
can't see! is a relative complaint for some this means 20/25 vision and for
others this means complete darkness.

Das PinhoIe!
A quick and easy way to determine whether refraction is the culprit, short of
actually testing different lenses, is with the
pinhole test. Punch a small hole in a paper
card, and have your patient reread the eye-
chart while looking through this pinhole.
This technique can actually improve vision
by several diopters. t works because the
paper blocks most of the misaligned rays
that cause visual blur, and allows the
central rays to focus on the retina. f your
patient shows no improvement with
pinhoIing, start thinking about other visual
impediments like cataracts or retinal
problems. Most occluders (the black plastic
eye cover used during vision testing) have
a fold-down pinhole device for this purpose.
Near Vision
Near vision can be assessed with a near-card or by having your patient read
small print in a newspaper. Don't try using the near-card to estimate distance
acuity as distance vision is quite different than close-up acuity. That 20/20
marking printed on the near-card only checks "accommodated near-vision.
Remember that older patients can't accommodate well and need a plus-
power lens (reading glasses) to help them read the card. Carry a +2.50 lens
with you when seeing older inpatients as most of these patients leave their
reading glasses at home. We'll cover accommodation and presbyopia in
greater detail later in the optics chapter.


PupiIs:
The pupils should be equally round and symmetric with each other. You can
test reactivity to light with a penlight, but a brighter light like the one on the
indirect ophthalmoscope will work much better. When testing the eyes, you
will see a direct constriction response in the illuminated eye, and a
consensuaI response in the other eye. These should be equal and
synchronous with each other. Also, check the pupils with near-vision, as they
should constrict with accommodation.

Pressure:
We measure pressure by determining how much force it takes to flatten a
predetermined area of the corneal surface. There are several ways to do this
and in the eye clinic we use the "Goldman Applanation Tonometer that is
attached to the slit-lamp microscope.
When visiting bedside patients in the hosiptal, or with patients who are
difficult to examine, we can check pressure using a handheld electronic
Tono-pen. This little device can be tricky and in the wrong hands becomes a
random-numbers generator. 'll talk more about pressure and its importance
within the glaucoma chapter.

ConfrontationaI FieIds:
All patients should have their visual fields (peripheral vision) checked. A
patient may have great central vision, with perfect eye-chart scores, but
suffer from "tunnel vision resulting from neurological diseases or glaucoma.
f one eye is injured, or not sensing light, then your patient
may have an APD or "afferent pupillary defect. Often
these defects are only partial, making them difficult to
detect on casual examination. To detect small APDs,
you need to perform the "Swinging Light Test.
Here's how it works:

When you shine a light back and forth between
two normal eyes, you'll find that the pupils constrict,
then dilate a fraction as the light beam passes over the nose, and
then constrict again. As you go back and forth you'll see constriction,
constriction, constriction, and constriction.
Things look different if one eye is partially blind. As before, when you
shine the light in the good eye there is constriction. But, when you
cross to the other bad eye, both eyes seem to dilate a little. The bad
eye still senses light and constricts, but not as well. So you see
constriction, dilation, constriction, and dilation. This phenomenon is
also called a Marcus Gunn pupiI.