Most ophthalmology practices employ ophthalmic assistants, technicians, and/or technologists (allied health personnel) to “work-up” or obtain pertinent information before the physician sees the patient. This workup information usually includes the patient’s chief complaint or history of present illness; medications; allergies; past, family, and social histories (both medical and surgical); and a review of systems. In addition to the medical information, the allied health personnel or AHP, performs preliminary elements of the examination and measurements. This examination assists the physician in assessing the patient and increases efficiency. The preliminary exam should be based upon a complete and thorough description of the chief complaint and/or presenting signs and symptoms.

The Patient Interview

The patient interview begins when he or she is called to the examination room. The AHP performs a two-part assessment: a visual examination and a conversational assessment to discern the problem, complaint or reason for the visit:

• Visual assessment. The AHP should do a brief visual assessment of the patient’s face and body. Does the patient have a droopy lid? Is he or she able to walk without assistance to the exam room? Does the patient seem to be paralyzed on one side?
• Conversational assessment. The AHP is usually under pressure to complete a new patient workup in 20 minutes or less. However, patients need to feel they are being treated with care and respect. The AHP should converse with the patient to gain his or her trust and confidence. Patients who don’t feel welcomed by the AHP may provide incomplete or otherwise misleading information. If that happens, the physician may need extra time to collect the necessary information when seeing the patient.
  The visual assessment and brief conversation with the patient should lead into a discussion of the presenting problem, complaint or reason for the visit or follow-up. The history of present illness is defined by the following:
• Chief complaint. The chief complaint is the focus of the exam. If the patient has several complaints, document them in order of importance. This information is frequently recorded by the AHP. Physicians will add additional information when necessary.
• Location. What is the site of the pain or discomfort? Is it unilateral or bilateral?
• Quality. What is the source of the pain? Is it constant, acute, chronic, improving or worsening?
• Severity. How severe is the pain or redness on a scale of 1 to 10, with 10 being the worst?
• Duration. How long has the patient had the sign or symptoms?
• Timing. Is the problem worse in the morning or evening, or is it constant?
• Context. Is it associated with any activity?
• Modifying factors. What efforts has the patient made to improve the problem? Heat? Artificial tears? Other?
• Associated signs and symptoms. Do other symptoms or problems occur along with this one?

Tech Sleuthing

Many retina patients are referred, and they often do not understand the reason for the visit. They do not have any visual complaints and often will simply say, “My doctor found something in the back of my eye and sent me here!” The AHP must therefore search out more information.

• Review the patient’s medical history, medications and review of systems.
• The medical information or review of systems may assist with determining appropriate questions to ask the patient. Through training, the AHP should be familiar with potential visual complaints associated with medical conditions and medications. For instance, hypertensive patients should be asked if their blood pressure is under control and how long have they had hypertension. Patients should be asked about spots or floaters in their vision, blacked-out areas in their vision, fog or veil over their vision, decreased vision, sudden loss or decrease in vision, vision blackouts that come and go (last less than 1 minute), double vision, loss of peripheral vision, and headache.
• AHPs also need to be familiar with or keep a list of common medications that patients take for their medical conditions. Patients do not always know why they are taking certain medications. For example, patients will often tell the technician they do not have hypertension, but after reviewing the list of medications, the AHP will realize the patient is taking medication for hypertension.

The Preliminary Examination

Following a thorough and complete history of the chief complaint and review of systems, the preliminary examination begins:

• Visual acuity. The AHP should obtain a distance and near acuity on every patient at every visit. The acuity should be measured with glasses or contacts. Pinhole vision should be obtained if visual acuity is decreased.
• Visual fields. Testing is important to screen patients for any possible interference in the nerve pathways from the eye to the brain:
  • Confrontation visual fields is an important tool for determining loss of field of vision, which may associated with stroke, hypertension, heart disease, diabetes or retinal detachment.
  • Amsler grid testing tests central 20 degrees and detects areas of distortion or “missing spaces.” It is useful for conditions such as macular degeneration and macular edema.
• Pupil assessment. Pupillary reflexes are assessed by direct and indirect light reflexes and with the swinging flashlight test. The size of the pupil in light and dark is assessed, as is the relative color of the irises. Size, shape and equality of size should be documented. A relative afferent pupillary defect (also referred to as a Marcus-Gunn pupil) may be caused by conditions such as retinal detachment, optic neuritis, optic atrophy or retinal vascular occlusion. Bilateral afferent pupillary defect may indicate a more serious condition. Anisocoria with dilated pupil in the affected eye may indicate a serious and life-threatening condition such as tumor, aneurysm, inflammation or bleeding. A tonic pupil frequently occurs with diabetes mellitus, alcoholism, viral infection or trauma. Iris defects may be caused by trauma or synechia. Anisocoria with a constricted pupil and lid droop (ptosis) in the affected eye may indicate the presence of a Horner’s syndrome.
• Examination of extraocular muscles. This examination is used to diagnose strabismus, paralysis of ocular muscles and gaze paresis. Evaluation should include the corneal light reflex test, cover/uncover test and six cardinal directions of gaze. Acquired ocular motility disturbances may be due to diabetes mellitus, multiple sclerosis, tumors, arteriosclerosis, central ischemia, AIDS, and trauma or other causes. Acquired nystagmus occurs due to multiple sclerosis, trauma or tumors.
• Color vision assessment. Test plates may be used to determine a change in color vision due to optic nerve or central retinal disorders. Only one eye at a time is measured, with the reading correction in place. A red bottle cap may also be used to determine slight differences in color saturation between the two eyes.
• Intraocular pressure. A tonometer, applanation tonometer or other device is used to determine the intraocular pressure of both eyes prior to dilation.
• Evaluation of angle structure. The depth of the anterior chamber is determined prior to dilation for narrow or shallow angles. This test may be performed using a penlight or slit lamp.
• Dilation of pupils. Ophthalmic dilating drops are instilled according to the physician’s order. The patient is then asked to sit and wait for dilation to occur so that the physician can complete the exam.

Other AHP Responsibilities

For practices that desire to improve their examination efficiency, the AHP could be trained to perform additional preliminary testing, including:

• Slit lamp examination. This test evaluates ocular structures for abnormalities. The pupil should be evaluated for iris neovascularization prior to dilation. The AHP should be trained to alert the physician to potential problems.
• Exophthalmometry. This text measures for forward protrusion of the eye, which can be caused by thyroid disease or tumors of the orbit.
• Diagnostic ultrasound. A-scan and B-scan. With an order from the physician, the AHP performs an ultrasound to view posterior (and sometimes anterior) structures of the eye.
• SCODI - Scanning Computerized Ophthalmic Diagnostic Imaging (OCT, HRT, GDx). With an order from the physician, the AHP performs a scan of the macular and/or optic nerve to evaluate retina and optic nerve structures.
• Fluorescein angiography and fundus photography. With an order from the physician, the allied health personnel obtains pictures of the posterior segment of the eye.

Conclusion

With proper documentation and orders from the physician, all preliminary testing should be performed on patients that are returning for follow-up before the physician sees the patient.

A well-trained and knowledgeable allied health professional will be able to perform thorough and complete patient workups including all the necessary preliminary testing and documenting the patient’s signs and symptoms, medical history, medications, and/or review of systems. This allows for efficient use of both the patient’s and the physician’s time in determining treatment and/or diagnosis.

References
Lang GK. Ophthalmology: A Pocket Textbook Atlas. New York and Stuttgart: Georg Thieme Verlag,  Stuttgart. 2000.
Ledford JK. The Complete Guide to Ocular History Taking. Thorofare, NJ: Slack Incorporated; 1999.
Stein HA, Stein RM, Freeman MI. The Ophthalmic Assistant: A Text for Allied and Associated Ophthalmic Personnel, 8th ed. Canada: Elsevier Mosby; 2006.

About the Author: Natalie Loyacano, COMT, ROUB, OCS is a practice administrator and Technologist at the VitreoRetinal Eye Center in Louisiana. She has 26 years experience in ophthalmology and is also a certified ophthalmic surgical assistant. Natalie has been the past President of ATPO and LATPO, currently a member of JCAHPO's Board of Directors, and the Executive Director for LATPO.