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Interpreting Regular and
Low Vision Eye Reports
BJ LeJeune, CVRT, CRC
Mississippi State University
November 1, 2012
2
Resources that Help
• Dictionary of Eye Terminology
www.eyeglossary.net
• Riordan P. & Whitcher, J.P. (2008).Vaughn & Asbury’s
General Ophthalmology
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Funded by RSA Grant # H264A080021. © 2012
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Two Types of Eye Exams
Regular Eye Exam
Low Vision Exam
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
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The goal of a regular eye exam
• Check general eye health
• To diagnose any eye problems
• To develop a treatment plan to address disease and
•
refraction errors
To maximize vision using traditional glasses or
contact lenses or refer for lasik surgery
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
What constitutes a “regular” eye
exam?
SOAP format
• S = subjective
• O = objective
• A = assessment
• P = plan
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Funded by RSA Grant # H264A080021. © 2012
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Subjective
• Patient History





“What’s going on?”
“Where is problem?” – (Which eye?)
“When did it start?”
“Why?” – (Did something cause problem?)
Modifiers
 Severity?, How often?, Does anything help?
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Funded by RSA Grant # H264A080021. © 2012
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Subjective (cont.)
 Medical History –
 Health history
 Meds - Rx, OTC, vitamins/supplements
 Previous eye care
 Brief Psychological evaluation
 O X 3 = oriented to person, place and time (date,
year, etc.) – Medicare requires this for a
comprehensive exam
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
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Objective Testing
• Visual acuity = VA
s = without correction, c = with correction
 DVA = distance, NVA = near
 OD = right eye, OS = left eye, OU = both eyes
 BVA = Best Corrected Visual Acuity
 Charts
 Snellen (or POC = “Project-o-Chart)
 = standard chart – gives 20/XX #’s - 1st 20 = test
distance (20 feet). 2nd number = size of letter seen.

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Funded by RSA Grant # H264A080021. © 2012
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Snellen Chart
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Objective Testing (cont.)
• Pupils
•
 PERRLA = Pupils equally round and reactive to light
and accommodation
 +/- APD (or MG) = positive/negative afferent pupillary
reaction (or Marcus-Gunn pupils) relative afferent
pupillary defect (RAPD)
EOM = Extra Ocular Muscles or Eye movements
 S & F = Smooth and Full
 Restricted – Which eye in which quadrant of gaze (up,
down, left, right or combinations)
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Funded by RSA Grant # H264A080021. © 2012
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Objective (cont.)
• Eye alignment
•
 Tropia = constant eye turn
 Phoria = intermittent eye turn
 Eso =in, Exo = out
Visual Fields – show field loss
 Confrontations = peripheral
 FTFC = Full to Finger Counting in all quadrants
 Can be used to map central or peripheral loss
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
12
Objective (cont.)
• Perimetry – measurement of the visual fields – Patient
•
•
must be able to fix on an object
Automated Fields (Humphrey, Dicon, Octopus, etc.)
 Static perimetry
 Gives detailed view of loss
 Can be used for central or peripheral loss
Manual Fields (Goldmann)
 Kinetic (moving)
 Evaluates the entire visual field
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
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Humphrey Visual Field Test
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Funded by RSA Grant # H264A080021. © 2012
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Results of Field tests
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Funded by RSA Grant # H264A080021. © 2012
15
Amslar Grid
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Funded by RSA Grant # H264A080021. © 2012
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Objective Continued
• Refraction
•
•
 Manifest = traditional
 Cycloplegic = dilated
Jaegar Near Vision chart
Intraocular pressures (IOP) or tonometry
 Combined with dilated fundus exam to test for
glaucoma
 Normal pressures 14-20
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
17
Objective (cont.)
• SLE = Slit Lamp Exam (Biomicroscopy)
 Examination of external structures of eye
 Lids/lashes, conjunctiva, cornea, anterior chamber,
iris. Lens
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Funded by RSA Grant # H264A080021. © 2012
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Slit Lamp
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Funded by RSA Grant # H264A080021. © 2012
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Dilated Fundus Exam
• DFE =Dilated Fundus Exam -internal eye exam
• C/D = cup to disc ratio of optic nerve
• V V = blood vessels
• Vitreous
• Periphery
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Funded by RSA Grant # H264A080021. © 2012
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Dilated Fundus Exam
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Funded by RSA Grant # H264A080021. © 2012
21
Fundus View of Diseased Retina
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Funded by RSA Grant # H264A080021. © 2012
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Jaegar Near Vision Test
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Funded by RSA Grant # H264A080021. © 2012
23
Intra Ocular Pressure
• IOP 10-21 normal
• Glaucoma is now diagnosed by changes in the disk to
ratio, not simply intra-ocular pressure readings
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
24
The Numbers
• IOP = intraocular pressure – measured by tonometry –
applanation, non-contact (“air puff”), old style = Schiotz
 Expressed in mmHg (millimeters of mercury – just like
a barometer)
 Glaucoma – pressure in the eye too high for the eye
to handle. Normal range = 10 – 21 mmHg. Can have
normal pressure and still have glaucoma (GLC). Can
have higher than normal pressures and NOT have
glaucoma.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
25
Assessment
• Also called Impression
 What the doctor thinks is going on
 Examples = AMD (macular degeneration), GLC
(glaucoma), BDR (non-proliferative or background
diabetic retinopathy), PDR (proliferative diabetic
retinopathy), Cataracts (NS = nuclear sclerosis),
Myopia (near-sighted), Hyperopia (far-sighted),
Presbyopia (you need bifocals)
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
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If there is Eye Condition, it is
noted…
• Most common abbreviations:
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
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

Age-related Macular Degeneration ARMD or AMD
Retinitis Pigmentosa – RP
Retinopathy of Prematurity – ROP
Background Diabetic Retinopathy – BDR
Proliferative Diabetic Retinopathy - PDR
Cataracts – lens removed (aphakia)
Leber’s Congenital Amaurosis - LCA
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
27
Plan
• How is patient to be treated
 Medical management
 Drug therapy
 Surgery
 Observation
 Optical management
 Glasses or contacts
 Referral – need to be sure they know about
Rehabilitation Services and Low Vision services
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
28
Low Vision Evaluation
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
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The goal of a Low Vision
Evaluation
• To confirm findings of eye report
• To maximize functional vision through low vision aids,
therapies, environmental modifications and patient
strategies
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
30
Low Vision Evaluation - History
• What is pt having trouble doing?
• Be specific – i.e. “How far are you sitting from
•
•
the TV? What type of reading light do you use?
How much reading do you need to do? Glare?
Vocation? Hobbies? Computer use?, etc.”
Glasses? (How old?) Contacts? What
magnifiers do you use now? (Look for “buzz
words” – i.e. “reading machine” = CCTV)
What is the one thing you want to do most?
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
31
Low Vision Evaluation
• Similarities to standard exam
•
 Most often will check the same areas, but with some
differences.
Differences
 History
 Most Important = functionality
 Most patients are referrals so Dx (diagnosis) is
known
 Current Medications – eye drops, orals,
supplements
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
32
Low Vision Evaluation History
(cont.)
• Include social info - living arrangements, transportation
•
issues (Are they still driving?!?), smoking, alcohol/drug
use
VA – most often use different charts
 Distance - Feinbloom #, EDTRS, Lea, etc.
 Why? – gradations between lines, test distances
 High contrast vs. low contrast
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Funded by RSA Grant # H264A080021. © 2012
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Feinbloom chart
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Funded by RSA Grant # H264A080021. © 2012
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Common Near Vision
• Bailey–Lovie
• Hoeft
• Mnread
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
Low Vision Evaluation – Visual
Fields
• Confrontations - but can use to map scotomas
•
and field restrictions
Amsler grid – use for quality of macular loss
 Scotoma density
 Metamorphopsia (distortion)
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
35
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Low Vision Evaluation
• Automated fields – sometimes less effective –
difficulties with fixation, etc.
 Nidek MP-1 – maps central scotomas
 Scanning laser ophthalmoscope
• Pupils/Eye movements = same but can give info
•
on undetected brain issues (stroke, etc.)
Eye health eval = seldom dilate – creates
artificial VA problems
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
37
Bi-Optic Driving Assessment
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
38
Bioptic Driving
•
•
•
•
•
•
•
•
Check fields
Ability to quickly find and track
Ability to anticipate
Accuracy of interpretation (VA)
Light issues
Eye Dominance
Contrast sensitivity
Motivation and Enthusiasm
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
39
Low Vision Aid Evaluation
• Start with what they want most
 Most often = READING!!
• Prescriptive process - Not just throwing
•
•
magnifiers at them!
May take more than one visit to determine best
aids for that person. Good to let them try before
purchase if possible.
Training on use of aids is critical.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
40
Helpful Hint
• If you have difficulty seeing in
different situations, bring
samples.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
Low Vision Evaluation –
Assessment and Plan
•
•
•
•
Diagnosis for billing purposes
Aids may or may not be Rx’d at first visit
May need additional visits
May include referral to other agencies for
services – O&M, home visits, OT/CVRT
services, VR services, Social Service agencies
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
41
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Causes of Low Vision Aid
Abandonment
•
•
•
•
Inability to use aid correctly
Wrong Aid for situation
Poor lighting
Aid too strong or not strong enough
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
43
Reading Reports
• Who is it from?




Primary eye care provider (ECP = OD/MD)
Low Vision Specialist (OD/MD, OT/CLVT/CVRT)
Interagency/Intra-agency
Neurologist or Neuro-Optometrist/Ophthalmologist
(Remember providers have their own “Lingo”)
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
44
Reports – Primary ECP (OD/MD)
•
•
•
•
•
•
Objective findings
Medical Dx and Medical/Optical treatment
When/how often they will see patient
Most often geared toward other medical
professionals
Do not expect opinions on low vision aids
You may only get “chart notes”
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
45
Regular Exam Letter Example
Dear XXX,
I had the pleasure of seeing XXX, a very pleasant XX
year old female for a comprehensive eye exam on
XX/XX/XX. Chief complaint was blurred vision. She has
a history of macular degeneration, worse in the right eye
than the left. Medical history includes hypertension and
hypothyroid, both controlled by medication,
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
46
Regular Exam Letter Example
(cont.)
Following is a summary of XX’s exam:
Best Corrected Visual acuities: OD 20/200, OS 20/80
Pupils: PERRLA, (-) APD
EOM: Smooth and Full
Visual Fields: Full to Finger Counting
IOP’s: OD 18mmHG, OS 17mmHg
Biomicroscopy: Nuclear cataracts – OD & OS, otherwise unremarkable
DFE: Macular drusen and RPE changes, otherwise unremarkable
Diagnosis: Age-related Macular Degeneration - OU
My plan is to see XX in 6 months for continued care. If there are
questions, please do not hesitate to call me.
Best Regards,
XXX XXX, OD
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Funded by RSA Grant # H264A080021. © 2012
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Reports – Low Vision Specialist
•
•
•
•
Visual acuities
Other pertinent findings
Diagnosis
Should include advice on low vision aids or at
least preliminary results and that there is ongoing evaluation
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
48
LV Letter Example
Dear XXXXX.
I had the pleasure of seeing your patient (client), XXX
XXXX, for a low vision evaluation on xx/xx/xx. As you
know, XXX is a very nice XX year old woman, who
suffers from macular degeneration. As you are
familiar with her medical history, I will not recount that
here. XXX lives at home with her husband.
XXX’s main concern is reading. She also has
difficulty with personal hygiene and other daily tasks.
Following is a brief summary of her evaluation:
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LV Letter Example 2 (cont. 2)
With her current eyeglasses, XXX’s vision measured at
OD 10/100 (20/200) and OS 10/40 (20/80). Reading
measured at 2.5 M (large print material size). Pupil
reactions were minimal and eye movements were full.
Visual fields by confrontations/Amsler grid showed a
large dense central scotoma in the right eye and a
smaller area of metamorphopsia centrally in the left eye,
with periphery full to finger counting in both eyes.
Additional findings were consistent with the diagnosis.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
50
LV Letter Example (cont. 3)
Various low vision aids were demonstrated. We also demonstrated
and instituted a course of eccentric viewing training. Best response
to low vision aids were: 4.0X (brand) LED lighted stand magnifier
for reading which allowed 1.0 M print (newsprint). We also
demonstrated a 4.0X LED hand magnifer for portability. For glare
issues, a medium plum sun filter (NoIR U81) was recommended.
We plan to see XXX for additional evaluation and training, at which
time we will demonstrate CCTV’s and other low vision aids.
Thank you for allowing us to share in the care of this delightful
woman. If there are questions, please feel free to contact us.
Regards
XXXX, OD
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
One Other Type of Assessment:
Functional Vision Assessment
• Field based – home, school, work
• Submitted by a LVT, TVI, VRT, O&M or CRC
• Friends and Family can assist with
observations
• Variety of factors beyond just eyes – fatigue,
environmental cues, experiences, glare,
contrast, etc.
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What do those Numbers Mean?
• Visual acuity
 20/XX
 1st 20 = test distance (20 feet)
 2nd number = Letter size – based on angle
subtended in seconds of arc
 The larger the 2nd number, the worse the vision
 Many low vision doctors work in shorter distances (ex.
10 feet) so may look like 10/40 – this equates to 20/80
(7/40 = 20/125, 5/40 = 20/160, etc.)
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
Legal Blindness – Social
Security 1934
• Best Corrected (!!) vision of 20/200 or worse in the
•
•
better eye OR Visual field of 20 degrees or less
YOU CANNOT BE LEGALLY BLIND IN ONE EYE !!!
YOU CANNOT BE LEGALLY BLIND IF YOU VISION IS
CORRECTED BY GLASSES OR CONTACTS TO
BETTER THAN 20/200.
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Funded by RSA Grant # H264A080021. © 2012
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Eccentric viewing
• Eccentric viewing forces the use of alternate areas of
retina with lower resolution that are often located outside
of the affected foveal/macular area.
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Funded by RSA Grant # H264A080021. © 2012
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Preferred Retinal Locus
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Refraction
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Filters (Sunglasses)
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The Numbers
• Magnification
 D (diopters) to X (magnification) = D/4
(or in Europe D/4 + 1)
 12 D = 3X (European = 4 X)
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Funded by RSA Grant # H264A080021. © 2012
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Results should be functional and
informed
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Funded by RSA Grant # H264A080021. © 2012
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Comments & Questions
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Funded by RSA Grant # H264A080021. © 2012
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Thank You
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
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Contact Information
BJ LeJeune, CVRT, CRC
P. O. Box 6189
Mississippi State, MS 39762
(662) 325-2001
[email protected]
Special thanks to
Dr. Garry M. Griswold, Low Vision Clinician
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
63
Education Credits
CRCC Credit - (1.5)
Approved by Commission on Rehabilitation Counselor
Certification (CRCC)
• By November 11, 2012, participants must score 80%
or better on a online Post Test and submit an
online CRCC Request Form via the MyTACE Portal.
My TACE Portal: TACEsoutheast.org/myportal
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
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Southeast TACE Region IV
Toll-free: (866) 518-7750 [voice/tty]
Fax: (404) 541-9002
Web: TACEsoutheast.org
My TACE Portal: TACEsoutheast.org/myportal
Email: [email protected]
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012
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Disclaimer
This presentation was developed by the
Southeast TACE Center: Region IV ©2012 with funds
from the U.S. Department of Education, Rehabilitation
Services Administration (RSA) under the priority of
Technical Assistance and Continuing Education Projects
(TACE) – Grant #H264A080021. However, the contents
of this presentation do not necessarily represent the
policy of the RSA and you should not assume
endorsement by the Federal Government [34 CFR
75.620 (b)].
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2012