Clinical techniques and refraction

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Clinical techniques and refraction
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Case History
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Clinical thought
Case history
(1)
Optometrical investigation
Tentative diagnosis
(2)
Specific tests
(3)-(4)
Treament plan
Definitive diagnosis
Analysis of information
(6)
(7)-(8)-(9)
(5)
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Objective of the clinical history
Objective
Extract information from the patient that
will be useful in determining the specific tests
that should be performed during the visual
investigation in order to, after their
interpretation and analysis, arrive at a
definitive diagnosis and a treatment plan.
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Reflections before beginning
Important points

• The patients case history begins in the first
  few minutes of the visit but continues throughout
  the duration of the clinical examination
• When creating a case history, keep in mind the
  prevalence and incidence of visual conditions and
  ocular illnesses as well as their relation to
  age.
• It is important to establish an appropriate
  professional-patient relationship.

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Reflection before beginning

• Example of the question in the case history

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Most frequent errors

• Premature or hasty conclusion a conclusion
  before obtaining all of the information necessary
  and stopping the investigation.
• Pseudodiagnosis or inadequate synthesis all of
  the information is extracted but at the end there
  is no diagnosis.
• Lack of trust on the patients behalf
• Letting oneself be guided by intuition, etc

Common errors
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Sections of the case history
Sections of the case history

• Personal information
• Main reason for the consultation (MC)
• Personal history (PH)
• Ocular and general health history
• Family history (FH)
• Ocular and general health history
• Visual needs at work and other activities

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Personal information
Personal information

• First and last names
• Date of the appointment
• Date of birth and current age
• Complete address and telephone number(s)
• Sex/Race
• Profession
• Sent/recommended by
• Observations

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Main reason for the consultation
Reason for the consultation
Reason for the consultation (MC) the objective
is to determine the possible etiologies of the
visual problem the person shows, depending on the
symptoms that the person manifests.
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Reasons for the consultation
Reasons for the consultation

• Reasons for the consultation (MC)
• Main reason for the consultation
• Open question
• What is the reason for your visit?, Why have
  you come to see us?, Whats wrong?
• Write it down in the patients words
• Continue with more questions in order to get to
  the main and any secondary symptoms when, how,
  where, from distances, from near

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Reasons for the consultation

• Examples of questions to center on the reasons
  for the consultation

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Most frequent symptoms
Most frequent symptoms

• Blurry vision
• Visual fatigue
• External ocular discomfort
• Headaches
• Loss of vision
• Other visual discomfort

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Most frequent symtoms

• Blurry vision (functional causes)
• Ametropia/Presbyopia
• Amblyopia
• Accomodative dysfunction
• Binocular dysfunction
• Simulation/ocular hysteria

• Blurry vision (pathological causes)
• Corneal/crystalline alteration
• Inflammation
• Vitreous opacities
• Macular problems
• Problems with the optic nerve

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Most frequent symptoms

• Visual fatigue
• Ametropia/Presbyopia
• Binocular dysfunction
• Accomodative dysfunction
• Anisometropia/aniseikonia
• Inadequate optical correction
• Inadequate environment

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Most frequent symptoms

• Double vision (diplopia)
• Ametropia
• Binocular dysfunction
• Monocular diplopia

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Most frequent symptoms

• Loss of vision (of visual acuity)
• Migraine
• Optic neuritis
• Occlusion of retinal vein or artery
• Temporary arthritis
• Papilloedema

• Loss of vision (of field of vision)
• Retinal lesions/loosening
• Anomalies of the visual pathway

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Most frequent symptoms

• Discomfort related to the anterior segment of the
  eye
• Excessive tearing
• Reddening/Itchy eyes
• Sensation of foreign body

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Most frequent symptoms

• Headaches
• Ametropia/Presbyopia
• Binocular dysfunction
• Accomodative dysfunction
• Vascular migraine, tensional, etc.
• Inflammatory, tumoral, etc.

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Most frequent symptoms

• Headaches
• Ametropia/Presbyopia
• Binocular dysfunction
• Accomodative dysfunction
• Vascular migraine, tensional, etc.
• Inflammatory, tumoral, etc.

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Personal history
Personal history

• Visual and ocular personal history
• If he/she wears glasses and/or CL
• How long have you worn glasses? How long have you
  had this prescription? When was your last
  check-up? When or for what do you wear the
  glasses? Do they work well for you?
• Test the graduation to the frontal focometer and
  the centration distance, ? effects, material,
  color, design, etc.
• If he/she does not wear glasses
• Have you ever worn glasses? When was your last
  eye exam?

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Personal history
Personal history

• Visual and ocular personal history
• Ocular traumas
• Is the person using any drops or creams for the
  eyes? Has he/she ever used any?
• Past or present ocular illnesses
• Ocular operations or operations in surrounding
  areas

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Personal history

• Personal history of general health
• General health
• Current state of health? Any health problems like
  diabetes, hypertensión, etc.?
• Medication
• Is he/she taking any medication? Why? For what?
  When? Since when? How much?
• Has he/she taken any medication recently?
• Are there any known allergies?

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Family history

• Family history (FH)
• Ocular history and general health
• Interrogation directed at conditions with a
  possible hereditary factor and that can affect
  the vision glaucoma, diabetes, retinal
  detachment, severe loss of vision, ocular or
  arterial hypertension, etc.

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Visual needs

• Visual needs
• What do you do? Distance, lighting, size, etc.?
• Any hobbies that require visual exertion?
  reading, painting, sewing, music, etc.

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Relevant observations

• Observations any relevant TRAZO from external
  factors

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Case file

• Personal information
• MC, PH, FH
• Refractive section
• PD
• AV
• Retinoscopy and Subjective
• Others
• Visual efficiency
• Binocularity
• Accomodation
• Ocular motility

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Case file

• Personal information
• MC, PH, FH
• Refractive section
• PD
• AV
• Retinoscopy and Subjective
• Others
• Visual efficiency
• Binocularity
• Accomodation
• Ocular motility

• Ocular health
• Anterior segment
• Eye exam
• Visual field
• Pupillary function
• Intraocular pressure (IOP)
• Ex. complementary
• Color vision
• Diagnosis

• Treatment plan
• Future visits

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Associated practice

• Practice 1 Case history between fellow students
  in the group
• Practice 2 Case history of external patients

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Work outside the classroom

• Creation of a list of questions to ask in
  distinct hypotheses
• 15-year-old that attends a revision due to loss
  of far vision
• 38-year-old adult that attends a revision due to
  loss of near vision
• 70-year-old elderly patient that attends a
  revision for loss of vision

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Bibliography