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Certified Paraoptometric Review Course CPO Lynn Lawrence, CPOT
Be thankful for your job!
Disclaimer…not sanction by CPC n Disclaimer: This review course does not prepare you for the national examination, what it does is review key areas from the most current test outline. To properly prepare for a national examination you should allow yourself ample time to fully review all the areas being tested
Objectives n Provide a 3 hour review of – Discuss practice management – Thoroughly review anatomy – Clarify terminology used in review – Explain the equipment used in review – Discuss primary diseases – Review test procedures n Give a 25 question review test
Eyecare Specialists and Ancillary Personnel (2%)
The Four “O’s” Optometrist…state over sight n Ophthalmologist…surgeon n Optician…makes the glasses n Ophthalmic Medical Personnel n – Optometry technicians – Ophthalmology technicians
Roles of a Paraoptometric Collect patient data n Administer tests of visual capabilities n Assist in managing the office n Assist in primary patient care examination and treatment n – Contact lenses – Low vision – Vision therapy – Optical Dispensing
Practice Management (10%)
Practice Management n Telephone Techniques…when/how messages n Appointments…when is the best time to book? n Record Filing Systems…which the best? – Alphabetical – Numerical n Recalls…which is the best method?
“Triage” use to categorize n Emergency – Must be evaluated immediately n Urgent – 12 -24 hours n Routine – Next available appointment
Triage Questions n n n What problem are you having? (chief complaint) How long has it been going on? (onset/duration) Is it getting worse? (severity) Does it affect your vision? (associated symptoms) Does anything make it better? (modifying factors) Which of these is most important?
Practice Management continued Fee Presentation n Collections n Third Party Payments…also know as? n Receipts n Explanation of charges n When do you apologize for your fees?
HIPAA n What is HIPAA? – Health Information Portability & Accountability Act – Took effect April 14, 2003 How long are you required to keep patient records?
HIPAA – continued Use and Disclosure n Use – The sharing, employment, application, utilization, examination or analysis of Protected Health Information (PHI) within the covered entity n Disclosure – The sharing or release of PHI in any manner outside the covered entity
HIPAA – continued n Office Responsibilities – Establish and maintain procedures consistent with the Privacy Act – Prepare and publish notice of the existence and character of those systems consistent with guidance by GSA – Establish reasonable administrative, technical, and physical safeguards – Maintain an account system of all disclosures for six years – Permit individuals to have access to personal records – Permit individuals to request records amendments
HIPAA – continued n Minimum Necessary Principle – Requires office to take reasonable steps to limit the use or disclosure of, and request for, PHI to the minimum necessary to accomplish intended purpose
HIPAA – continued n Considerations Prior to Disclosure – – – – Patient notification before release Mutually agreed upon alternative communications Mutually agreed upon authorizations Potential or serious threat or imminent danger to patient or public Authority of requestor Minimum amount of information necessary for purpose Can information be de-identified Documentation of release
HIPAA – continued n Requirements for Document – Date of disclosure – Name, address, and identity of requestor – Brief description of PHI disclosed – Brief statement of the purpose of the disclosure that reasonably informs the individual of basis for disclosure or copy of written request – Verified identity of requestor
n 7 Layers of the eyelids 1. Skin-thinnest layer 2. Subcutaneous connective tissue 3. Striated Muscle 4. Sub-muscular connective tissue 5. Tarsal plate or fibrous layer 6. Smooth muscle 7. Conjunctiva (Bulbar/Palpebral) Eyelid
Lipid Secretion: Meibomian Glands (WC Posey, Diseases of the Eye, 1902) n Transillumination of meibomian glands The lipid layer restricts evaporation to 5 -10% of tear flow – Also helps lubricate (Transillumination image from Dry Eye and Ocular Surface Disorders, 2
Tear Film Layers oil snot aqueous
Healthy Tears…. gee whiz slide A complex mixture of proteins, mucins, and electrolytes coated by a lipid layer • Antimicrobial proteins • Growth factors & suppressors of inflammation • Soluble mucin helps stabilize tear film • Electrolytes for proper osmolarity (295 -300) – p. H slightly alkaline (7. 4) This is not testable, info only
Conjunctiva n n n An epithelial membrane which covers the anterior sclera and continues to the back surfaces of the lids to form a conjunctival sac Has blood vessels which can burst and cause subconjunctival hemorrhage Three parts – – – Bulbar Palpebral Fornix - where bulbar and palpebral meet
Adnexa: Orbital Bones n 7 Orbital Bones – – – – Maxilla Frontal Zygomatic Ethmoid Lacrimal Palatine Sphenoid Which bone is the weakest? Sphenoid Palatine Maxilla Ethmoid
Adnexa: Extraocular Muscles n 4 Rectus Muscles – Superior – Inferior – Lateral – Medial
Adnexa: Extraocular Muscles n 2 Oblique Muscles – Superior – Inferior
Lipid Secretion: Meibomian Glands What eye is this? Transillumination of meibomian glands (WC Posey, Diseases of the Eye, 1902) How does the lipid layer aid in contact lens wear? (Transillumination image from Dry Eye and Ocular Surface Disorders, 2
Adnexa: Lacrimal System Lacrimal gland Superior punctum Superior canaliculus Lacrimal sac Excretory ducts Inferior punctum Inferior canaliculus Nasolacrimal duct Nasal cavity
Anatomy and Physiology of the Eyeball 3 Layers n Fibrous Layer *Cornea *Sclera n Vascular Layer *Choroid *Ciliary body *Iris n Nerve Layer *Retina *Macula *Optic nerve What function does each layer have?
Anterior Segment…where is it n n n Cornea Conjunctiva – Palpebral – Bulbar Anterior chamber Iris – Pupil Crystalline lens – Accommodation Ciliary Body – Muscle/Processes Graphic courtesy of National Eye Institute, National Institute of Health
Posterior Segment Vitreous humor n Choroid n Retina n – Macula – Fovea Centralis How many layers are in the retina? Retina
Posterior Segment: Macula/Fovea n Function – Central vision – Color vision What is the purpose for rods and cones?
Posterior Segment-Optic Nerve n Optic Disc – Correlates with the physiological blind spot n Optic Nerve – Cranial nerve # 2 What type of vision is in the Optic nerve head?
The Eye Examination (17%)
Case History ■ ■ ■ Chief Complaint…critical for insurance filing! ■ Reason for visit-recorded in patient’s own words History of present illness ■ Detailed information on chief complaint Medical/ocular history (Dx) Family History (FHx) Social history (age-appropriate) ■ Alcohol? Smoke? Occupation? Live alone?
Ocular History n Rule out specific ocular problems and conditions, such as: – Glaucoma – Cataracts – Keratoconus Match the diseases to the structure…
Medications q Name q Amount taken q Frequency q Prescribed for q Prescribed by q Illegal drugs too! Why is illegal drug use important?
Visual Acuity: Snellen Fraction n Numerator – Represents the testing distance in feet or meters – 20/_____; 6/______ n Denominator – Represents the distance at which the letter subtends a 5 -minute angle of arc in distance or meters. Also referred to as the letter size. How would you document a patient that can only see the big “E” at 10 feet?
Visual Acuity Test of macular function n Snellen fraction n – Numerator-# of ft. away from viewed letter – Denominator-# of ft. a person with “normal” vision could see the letter What is optical infinity?
Accommodation vs Acuity Accommodation is the ability of the to focus from a distance to near and vice versa n Acuity is the ability of the eye to see fine detail n
Keratometry n Keratometer – Measures the curvature of the cornea – Response from the patient not needed to perform = objective test Measures how much of the cornea?
Manual Keratometry End Point Starting Point + +
Prize slide Clearly explain these instruments and what they function they perform?
Refraction n Objective Refraction – Retinoscopy – Auto-refractor n Subjective Refraction – Phoropter – Patient needed What is the difference between subjective and objective refractions?
Ophthalmoscopy n n n Evaluates the posterior segment Patient must be dilated Types of ophthalmoscopy Indirect Ophthalmoscope – Indirect…on head n Less magnified, wider view – Direct…in hand n More magnified, narrower view Direct Ophthalmoscope
Biomicroscopy Commonly called “Slit Lamp” – Evaluates the anterior segment of the eye (cornea to lens) – Evaluates intraocular pressure by attachment of a Goldmann applanation tonometer
Tonometry n Goldmann Applanation – Mounted on slit lamp – Requires anesthesia and fluorescein dye n Tonopen® – Portable – Requires anesthesia n Non-contact (air-puff) – Easy to use – No anesthesia required
Fundus Photography Terms n Fundus – interior posterior surface of the n n n eyeball Posterior Pole – refers to the retina between the optic nerve and macular area Arcades – normal pattern of retinal blood vessels as they leave the optic nerve head and arch around the macula Cup-to-Disc ratio – numerical expression indicating percentage of disc occupied by the optic cup
Fundus Photography Terms n n n Exudates – protein or fatty fluid that leaks from blood vessels into retinal tissue (hard is less fluid, more dense) (soft fluffy looking also called cotton wool spots) Cotton Wool Spots – fluffy looking white deposits resembling small tufts of cotton within the retinal nerve fiber layer that represent small patched of retina that have lost their blood supply from vessel obstruction Nevus – mole small and flat usually pigmented area, benign tumor made of specific cells called nevus cells found in skin and eye tissue
Fundus Photography Examples Normal Papilledema Fluorescein Angiography Lasered Diabetic Retinopathy
Optical Coherence Tomography (OCT) What is this machine used for?
Corneal Topography § Measurement of the curvature of the anterior corneal surface.
Pachymetry n A Pachymeter determines thickness of the cornea by use of ultrasound – Refractive surgery – Glaucoma diagnosis How might IOP pressure be impacted by The thickness of a cornea?
Optical Coherence Tomography (OCT) n n A laser-based, non-contact, non-invasive imaging technique that is capable of obtaining high resolution images of the retina and its components. Clinically useful in visualization of: – Macula holes – Macula edema – Age-related Macula Degeneration – Epiretinal membranes – Central serous chorioretinopathy
Tomography Advantages n Non-contact, non-invasive scan obtained in one second n Shows living histology with minimal discomfort to the patient n No injections of exposure to painful high-intensity light n Increased patient comfort and safety, reduced photophobia
Visual Field n What is a visual field? – The area of space visible to the eye n What is a scotoma? – Blind spot n What is used to measure a visual field? – Perimetry
Refractive Status (12%)
Refractive Errors n n n Myopia Hyperopia Astigmatism Presbyopia Amblyopia
Emmetropia vs. Ametropia n Emmetropia – No refractive error – Rays of light focus on the retina n Ametropia – An optical error – Corrected by glasses, contact lens or refractive surgery
Emmetropic Eye Emma is a perfect woman
Myopia Also called “Nearsighted” n Axial myopia n – Eye is too long – Rays of light fall in front of retina n Index myopia – Diabetes/cataracts n Corrected by a concave, or minus lens
Myopia n n A refractive condition where parallel light rays focus in front of the retina when the eye is at rest Termed nearsightedness Patient may have 20/20 vision at near, but distance vision will be reduced Corrected with minus lenses
Hyperopia Also called “Farsighted” n Axial length of the eye is too short n – Rays of light fall virtually behind the retina Affected by accommodation n Corrected by a convex, or plus lens n
Hyperopia n n A refractive condition where parallel light rays focus behind the retina when the eye is at rest Termed farsightedness Patient may have 20/20 vision at distance and near Corrected with plus lenses
Astigmatism n Corneal Astigmatism – 2 different points of focus – Cornea is “football-shaped” – Corrected by cylinder at a specific axis n Lenticular Astigmatism – Crystalline lens n Irregular Astigmatism – Cannot be corrected by a lens n Keratoconus n Corneal trauma
Astigmatism n n n A refractive condition where different meridians of the eye have different powers Corrected by lenses which incorporate cylinder power Usually due to different curvatures of the cornea
Presbyopia Natural aging of the crystalline lens n Affects accommodation n Corrected by additional plus power at near n – Bifocal – Trifocal – Progressive – Reading glasses
Presbyopia n n A condition in which lost elasticity of the lens leads to the inability to accommodate Age related condition What age does presbyopia begin?
The Ophthalmic Prescription (9%)
The Ophthalmic Prescription n Components of a lens prescription – Sphere, cylinder, axis – +2. 00 -1. 00 x 095 – Add power – Prism n Lensometer – Used to measure lens components
Unit of Measurement n Diopter - unit of measure for optical lenses. – Based on fact that a 1 diopter lens will focus parallel light at 1 meter.
1 Diopter Focus Light at 1 Meter +1 D -1 D
Ophthalmic Lenses (5%)
Refraction n Definition – Altering of the pathway of light from its original direction as a result of passing obliquely from one medium to another of different density – Pivoting or bending of light rays
Light Visible wavelengths extend from 400740 nanometers (nm), 400 nm being violet and 740 nm being red. n A change of wavelength is perceived as color change. n 400 500 600 700
Light n Light travels in a vacuum at 186, 000 mps and in various other transparent media at slower speeds. It is this characteristic of light, traveling at different speeds in different media, that causes the bending or refraction of light, for example, light travels at 77, 000 mps in diamond and 120, 000 mps in crown glass
Deviation Bending of light n Image deviates towards the Apex n Light is deviated towards the base n Apex Base
Prescriptions: Light Rays n Rays move from left to right n Converging n Diverging Rays Light always deviates toward the base of a prism
Prescription: Prism n Displaces light Light bends toward base, Image displaced toward apex
General Lens Forms
Lens Types n Types of Lenses – Single vision – Spherical – Planocylindrical – Spherocylindrical – Multifocal n Bifocal n Trifocal n Progressive addition
Lens Materials n Lens Materials – – – Glass Plastic (CR-39) Polycarbonate High index Trivex ™
Bifocal Lenses (FT-28, D-28) Trifocal Lenses (Executive) 7 mm 17 mm 28 mm
Progressive Lenses Progressive Addition Lenses Distant Viewing Zone Near Viewing Zone Intermediate Viewing Zone Aberration Zones
Ophthalmic Dispensing (8%)
Lenses n Plus- Lens that is thicker in the center than at the edges, adding optical power to incoming light rays. Corrects farsightedness n Minus- Lens that is thicker at the edges than in the center, increasing divergence of incoming light ray. Corrects nearsightedness n Cylindrical- Lens that produces a different refractive power in each meridian; used for correcting ocular astigmatism. n Prism - Power = Deviation in cm/distance- Wedge-shaped, transparent medium that bends light rays toward its base. Does not focus
Lenses cont… n n n Prism and decentration Multifocals Lens Types - Crown glass – heavy, scratch resistant - CR-39 – thicker, scratch easily hard resin Polycarbonate –thinner, safest High Index – thinnest, lacks strength
Frame Anatomy n Frame Anatomy – Frame front n n Eyewire Bridge Hinge Nosepads – Temples
Frame Size and Measurements Boxing System DB L ED B A
Frame Materials n Frame Materials – Plastic – Metal
Frame Selection n Frame Selection – Frame fit is most important – Frame width equal face width – Longer face, deeper the frame can be – Bridge fit important – Temples need to be long enough for a proper bend – Cosmetic concerns
Pupillary Distance 1 2 3 4 5 6 7 1 st measurement 60 mm 1 2 3 4 5 6 7 2 nd measurement 64 mm Pupillometer
Seg Height Bifocal Seg Height Trifocal Seg Height
Frame Adjustments n Basic Frame Adjustments – Fitting triangle – Frame height – Vertex distance – Face form – Pantoscopic angle – Retroscopic angle – Temple adjustment
Basic Adjustments Fitting Triangle
Pantoscopic Angle Correct 4 mm 17 degree tilt Optical center Wrong Optical center
Polarizing lens A lens that transmits all light rays in one meridian, and eliminates all light rays in the meridian 90 degrees away n Light reflected off a surface is partially polarized n
Elements of an Rx – Abbreviations - the following is a listing of accepted abbreviations: n O. D. = right eye n O. S. = left eye n O. U. = both eyes n + = convex, plus n - = concave, minus
Contact Lenses (8%)
Contact Lenses n n Soft contact lenses Rigid contact lenses Care & handling Patient education Success with a contact lens candidate begins with what?
Contact Lens Parameters n Parameters – Base curve radius – Lens power – Overall diameter – Optical zone diameter – Peripheral curves – Edge & center thickness
Contact Lens Design Overall Diameter (OAD) Optical Zone OZ Secondary Curve (SC) Peripheral Curve (PC) Secondary Curve Width (SCW) Peripheral Curve Width (PCW)
Contact Lens Design Center Thickness (CT) Base Curve (BC) Edge Shape Secondary Curve (SC) Optical Zone (OZ) Peripheral Curve (PC) Overall Diameter (OZ) What type of contact lens has correction for astigmatism?
Tri-Curve Contact Lens Design PCW SCW JUNCTION OAD OZ SCW PCW OAD = Overall Diameter PCW = Peripheral Curve Width OZ = Optical Zone SCW = Secondary Curve Width JUNCTION
TORIC What is a high water contact lens?
Types of Contact Lenses Soft Contact Lenses Rigid Contact Lenses What are advantages and disadvantages of soft and rigid contact lens?
TRAUMATIC IRIDECTOMY What is used to measure the power of a contact lens?
COLOR What is used to measure the base curve of a contact?
SPORT TINT n n Amber—tracking fast moving balls (baseball, soccer, tennis, football) Grey-green—decrease sun glare (golf, running)
Safety First! n Wash your hands! n Procedure must be safe Explain procedure Explain do’s and don’ts n n
Insertion and Removal Techniques n Soft – Patient comfort n RGP – More difficult – Use gravity
Contact Lens Care
Questions What parameters are needed to order Contact lens’s? n What is used to measure the base curve of a contact lens? n What is used to measure the power of a contact lens? n What is the primary curve of a contact? n What medication is used to view CL’s? n
Common Eye Disorders (6%)
Blepharitis…inflammation of the lids
Conjunctivitis…inflammation of the conjunctiva Why do you get more mucus when the conjunctiva is swollen?
Subconjunctival Hemorrhage Trauma induced Non-trauma related
Pinguecula…is small like penguin Normally at 3 and 9 o’clock
Ptygerium…is large like pterodactyl Covers the cornea
Cataract…an opacity of the lens n Eye without cataract n Eye with cataract
Cataract n Mature cataract
Glaucoma…acute and open angle Increased intraocular pressure n Increased cupping (cup to disc ratio) n Decrease in peripheral vision n Optic Nerve Head (ONH) involvement n
Effects Of Macular Degeneration
Diabetic Retinopathy Background n Proliferative n – Neovascularization
Floaters Why is it that older patients complain more of floaters than younger ones?
Significance 8 -10% Males n. 4% Females n Green defect occurs most frequently n – This is strange due to the color of money Who passes the defected gene that causes color deficiencies?
Exam Equipment n Retinoscope n Ophthalmoscope n Biomicroscope (Slit lamp) n Phoropter n Keratometer n Fundus Camera n Optical Coherence Which one of these can be used during objective refraction? Tomographer
Pupil Testing Size n Shape n Response to direct light n Response to indirect (consensual) light n What is the proper room lighting condition?
Prefixes a, aniso-without n epi-above n sub-below n Endo n What is a contextual clue?
Root Words Kerat-cornea n Blephar-eyelid n Palpebr-eyelid n Cor-pupil n Lacrim-tear n
Suffixes itis-inflammation n al-pertaining to…(palpebral) n metropia-eye measurement n Opia- disease n Edema- swelling n What is papilledema?
Cataract Surgery n Opening the lens
Cataract Surgerycontinued Phacoemulsificati on n Aphakia n
Cataract Surgerycontinued IOL in capsule bag n Psuedophakia n
Intraocular Lenses Iris Fixated Posterior Chamber
Refractive Surgery n Uses laser to reshape the cornea, resulting in a diminished refractive error
Types of Refractive Surgery n n n PRK-Photo Refractive Keratectomy LASIK – Laser-Assisted In Situ Keratomileusis LASEK – Laser Epithelial Keratomileusis Epi-LASEK ALK – Automated Lamellar
Basic Pharmacology (2%)
Drop Instillation n n Clean hands Explain procedure Remember safety Inspect bottle Check date What is wrong with this picture?
Diagnostic Drugs n Dilation – Mydriatic n Neo-Synephrine – Cycloplegic Cyclogyl n Mydriacyl n Atropine, n Homatropine n Scopolomine n n Dyes – – Fluorescein…used to evaluate contact lens Rose bengal
Therapeutic Drugs Antibiotics n Antivirals n Antifungals n Glaucoma drops n Steroids n Lubricants n Which medication stops inflammation?
Mydriatic And Miotic Effects Which is miotic and which is mydriatic?
Readings n Normal – The “normal” for adults is approximately 120 mm. Hg /between 70 -80 mm. Hg n Abnormal – Mild Hypertension n 145 -159 mm. Hg/90 -104 mm. Hg – Severe Hypertension n 160 mm. Hg or more/100 mm. Hg or more – Hypotension n Below normal blood pressure
Abnormal Blood Pressures Systolic greater than 140* n Diastolic greater than 90* n Difference less than 30 between the Systolic and Diastolic Pressures. * n v These are general guidelines and may differ from the guidelines that the provider you are employed by uses.
What’s Next? n Today – Lightly review the material – Get a good night’s sleep – Arrive a little early to test n Future – Look for details about the CPOA test begin studying the Self-Study Course for Paraoptometric Certification
25 Gun Salute Review n Here are 25 review questions that you can test your skills with… n No multiple choice answers…do you know the answer?
Review Questions n What part of the Rx is the cylinder power? – +1. 25 – 0. 75 X 130 n What is the difference between acuity and accommodation? n What does Blepharitis mean? n Which encroaches upon the pupil, a pterygium or pinguecula?
Review n Opia means what? n What is the difference between a tropia and a phoria? n Avascular means what? n How many extra-ocular muscles are oblique?
Review Questions n How long do you keep records for HIPAA? n Where do you measure a trifocal height? n What part of the eye regulates light? n What instrument measures the power of a contact lens?
Review Questions n Identify the name for the parts of the conjunctiva on the eye and back of the eyelid n What is the near vision test distance? n In what layer of the eye will the retina be found? n What is the strongest bone of the bony orbit?
Review Questions n What in the macula controls the ability to see color? n Which lens is thicker in the center? n What is the most important part of the Hx? n Which lens is the safest? n What is the rating on a high water contact?
Review Questions n What is the difference between a subjective and objective test? n Where is the anterior chamber and what instrument do you use to look at it? n When is the best time to schedule an appointment? n What handle held instrument aids in refraction? n Where is your central vision located?
Questions n How often should a EW SCL patient enzyme their contacts? n “Ex” as in exo means _______ and “es” in “eso” means ____? n n What is the unit of measure for lens power? How many extra-ocular muscles are there? Name them if you dare…. . n Which lens is designed to be shatter resistant?
Questions n n What is the purpose of the fitting triangle? Which tonometers require an anesthetic? What instrument is used to obtain a prescription from a contact or ophthalmic lens? What is the heaviest lens material?
Questions n n n What is the difference between acuity and accommodation? Spell the scientific name for your eyelid _______? What percentage of water is in a low water content ______ or high water content _______ contact lens.
Questions n n n The person who normally grinds lenses is called a(n) _________? What is the difference between a mydriactic and miotic? What is the definition of the word “plano”?
Review Questions n The point where the upper and lower eyelids meet is called? n The blockage of the meibomian gland is called the ______ when it causes pain, and the _____ when it does not cause pain? n What is a good tear break up time? n What is amblyopia?
Review Questions n The eyelid will protect your eyes from what? n What main muscles raises the eyelid? n What is the main layer of the eye lid?
Review Questions n What is the difference between visual acuity and accommodation? n What is decentration? n Name a test performed binocularly? n Through a prism the image deviates which way?
Review Questions n Which is the heaviest lens material? n What is the ora serrata n What comprises the vascular layer? n Name one of two indentation tonometers
Review Questions n What is the speed of light? n What is optical infinity? n n What chronic disease is normally associated with internal bleeding in the eye? What is conjunctivitis? Another name for it is?
Review Questions n What is emmetropia? n Papilladema refers to what structure? n What is vertex distance n What are the parts of a standard frame?
I want you to pass life’s test
Good Luck! The person who makes a success of living is the one who see his goal steadily and aims for it unswervingly. That is dedication. Cecil B. De. Mille (1881 - 1959)
Credits Individual support: n n n n n Al Levin, O. D. Darrell Grise, O. D. Mile Brujic O. D. Billie Taylor Mary Jameson, CPOT Kathy Wood, CPOT Belen Holbrook, CPOA Emma E. Gomez, CPO Lynn Lawrence, CPOT Leah Schneider, NREMT Industry Support: n Ziess/Meditec n Vistakon n Xalatan n 3 D Eye Imaginations n Google search sites…
Course Evaluation Thank you n Please take a few moments to complete the course evaluation. n