Low Vision

When you have a patient with a very large pupil, you want to make sure that you pick a telescope with a big exit pupil (if brightness is important). -Ex: The patient had 6 mm pupils and very poor contrast sensitivity. She could only function with an 8 x 50 telescope. The exit pupil was 6.25 mm. When exit pupil is smaller than the pt's pupil brightness is reduced from that unaided eye. How can you calculate light reduction given pupil?

*(Exit pupil)^2 / (Entrance Pupil) ^ 2*

Lecture 1

**

Given a galilean telescope with an objective of 2D and an eyepiece of 10D. What is the magnification?

*-(-10/+2) = 5X* -*Mag = - oc/obj* -*Galilean always have (-) ocular*

Magnify: Uses a combination of the enlargement ratio and working distance. The result is known as equivalent viewing power or EVP. -Example: if a patient's goal is to read 1 M and he has +2.50 D EA what power stand would he need if he is reading 4M now with just his +2.50 D EA? -So what power would you need to focus this material at 10cm?

*1) Find EVD: .4m/4M = EVD/1M = 0.10m=10cm* *2) Find EVP: 1/.10 = +10D EA* *3) Find ER: +10 = ER x (1/.4) = 4x* -*One*

What are the three most common goals?

*1) Read the newspaper* *2) Watching Television* *3) Drive(Be careful to know state laws.)*

Determine Angluar FOV: Example: Computer Screen is 17", patient is sitting 40 cm away. -What is the angular FOV? 1/2 letter = 1 letter better.

*1. Tan0= opp/adj* *2. Theta= -1Tan[opp(1/2 screen) / WD*] *3. 17(0.254) = 0.4318 m (1/2) = 0.2159 m* *4. InverseTan(0.2159/0.4) = 28.35* *5. Angular FOV = 28.35 (x2) = 56.71 deg*

At what distance would you hold a +16D IHHM from the desired text?

*1/16 = 6.25 cm*

What is JND for 10/50?

*10/50 x 2 = 20/100 = 1.00 = +/- 0.50 D*

Bracketing lenses for 10/60

*10/60 x 2 =20/120 = 1.20 = +/- 0.60 = +/-0.75D*

What is JND for 10/63?

*10/63 x 2 = 20/126 = 1.26 = +/- 0.63 D but you would round up and use +/-0.75D*

Chief Complaint: How does the patient see. (Give them some examples to help them paint a picture of their vision; remember no 2 patients see the same way). Give them time to explain their story. How long will it take the average person to talk?

*2 minutes*

1m/1M = 20ft/20ft -If a patient sees 20/40 (Snellen) what is value converted to M notation for 6meters?

*20/40 = 6/x = 6m/12M*

What is JND for 20/50?

*20/50 = 50/100 =0.5D* -*Bracketing is (1/2)(0.5) = +/- 0.25 -(Could not do less than this, because would not be seen)*

Supply: Only 50 low vision diplomats certified by the AAO who actually see patients. Only 12 optometric residencies focused on low vision. Less than 20 low vision OD's graduating annually. Demand: EDPRG (2004): Age 40 years and older, 20/40 or worse came to be 3.3 million people of the population. Baltimore Eye Survey, Mass of, US Census showed similar statistics with approximately _______% of the US population over 40 being visually impaired. On a fast day in low vision you see a 4-6 patients maximum.

*3%*

If TS is not at least ____ meters away from target, you will have amplification. (Why: Light coming into TS is divergent, amplified by TS, requires accommodation).

*4*

MNRead: Time in seconds and plot. If mistakes, circle on scoring sheet and adjust. Continue to read until print is impossible. A plot is made of results. -Based on _____ letters on a line. Critical prints size would give you an idea of how much mag you may need to start with. Near acuity is where they can see the letters but it is very tiresome....bare minimum acuity....likely not what you would Rx.

*60*

Worsening Problem: In 1995, there were 33.9 million Americans over the age of 65. By 2030 there will be approximately _________________, these people will need low vision care and optometry is best equipped to provide it.

*70 million*

Calculate the FOV for a +10 D IHHM when a patient is viewing from a distance of 5 cm and 20 cm?

*A = 5 cm (diameter of aperture)* *f = 10 cm* -*5 (10/5) = 10* -*5 (10/20)= 2.5*

What is a telescope with a fixed tube length called?

*Afocal*

What should you always try first when Rxing?

*Always try spectacle Rx first*

This is the idea of using an optical system to increase the angular subtense of the image compared to the angular subtense of the object (via optical system).

*Angular Mag (Lateral Mag)*

This is when you increase the angular subtense of an image entering an eye

*Angular Magnification*

Binocular, telescopes and magnifiers are what type of magnification?

*Angular magnification*

Field of View is found using what equation?

*Aperture diameter (focal length/distance from eye to lens) or (A (f/z) )*

This method is like what we did in lab where we measured the distance between telescope and stand magnifier.

*Bailey Method*

Children: Visually impaired children will bring books closer to their eyes to use accommodation. -Find a ______ between how close a child wants to hold the print, the accommodative demand and complement with a microscope for comfort.

*Balance*

Little More on MAR and LogMar: Gives more accurate measurement of VA why?

*Because can determine to letter size* -*Measures the angular size of critical detail within the just resolvable optotype* -*Measures MAR, reciprocal of decimal acuity*

There are specialized charts of VA. At near always do M notation. Never what to do a phoropter refraction, why?

*Because it does not mock the normal/natural use of vision* -*May want to refer to a rehab psychologist and these are people who specialize in loss.*

Which device is prescribed for DRIVING?

*Bioptic*

Vistech chart is what type of test?

*Contrast*

-_______________ is the leading cause of new blindness in the U.S. Capillary walls weaken allowing microaneurysms to form. Breakdown of BRB and blood and fluid leakage. Edema and nutritional deprivation can occur. MA, DB hemes, CWS, VB, IRMA, Neo. VA: 20/20 NLP . Lens changes and macular edema is common VF: Proliferative disease, retinal ischemia, laser scars and RD Excessive thirst, urination, hunger, fatigue, weight loss, recurrent infections and slow healing. Ocular Signs: NPDR. Severe NPDR (4/2/1). PDR (High risk: <1/4 DD of NVD with or without vitreal heme; NVD with vitreal heme; >1/2 DD of NVE with vitreal heme; any NVI)

*Diabetic Retinopathy*

You should have a goal for which distances? Device evaluation is based on goals and case history. Formulate a plan and make the appropriate referrals.

*Distance, Intermediate and Near*

Stand Magnifier (Non-Collminating) -Designed for object to rest within the focal point. Light leaving is _____. Requires accommodation or ADD to focus (compound system). Mag depends on z, eye to lens separation.

*Divergent*

What is the equation for Entrance Pupil diameter?

*EP = Objective lens diameter/magnification of telescope*

Equivalent Viewing Power Equation

*EVP = ER x (1/WD)*

Adjusting the Trial Frame: Pre-adjust before placing on the patient's face (panto tilt, PD, place eyes in center of lens wells; place wells so you can slide lenses in and out easily). _____ patient (need a break, warn patient about weight and size of frame).

*Educate*

This is the limiting aperture of the system.

*Entrance Pupil*

A patient has an EVP of +10D FFMS and reads 0.8M print at 200 wpm with good fluency and accuracy at 10 cm. Discussed use of device, not to walk around, scan print in front of MS, and frequent breaks.

*Example of recording*

How do you find the exit pupil size?

*Exit = Objective lens (mm) / M(TS)*

This is the image of the objective lens formed by the eyepiece lens (ocular).

*Exit Pupil*

What is the image of the objective lens as seen through the telescope?

*Exit Pupil*

What is one disadvantage of using a bioptic?

*Expensive*

KMK Equation for finding HHM FOV

*FOV = d/((Fe)(l))* -*d: lens diameter* -*Fe: Equivalent Power* -*l: Distance btw mag and spectacle plane*

You have a +20D ISM with a stand height of 4cm. -What is the focal length of the magnifier? -What is distance from lens to new image? -ADD required if viewed from a distance of z = 10 cm.

*Focal Length:* -* +20 = 1/20 = 5cm *Image Location:* -*F + L = L'* -*20D - 1/0.04 = -5D* -*1/-5 = -20 cm (image behind magnifier) *Add* -*EVD = z + l'* -*10 + 20 = 30* -*Add = 1 / (20 + 10) = 1/0.33 = +3.33 D*

Hand Held Magnifier optics are held within what?

*Focal length of lens*

Low Vision Evaluation: What is one of the gold standards of a low vision evaluation?

*Functional Assessment with visual function questionnaire* -*This grades how difficult certain tasks will be for patients. Goals are also super important for patients because if they don't want to be there it will be difficult to help them*

Reduced Vision Usage: -What helps you start thinking about what types of low vision devices may be needed?

*Functional Assessment* -*VFQ: 20 item list: evaluation of ADL for patient and how they feel about the difficulty of the task. This information may help guide you with goals. May need to ask how big is the television or how far away o they sit (bigger TV may be worse because pixels are farther apart and more blurry).*

Is Contrast affected more in GLC or RP?

*Glaucoma*

JORDY is what type of device?

*Head Device*

Medical Decision Making: Minimal: One self limited or minor problem (Rest, monitoring) Low: Two or more self limited or minor illnesses; One stable or chronic; One acute; Uncomplicated illness or injury (Allergic conjunctivitis,. Mgmt: OTC drops). Moderate: One chronic with mild complications; Two stable chronic; Undiagnosed new problem; acute illness; acute complicated (Head injury; Mgmt: prescription) High: One or more chronic with severe complications. Acute or chronic posing a threat to life. Abrupt change in neurological status (Major surgery). -Which of these do optometrists not really perform?

*High Decision making*

E and M Codes: -What are the three major components? Others include counseling, coordination of care, nature of presenting problem, and time (LV) Coding Basics: History (4 levels) Physical (4 levels) Medical Decision (4 levels)

*History, phyiscal exam, medical decision making*

Telemicroscopes allow for what? (Music, playing cards, and eliminate bendingback)

*Increased working distance*

Patient Observation: -If patient walks slowly, shuffles feet, or bumps into objects, what should you do?/

*Intervene, demonstrate sighted guide technique* -*If patient easily walks into the office, approaches office staff, Sighted Guide Technique may not be necessary.*

This is the amount of spherical lens change at which a change in clarity or blur is first noticed.

*Just Noticeable Difference*

Myopes: Have a built in microscope. Myopic adults without accommodation, use Rx to advantage. -If a -10D myopic patient is encouraged to read at 10cm, what can you tell the patient to do to increase reading speed?

*Just have patient take off distance Rx*

This type of telescope is made up of 2 convex lenses (+). Posterior focal point of F1 coincides with anterior focal point of ocular F2.

*Keplarian*

History: Problem Focused (Level 1): CCx; 1-3 HPI Expanded (Level 2):CCx; 1-3 HPI; ROS Detailed (Level 3) : CCx; 4 elements HPI; Ocular ROS; ROS; 1 item for past, family or social Hx* Comprehensive (Level 4): CCx 4 elements; Ocular ROS; Review 9 systems; 2-3 items for past family or social. Which one of these are we doing in clinic?

*Level 4 CEE*

What is the goal of bracketing?

*Looking for a reversal*

Measuring Vision: (________ Gold Standard) -Measure: _______ VA, _____ print size and maximum ____ ______. -As a patient gets closer to threshold, reading speed _____. -The smallest print size patients can read at their maximum reading speed is known as what? -The smallest print size that can be read at slowest speed is what?

*MNRead* -*Threshold, Critical, Reading Speed* -*Decreases* -*Critical Print Size* -*Threshold Visual Acuity*

You wanted a total magnification of 6x. You have a 4x HHTS. -What power reading cap would b required to obtain 6x magnification of the system? -What is the patients new working distance? -If you wanted the same magnification with a (+) lens what power would you use? -What would your working distance be for this lens?

*MT = MTS [F(Reading Cap)/4]* -*6 = 4 [(x) /4] =+6.00 D* -*(1/6) = 16.67* -*24 D* -*(1/24) = 4.167 cm*

Evaluation and Management Codes (Billing ______). 9920X, 9921X (5 levels). 92015.

*Medical (92015 Never paid for by medicare)*

Low Vision Billing: In LV, the LV code is first and THEN the disease code. Otherwise, the vision impairment chart is needed to bill and for the patient. -When doing a medical exam what is first?

*Medical codes*

Retinitis Pigmentosa: VF loss, night blindness, abnormal ERG, most common of retinal dystrophies Most are AR inherited (X linked is most severe and earlier) Mutations in rhodopsin gene and RDS gene result in abnormal amino acid composition of proteins whose production is regulated by those genes VA: 20/20 to NLP -VF loss is where? Ocular: Bone spicules, moth, choroidal vasculature tessellated, attenuated vessels, waxy pallor, normal to small C/D, CME, PSC common, High myopia and astigmatism, nyctalopia, delay and dark and light adaptation, decreased color, photophobia

*Midperiphery lost 1st (donut shape)*

Clinical Pearls: -Use R hand for + and L hand for - (keeps things straight) -Show ______ first* -Show them the difference between trial frame and glasses. May see better simply because you've been training them with EV during refraction. Watch for patients who are looking for magic glasses.

*Minus*

Prescribing: -In what five cases should you prescribe a telemicroscope for monocular? Binocular?

*Monocular:* -*2.75-12 x* -*Infinity to 20cm* -*Mounting* -*Reading caps* -*No VA symmetry* *Binocular:* -*6-8X* -*Infinity to 20cm* -*Mounting* -*Reading caps* -*VA symmetry present*

Phoropter: Limits patient's head position; ________ field of view; hard to adjust vertex distance when have larger Rx.

*Narrower*

Does the microscope magnify the image?

*No, lens only focuses light on retina and is relative distance that the patient is holding the material that is creating the magnification (the way the light focuses does not change)*

Humanware Prodigi: Can be adjusted to comfortable location; android can be added to mold products

*Note*

What is the equation for exit pupil?

*Objective lens diameter/mag*

Why the practice of low vision: Due to the knowledge of optics, who are the best suited to treat low vision patients?

*Optometrists* -*However, there is a lack of training and interest that results in few ODs specializing in this. Occupational therapists, however, do like low vision.*

Why might nasal hemianopsias not be as much of a problem as temporal?

*Overlapping nasal fields*

Keratoconus: Bilateral noninflammatory corneal ectasia that is progressive with corneal steepening and thinning resulting in irregular myopic astigmatism. 20/20 to diminished. No VFD but visual field sitortion. Associated with atopic dermatitis, vernal catarrh, asthma and hay fever. Scissor reflex, keratometric mires; vertical striae; pronounced corneal nerves; Fleischer's ring; Munson's signs; Hydrops (painful); starbursts -Systemic: Down's syndrome; marfan's; ehler's danlos; osteogenesis imperfecta Adjunct: Corneal topography and OCT -Medical: ______ (90% success); lamellar keratoplasty

*PKP*

What is the key with telescopes?

*Patience*

What is likely the most important part of the exam?

*Patient's Goals*

Left homonymous superior quadrantanopia make cause what problem?

*Reading problem*

Keplerian TS have a _____, floating exit pupil.

*Real*

What is the key?

*Reassurance*

A patient walking a up to the VA chart is an example of what type of magnification?

*Relative Distance Magnification*

This is the idea of making it bigger by bringing it closer

*Relative Distance Magnification*

This is when you move an object closer

*Relative Distance Magnification*

Large Print or "pinching your iPAD screen" is what type of magnification?

*Relative Size Magnification*

This is the idea of making print bigger by increasing the size

*Relative Size Magnification*

This is when you physically increase the print size

*Relative Size Magnification*

MS Low Vision: -Magnification works well -Consider _______ contrast -CPF, tints, sun filters -Direct lighting -Glasses -Support groups

*Reverse (if optic neruropathy)*

Glaucoma patients enjoy what type of polarity of a CCTV.

*Reverse*

Ophthalmological Office Visit Code (___ _____). 92004. 92014. 92002. 92012. 92015.

*Routine Visit*

Before the exam starts consider what?

*Safety* -*Orientation and Motility Techniques: Basics must be understood by OD and staff. Demonstrate proper techniques to patient and caregivers. For additional training, referral to an O&M specialist may be necessary*

Types of Charts: Projector (snellen), printed and back illuminated charts. -What is the most common projected chart?

*Snellen*

Previous Low Vision Devices: Which, if any, have been used? Were they prescribe or just purchased? This is a good time to explain the importance of using prescribed devices and the fact of what?

*Stronger does not necessarily mean better*

What is the equation for tube length?

*TL = ocular (l) + objective (l)*

Left homonymous hemianopia due to lesion of right occipital lobe will benefit from what LV device?

*Telescope*

What allows for increased retinal image size without changing the working distance?

*Telescopes*

What is the only low vision aid to help with distance goals?

*Telescopes*

Low Vision Billing: Exam Time: 10: 00 am Refraction: 7 minutes Testing: 20 minutes 35 minutes (Counseling) Exam ends: 11:02 am -What code would you bill? 99201-10 min 99202-20 min 99203-30 min 99204-40 min 99205-50 min 99206-60 min (life or death)

*Total Exam 62 minutes* *62 minutes - 7 min refraction: 55 min* *Counseling (>50% of 55 min (35/55 min)* -*Bill 99204 (35 minutes)*

For You practice pay attention to medical billing fee schedules -T/F. Know the value of your knowledge and code appropriately. -Which pays more: 92004 or 92002?

*True 92004 (new patient always poor more)*

Managing Expectations: T/F. Research shows that visually impaired do not have any more accidents then teenagers.

*True*

Patient Observation: -T/F. Observation provides a tremendous amount of information concerning the patient's primary needs.

*True*

T/F. Folding a newspaper can help a patient prevent visual confusion.

*True*

T/F. Just because you have a stroke doesnt mean that you have a field cut.

*True*

T/F. Low vision is NOT the same as legal blindness. A person can have functional vision loss and not be legally blind.

*True*

T/F. Many times you get a better assessment of true visual function outside the instruments.

*True*

T/F. Some studies show that blindness is feared worse than death.

*True*

T/F. Telescopes are vergence amplifiers.

*True*

T/F. The closer the exit pupil is to the eye, the larger the FOV.

*True*

T/F. The more congruous the field the further back in the brain it occurs.

*True*

T/F. You should test a low power telescope first (introduce concept).

*True* -*For kids you can practice with a toilet paper roll*

The telescope eyepiece is used to compensate for what?

*Uncorrected RE*

How do we fix the effects of vergence accommodation?

*Use a reading cap*

Galilean TS have what type of pupil?

*Virtual exit pupil (inside the telescope)*

S Codes (Vision care plans, medicaid plans). Typically NOT medical. ______ Coverage Only. S0620. S0621 (Includes 90215)

*Vision*

This is a limitation of the abilities of the individual to perform specific tasks.

*Visual Disability*

This is a loss of personal independence resulting from vision loss (more the low vision realm).

*Visual Handicap*

This is a functional limitation of the eye or visual system which may include reduced VA, CS, VF loss, photophobia, diplopia, visual distortion, visual perceptual difficulties or any of the above combinations.

*Visual Impairment*

Macular Hole Stages: -Stage 0: Looks normal but on OCT shows pre-retinal thin band -Stage 1 a: yellow lesion -Stage 1 b: yellow ring -Stage 2: early hole -Stage 3: Full hole with CME -Stage 4: Full hole with___ ___

*Weiss ring (PVD)*

When should you consider a microscope?

*When you need a high reading Rx*

Does having an add make a difference? What is equation for equivalent power?

*Yes, it changes the overall power of the system and thus the overall focal length* -*Fe= Fa+Fm - (Fa x Fm x z)* -*z = (separation between add and magnifier)*

Optic Atrophy (like a glaucoma patient): Most common damage to ganglion cells. Many causes. Types: primary, secondary, heterodegenerative (bilateral). VA: 20/20 to HM -VF: generally affect _____ vision Ocular signs and symptoms: Pallor, decreased vision, diminished color, sluggish pupil, photophobia, nystagmus LV Mgmt: magnification at distance and near; -Avoid excessive _______, sun filters, tints both indoors and outdoors. Genetic counseling -Prognosis: usually stable (dominant and juvenile can b progressive)

-*Central* -*Lighting*

RD Low Vision: Tints, filters, teat phophobia or glare. -____ vision treated with glasses (wait until SO is out), magnification, prisms for O and M Prognosis: repair is successful with early intervention; macula on is emergency -What tint is best for metamorphopsia?

-*Central* -*Yellow*

Keplerian Telescope and the Hyperope: -What are three ways to account for uncorrected refractive error?

-*Change eyepiece lens* -*Change objective lens* -*Change tube length (increase adds plus) (decrease adds minus)*

Visual Hallucinations experienced by some low vision patients. You may be the first to diagnose this.

-*Charles Bonnet Syndrome* -*They physically believe it is there. It is something that is going to be out of the normal...makes no sense. The brain tries to summate and make up for things that are not there. Brain fills in scotoma with something from memory.*

Microscopes: -Use a _____ working distance (bring up to eye and pull away till focuses). -Focuses strong _____ light to provide a clear image on retina. -Can it be used binocularly or monocularly? -Less than _____ x differnce between two eyes before going binocular. -Can be ______ to patient (cylinder power and PD). Make sure to write as script when you Rx to avoid prefabrication.

-*Close* -*Divergent* -*Both* -*1.5* -*Tailored*

Limitations of Microscopes: -The more magnification needed, the _____ the working distance -What is also an issue at closer working distances? -Goal: Determine the ________ amount of magnification necessary to provide the GREATEST ____ _______ while giving the patient the reserve acuity needed for optimal reading.

-*Closer* -*Lighting* -*Minimum, working distance*

-______________ is a congenital result of a defect in the closing of embryonic cleft. Can involve optic nerve, choroid, retina and iris. Most likely AD (although sporadic and non inherited do occur). -Usually monocular or bilateral? VA: Normal to 20/400 depending on what is affected. 20/200 or worse if optic nerve is involved -VF: Can Have _______ field loss if posterior pole is involved

-*Coloboma* -*Bilateral* -*Superior*

What are the five most important aspects of training?

-*Color* -*Contrast* -*Field of Vision* -*Magnification* -*Lighting*

If you do not know the powers of the lenses, then what are two options?

-*Comparison Method (Galilean or Keplarian)* -*MTS = Object. lens diam (mm)/exit pupil diam (mm) (Keplarian only)*

Medicare: -When a beneficiary goes to a physician with a _______ or symptoms of an eye disease or injury, the physician's services are ____ regardless of the fact that only eyeglasses were prescribed. -However, when a beneficiary goes to his/her physician for an eye examination with no specific complaint, the expenses are not ________ even though as a result a ______ condition is discovered.

-*Complaint; Covered* -*Covered; Pathological*

Other considerations: -When may a light tint be necessary? -Why might you need to consider rivalry between the two eyes? Looking at suppression training or occlusion therapy may be necessary because Rx may not be successful if you didn't look at everything.

-*Contrast issue* -*Problems that limit success of patient*

When to consider CCTV: -Patient has issue with ____ impairment -Patient is not doing well with ____ ______ Training -Patient wants a "______" fix -Patient needs a high amount of _______. -Reading ______ and _____ may be increased -When patient is not responding to magnification as you ____ them to (spinning your wheels). Use equivalent device.

-*Contrast* -*Eccentric Viewing* -*Quicker* -*Magnification* -*Endurance and efficiency* -*Expect*

-This is how many magnifiers are labeled. Reference point of 25 cm. Mag= Power /4. Manufacturer mag often add +1 D. -Example: What is the conventional mag of a 20D IHHM?

-*Conventional Magnification* -*20/4= 5 x*

A -18.00d presbyopic myope needs a +16.00 microscopic lens system. What are two options?

-*Correct for -18 D and give patient a +16 focusing him at 6.25 cm (1/16=6.25)* -*Partially correct with a -10 contact lens and use a telescoping system (since patient already used to some level of blur)*

Using the ER to prescribe SM: -When you know the ____________ needed to help a patient you can translate it to any device. -If the patient has an add and you know the power needed to reach goal print, calculate ________ and pick a stand -Make sure that z+l' _____ the focal length of glasses otherwise may not work with patient.

-*D power (EVP)* -*ER* -*≥*

Achromatopsia: Field is usually normal but can be constricted (especially with colors). Ocular Signs and symptoms: Poor VA in bright light. Decreased Color Perception. Photophobia. Pendular Nystagmus. Sluggish pupils. -Paradoxical responses in ______ Adaptation. Adjunct Testing: -EOG (normal or abnormal?) -ERG (normal or abnormal)? D15 can help. FA may show mild hyperflurescence when RPE disruption is present.

-*Dark* -*EOG: Normal* -*ERG: Photopic (abnormal); Scotopic (normal)*

Telescopes and Retinal Perception: -______ field, spatial _____ and increased _______ distort image sent to the brain (problem with amplification) -Patients may see 20/20 but don't _______ what they see. -What is important to overcome this phenomenon? Systematic tracking and memory skills.

-*Decreased, distortions, movement* -*Understand* -*Training*

Macular Hole: Round lesion in fovea. Trauma, myopia, CME, inflammation, idiopathic (vitreal traction). Unilateral but can become bilateral in 30% of patients. VA: 20/25-20/80. Stabilize at 20/200 (stage 3-4) . -What is VF look like? -Low vision: RE; ______ _____; direct lighting; ______ techniques Prognosis: Stage 1 can spontaneously regress; can be promising surgically

-*Dense Central scotoma* -*Eccentric viewing; suppression*

Medical Decision Making and Complexity of Data: -________ services ordered, planned, scheduled, or performed -_______ of diagnostic tests -Decision to obtain old ______ or take additional history -Relevant findings from old records or additional history taken -Discussion with another ______ -Independent ______ of previously taken images or studies

-*Diagnostic* -*Review* -*Records* -*Physician* -*Interpretation*

Facial Amsler: -Test done at 40cm. What is a problem? -What is an advantage? Have patients look towards center of face, describe to you if areas of face are washed out, missing, blurry, etc. -If patient has issues with ________ this test may be hard to perform. -_______ assessment if patient has problems fixating and need to know general idea of where scotoma is located.

-*Difficult for patient* -*Good if not much equipment* -*Contrast* -*Quick*

Achromatopsia MGMT: -Patients will do best in what type of illumination? Filters, tents, and sun lenses for indoor and outdoor. Sun shields on spectacle frame. Red CL. Magnification devices for distance and near. -Tell patient that condition is (progressive or nonprogressive?) Nystagmus and photophobia will (increase or decrease?) in teenage years?

-*Dim* -*Non-progressive* -*Decrease*

Veiling Glare (2nd Glare): -Aka what? -Caused by random stray light or ______. -What is a common cause? Looks like driving through fog with headlights. Patients in your PC clinic can have this type of glare. -Depends on _____ visible wavelengths. Observe severity by squint reflex.

-*Disability glare* -*Scattering* -*Ocular media opacities (cataracts, PVD, syneresis)* -*Short*

-____________ glare is the first symptom to evaluate. It occurs when there is confusion in the visual system (pupil constricts because of the glare but needs to expand to see road). -Any patient can have this problem and the main ones are those who have an intact what? -So would an end stage RP patient likely have this? -Example of patients who would include what three? Identify by watching them cover their head during filter evaluation.

-*Discomfort Glare* -*Visual Field (need 10deg)* -*No* -*Anaridia, Cataracts, AMD*

What are three types of glare?

-*Discomfort* -*Veiling* -*Dazzle*

Living Situation and Physical Health: Living situation often determines how medications are _____ and activities of daily living are ________. Also will help to cue you into any ______ that need to be made to low vision rehabilitation team.

-*Dispensed, handled* -*Referrals*

-VA is measured how? -VA provides you with info to help to determine if disease is _______. -Helps to ____ the patient's vision loss to aid them in receiving surfaces, benefits and maybe to keep driving. -What is a word of caution regarding this? -Is counting fingers a visual acuity?

-*Distance / Letter Size* -*Progressing* -*Quantify* -*Be careful to not push patient too hard as they do not receive services or benefits* -*No*

Wearable: Camera with display screen. -Can be used for ____ and ______ tasks. -Good for what two types of patients? -Can you walk with it? -What is a con of this machine?

-*Distance and near* -*Very active patients with many visual needs for distance and near (Students); need an "all in one" unit (distance, intermediate, near).* -*No* -*Heavy*

Take Home Points: Telescopes are only aids to help with ______ magnification goals in low vision. -Uses what type of magnification? -What are two types of telescopes? -What is important for field of view and brightness? --T/F. Accommodation is seldom enough when object is moved out of he plane of the TS focus (i.e. not infinity). Understand the training steps. Patience is key. Practice the math.

-*Distance* -*Angular* -*Galilean and Keplarian* -*Exit pupil* -*True*

Patient's Goals: Good to get 3 kinds of goals: _________, ______, and _________ and know which is most important to them...why?

-*Distance, Intermediate, and Near* -*Helps patient emotionally and a rapport builder*

Pitfall of SM: -To an untrained examiner, important to understand that +20 D IHHM (Does or does not?) equal +20 ISM. -The reason is that IHHM uses _____ light emerging from lens into eye and can be used at _____ distance in which light is parallel. -Instead the stand magnifier combines what two things? -What is the only time IHHM = SM?

-*Does not* -*Parallel* -*Any* -*Relative distance mag and enlargement ratio (ER= L/L' or l'/')* -*When IHHM is held at the height of the stand magnifier*

What are the newer options?: Windows and apple have internet accessibility options to enlarge text (Great for computer users) -_______ software (Zoomtext and JAWS). Good for patient not ready to invest. -_____ tablets (kindle, nook, and IPAD)

-*Downloadable* -*Reading*

Prescribing Stand Magnifiers: A patient's near acuity is 0.4/4M and would like to read 1 M print. You chose the same 20D ISM from previous problem. -What is patient's EVD? -Where is image? -Image is enlarged by what magnification? -If he is 10cm above magnifier what is acuity? -Will this device work?

-*EVD : 10 cm* -*Image: 20cm behind magnifier* -*Magnification: 20/4 = 5x* -*Distance: 20 + 10 = 30 cm (0.3/5M) -*Will it work: Yes*

Steps to Prescribing a Stand Magnifier -Determine BCVA with TF refraction -Determine __ and ____ for near -___ ___ (Remember to give pt. reserve) Decide if you will use patient current bifocal or a FF reading Rx Calculate stand/reading rx that will give patient most FOV and/or WD -_____ devices and have patient decide what they prefer

-*EVP and EVD* -*Goal Acuity* -*Demonstrate*

Feinbloom Advantages: -Test distance can be easily altered, large range of optotypes, easily monitor for _____ _____. -What is a disadvantage? -Do not convert to 20' unless you need a snellen equivalent for _______. Notes: You are always going to use the FOOT letter size. The feinbloom chart can be used at any test distance. These charts allow you to monitor the patient the whole time. Acuities can be made finer to figure out the correct devices. Also, if you don't have enough space between acuities you may have your patient lose their drive's license (20/400-20/80 in 40 steps).

-*Eccentric viewing* -*Not sufficient to measure at better VA's* -*Benefits*

Management of Sectoral Loss: *Fresnel Prism:* -______. -Can use _______ prism powers (>45). -Image distortion aids in _______. -What is a problem? *Ground in sector prism (Heavy):* Graduate from Fresnel. Can be _____ (prism is clear image shifted). What are two other cons of this type of mgmt? What is a pro? *Gottlieb Prism (button into glasses): * Can also have visual _______. Expensive or cheap? Va reduction or not?

-*Economical* -*High* -*Training* -*Degrades VA* -*Confusing* -*Expensive; Permanent (15 PD only)* -*No VA reduction* -*Confusion* -*Expensive* -*No VA reduction*

Training: -______ on expectations -set up a ______ _____ with print, lighting and reading stand How to use the device (pipe cleaner trick) -Be sure not to _____ Around with device because you can become dizzy or fall or have lower field loss with eyes or bifocals -With a stroke patient you never want to use what three lenses? -Record ___ ____ and WD with device

-*Educate* -*Working station* -*Walk* -*PAL, BF, TF* -*Reading speeds*

Enlargement ratio = ______ ____ (over best correction)

-*Effective Add*

-________________________is relative to a specific distance. -An object must be at the primary focal point of a _________lens. It is how the object is enlarged relative to image. This is the hand held magnifier when light is traveling parallel.

-*Effective Magnification* -*Plus*

Glaucoma: Optic neuropathy classified as open angle or angle closure and subclassified as primary or secondary. Risk factors include age, family, race, vascular disease, PDS, PseuoEx, iridis, uveitis, steroid use, glc in fellow eye. ICE, plateau iris, reiger's sendrome, peter's anomaly, axenfield's syndrome, sturge-weber. Adjunct: Gonio, pach, photos, HVF, OCT, IOP. Lower IOP LPI. Educate on drops Low Vision: -Usually at _____ of treatment. Magnification. Increased contrast and brightness. CPF filters for glare. Non-optical systems should be explored. -_____ lenses or _____ telescopes. O and M. Flashlight. Driving.

-*End* -*Minus* -*Reverse*

Minification and Telescopes: -Reverse Telescopes: Good for field ______ and what? Estimating Acuity: 2x TS will in theory reduce the vision 2x in reverse design -Is OandM covered by insurance?

-*Enhancement; Orientation and Mobility* -*No*

-_______________is the image to object size relationship that can also relate working distance. -Equation involving working distance? -If the student from the previous slide moved materials from 40cm to 20cm they have an enlargement ratio of what?

-*Enlargement ratio* -*WD/EVD* -*40/20 = 2x*

-____________ is the distance at which an individual must hold an object to get required magnification. -Example: A college student has a near acuity of 0.4/2M. He would like to read 1M print. -At what EVD would he perceive 2x Magnification? -This is the dioptric power required to produce a clear retinal image of desired magnification. Equation? What is the EVP for above question?

-*Equivalent viewing distance* -*2x closer = 0.2 m or 20 cm* -*Equivalent Viewing Distance* -*1/EVD* -*1/0.2 = 5 Diopters*

Loupe: -A variation of a microscope with an _____ working distance. Good for mobility. Working distance is increased by mounting the lens further away from spectacle plane. -_________ field of view than spectacle microscope but ___ than bifocal. Available as a head borne or clip-on version (OPTIVISOR). Good for patients who need magnification but not the really short working distance.

-*Extended* -*Smaller, larger*

Histoplasmosis Syndrome: -Triad VA: Depends on location VF: depends on lesion Ocular: histo spots midperiphery, macular histo spots, -Damage Buch's membrane (causes _______); granulomatous atrophy; streak lesions FA, Chest x ray, skin test Treatment: amsler grid, and Tx CNVM -LV Treatment: magnification at distance and near; _____ viewing training; direct illumination Prognosis: depends (12% decreased VA in 1 eye develop 2nd eye problems in 5 years and 10 years)

-*Histo spots, PPA, and CNVM* -*Metamorphopsia* -*Eccentric*

Setting Up Chart: -Have good _____ for patient's condition. -When you reach threshold and need a suprathreshold target look for rounded letters...why?

-*Illumination* -*Round letters include all spacial frequencies*

Types of Lighting: -This is the most common household light; the "warm light" giving off long wavelengths. What is the disadvantage of this? -What is disadvantage of a halogen light? Fuorescent Lamp: Give off low wavelength light (good in kitchen/bathroom). Blue wavelength. -LED (Daylight Lamp): Similar to sunlight/natural spectrum. It increases ____, ________, reduces _____, most _____ friendly, _____ light, and most _______

-*Incandescent* -*Can get too hot and burn* -*Can fail if touched (change with tissue)* -*Contrast, clarity, glare, environmentally, safest, comfortable*

Challenges of Low Vision Rx: -Can have large change in Rx from what wearing with ________ responses. Lens presentations must be greater than +/-0.25D. No obvious ______. Can't predict Rx based on _______ (change in D does not correlate to change in VA). -High plus can be aphakia or albinism. High minus could be pathological myopia. -*More challenges: They don't think that glasses can help them. They've been told nothing can be done for them. Everything is blurry even when you get it better.

-*Inconsistent* -*Endpoints* -*VA*

Keplerian: -Magnification is _____ than 4X. -Image is ______. -FOV is _____. -Exit pupil is ______. -Size of image is _____.

-*Increase* -*Inverted* -*Sharp* -*Floating* -*Large*

RP: -Sector RP: More common _____ Associated: Usher's; Laurence Moon; Alstrom's, Kearns-Sayer, Bassen Kornzeig, Refsum's -Adjunct: ERG shows reduced what waves? Medical treatment: None. Maybe Vitamin A and E. DHA and Vitamin A. -LV: Enhance __ vision (reverse TS or minus lens); magnification at near; excessive or bright illumination is bad; CPF lenses; non-optical; O and M; genetic counseling Prognosis: Slow to progress to total blindness; X linked; AR loss in 60-70; AD loss by 80s

-*Inferonasal* -*A and B* -*Side*

-Lateral magnification works well for objects placed where? -What is the equation for this?

-*Inside and outside of F* -*M = Image/Object (hi/ho)*

What are four word and continuous text chart? Which one do we never use in low vision?

-*Jaeger Card (Never in low vision) * -*Lighthouse Game Card* -*Lighthouse Continuous Text Card* -*MNRead Card*

-Which is longer, heavier and inverted: Keplarian or Galilean? -Keplarian: requires a ________ system or prism to erect the image -The system is considered a ______ lens separated by tube length.

-*Keplarian* -*Mirror* -*Thin*

Peripheral Testing (Arc Perimetry): -Quick economical way to test _____ perimetry. Field is mapped by moving a wand along curve of arc until the patient sees the wand. Continue to fixation point to determine if there are any scotomas. -Can gauge patient's peripheral fields (should to should should be _______ degrees). Can be tested in all meridians. Use smallest target can be seen.

-*Kinetic* -*20*

Optics of Stand Magnifier: -Most important formula is what? With this simple Gaussian formula, vergences and enlargement ratios may be calculated. L: Obj vergence (l= object location = stand magnifier_____) L': Img vergence (l'= image location) F: Power in diopters of stand magnifier - -What is equation for bifocal working distance? Bifocal must be able to meet total WD.

-*L=L'+F* -*Height* -*z + l' (z= eye to lens)*

Identifying Telescope Power: - - -Objective Diameter: Diameter of what? (Keplerian only)

-*Label* -*Comparison Method* -*Exit Pupil*

Demonstrating Stand Magnifier: -Have patient hold SM flat on page and make sure they are in their bifocal. Use occlusion or suppression if there is rivalry. -Use a ____, _______ or ________ -Use a ______ to make sure pt is using correct distance -Turn ____ overhead light or move away from patient -What if patient keeps lifting the SM off the page?

-*Lap Desk, reading stand* -*Tape measure* -*Off* -*Pt wants more magnification*

Tangent Screen: -Helpful for determining what type of scotoma? -Good to determine habitual _____ of person with central scotoma. For fixation have them look at center of an X made with white tape. Target sizes can vary to more precisely explore the scotoma. -Testing is usually where? -Performed monocular or binocular? Use the smallest dot the patient can see. Can also measure EV position. -________ letter in center of screen and map out scotomas. May also be good for malingerer because should get smaller if closer not larger.

-*Large* -*EV* -*1 m* -*Monocular* -*Suprathreshold*

Visual Field Testing: -Why do we test it: determine _____ blindness, eligibility for ________, help patient ____ functional loss; _______ to monitor change; recommend what? -Can be broken into 3 categories: what are the three?

-*Legal* -*Driving* -*Quantify* -*Baseline* -*O and M training* -*Central 10 degrees radius, Central 25 degrees radius, Peripheral Visual fields (Kinetic Perimetry, Static)*

Galilean: -______ than 4X. -Image is ______ or ______. -FOV has _____. -Exit pupil is _______. -Size of image is ______

-*Less than* -*Erect* -*Peripheral blur* -*Internal* -*Small*

The higher the power, the less _____ and the lower the ______....why over or underprescribing may be a big deal.

-*Light* -*Contrast*

Hand Held: -____ with a screen. Camera can enlarge the images and have light sources built in. -______ enhancement and color options as well. Many to choose from, each have their own features (options that can be added). -What are two cases in which these should be considered? May have option of wider screen (=wider field of view). Can increase after picture is captured. Uses: Reading medicine bottles; signing income taxes; doing household tasks; enlarge if needed; reverse contrast -May help with what problems?

-*Lightweight* -*Contrast* -*Spotting tasks, quick tasks (writing signatures, medicine bottles)* -*May help with noise problems*

Clinical Applications: Understand patient's eye condition Understand patient's goals -Know patients ______ (hand tremor, neck problem, head problem) What is patient's goal print What magnification do they need (EVP and EVD) -Consider _____ As a concern Will you combine CL and telescopes? Will they be using monocular or binocular? -Do they need a full lens system or is _____ An issue?

-*Limitations* -*Cosmesis* -*Mobility*

Stargardt's: -Excessive _______ storage with macular atrophy or flecks at RPE level. AR. VA: Bilateral decrease in vision as child 20/40 by 20s decline and stabilizes to 20/200 or worse -VF: ____ scotoma to absolute scotoma Ocular: Normal or loss of foveal reflex; yellow flex in macula; RPE atrophy; beaten metal appearance in macula; decreased vision; abnormal color vision; nyctalopia

-*Lipofuscin* -*Central*

Training: - - - - - - -Remember visual perception. What is the key with training TS?

-*Localization without TS then..* -*Focusing (Toggle)* -*Spotting* -*Tracing (Stationary lines)* -*Tracking* -*Scanning* -*Patience*

Word and Jaeger Charts: -No _____ or ____ Relationship between rows. Nonlinear progression so not much mathematical notation to it. -Doesn't use the correct font....we want what in low vision? We do not use this chart.

-*Logarithmic* -*Predictable* -*San Seraf*

Hemianopic Field Defects: -Usually omit the side they have ____. -If a patient has a stroke on the right side of the brain they may omit the letters on the _____ side of the chart. -They may also start in the ____ and go across. -Peripheral field loss may not be able to see a ____ letter but when you go down to smaller letters they can see better.

-*Lost* -*Left* -*Middle* -*Large*

______ power stands have much bigger lens and this is often what patient wants. Also the stronger the lens the worse the ______ aberrations

-*Lower* -*Worse*

Keplerian TS and The Hyperope: -Calculate the tube length given an objective lens of +20D and a eyepiece lens of +60D -If the tube length is fixed you have to change the objective lens. What would the new objective lens have to be in order to compensate for adding -10D to the eyepiece with a fixed tube length? -What is the new magnification? -If the objective lens is unchanged what would be the new tubelength with the 50D eyepiece? -With this change the tube length and magnification increases or decreases?

-*(1/20) + (1/60) = 6.66cm* -*0.066= l(obj) + 1/50 =0.0466 --> 1/0.0446=21.59D* -*50/21.59 = 2.32 X* -*(1/20) + (1/50) = 0.07m or 7cm* -*Decreases*

What is the equation for magnification given the power of objective and ocular? What is magnification given the entrance and exit pupil?

-*(Focular/Fobjective)* -*Entrance pupil diam/exit pupil diam*

Contact Lenses: -Great for patients with RE of what? -Even more beneficial for patient with a peripheral field of _______ or less. Magnification system is up to _____x. Can create a telescope as well.

-*+/- 10.00 D* -*10* -*2*

Given a keplerian telescope with an objective of 2 and a eyepiece of 10. What is the magnification? Inverted or upright?

-*-(+10/+2) = -5X* -*Inverted*

Contrast Testing: Pelli Robson Chart 16 triplet Sloan Letters -Each subtends ______ Degrees at 3 meters -We test at ______ meter Each triplet has same contrast (decreases 0.1log unit for each triplet) -5-6 lines is _________, 3-4 lines is _____ and 1-2 lines is ______ __________. -Should be tested at luminance level of _______Cd/m2. If you do this test at 1meter you need to account for accommodation and a plus 0.75D lens to correct for this.

-*0.5* -*1* -*Normal, reduced, severely reduced* -*85*

How many degrees should my patient see? (Rule of 57) -At 57 inches away from an object; 1 inch = ____ degree.

-*1 degree*

Goal: Match the patient's visual threshold with their visual demand. -1 M print size subtends 5' of arc at ___ m. 20/20 optotypes subtends 5' of arc. -VA = ______/________ or ______/____

-*1 meter* -*Test Distance (ft)/ letter size (ft)* -*Working distance (m) / Letter size (M)*

MARS Card (Contrast Chart): 0.04 log unit decrease per letter. Handheld chart @ 40-50cm distance. -Can be done <_____ minute. -Test continues until ______ consecutive errors. -CS = last letter minuse _______ each incorrect letter. -Used more for _____ and ______ distance. Will use add for Rx.

-*1 minute* -*2* -*-0.04* -*Near and comfortable* (Like the Pelli-Robson: 8 lines of 6 sloan letters; covers same contrast range; results correspond)

For a +8DD IHMM: -A viewing distance of 25 cm gives what relative mag? -What apparent mag? -A viewing distance of 40cm gives what relative mag? What apparent mag? -A viewing distance of 100 cm gives what relative mag? What apparent mag?

-*1) 8/4=2x 2) (.25/.125) = 2X* -*1) 8/4 = 2x 2) (.40/.125) = 3.1x* -*1) 8/4 = 2x 2) (1.00/.125) = 8x*

Scoring Physical Exam: -Any 5 elements or less: level ____ -6-8 Elements: _____ -9-13 elements: _____ (must include mood and orientation) -All elements _______

-*1* -*2 -*3* -*4*

A 10 year old emmetrope holds a reading material at 10cm. -What is the accommodative demand? -What add is needed? -Where is working distance and why? -What if patient pulls material closer?

-*1/.10 = 10D* -*18-.3(10) = 15 /2 = 7.5 D 10-7.5 = 2.50 add* -*Working distance is 1/10 = 10 cm because included accom* -*Pt. wants to use more accom, so less power in Rx*

What would the lens separation (d) in cm for a Keplarian TS with a +10 Objective an a +20 Ocular?

-*1/10 + 1/20 = 15 cm*

If a presbyopic patient needs a +10.00D lens to read what is the working distance? How about with a +20.00D lens

-*1/10 = 10 cm* -*1/20 = 5 cm*

-What is the entering vergence into a TS when viewing and object at 3 meters with a 5X TS? -What is the emerging vergence out of TS if you do not put a reading cap in front to compensate for accommodation?

-*1/3 = -0.33 D* -*(5^2) (0.33) = -8.25 D*

Feinbloom Chart: Test Distance/Letter size (10ft, 5 ft, 2ft, any ft). Typically tested where? What if they cannot see the 700' letter (what are three solutions...if none of these work what else can you do?).

-*10 feet* -*Move head around, move chart in clock motion, start moving forward (if letter is outside field restriction, may need to use a smaller letter)*

-If you correct a -18D myope with a -10D CL and needs a +16D microscope what new microscope power would you give them? -What would the working distance be? -What is advantage of this system?

-*18D - 10 = 8 D microscope* -*Total power is still 8 + 8 = 16 so still 6.25 cm* -*Larger field of view*

Scoring a History: HPI ROS Medical History Family History Social History Problem Pertinent: 1 Question Complete: _____ areas for established and ______ for new patient. What is a new patient?

-*2* -*3* -*First time you have seen them or if they have not seen you or anyone in your practice in the last 3 years*

Convert 2/32M to snellen. What is the MAR? What is the logMAR?

-*2/32M x 10/10 = 20/320* -*32/2 = 16 degrees* -*log 16 = 1.20*

It takes about _______ minutes to take a good case history (1/3 of your exam time). Treatment is important for patients in current therapies (i.e. a macular degeneration patient who is receiving injections). VFQ = visual functioning questionaire.

-*20*

How well should my patient see: -In normal viewing (infinity) telescope enhances vision by the power it provides. So a 2x telescope would make a 20/200 patient see what? -In reverse design it should minify by power. 2x TS in reverse would do what to 20/200 vision? -Do not want to prescribe a reverse TS that reduces vision more than ______.

-*20/100* -*20/400* -*20/150*

Meter System (M) Lighthouse near acuity chart: -A 1M optotype subtends 5 MAR at 1 meter. 1m/1M = ________ snellen equivalent. -If moved from 1 m to 40 cm this is 2.5x closer so 1 M letter at 40 cm is what? Sloan chart can measure ____M___to______M -3 line difference ____ in size or minimizes by ____ depending on which way you are going. -_______M is bible print size. Large print bible is ___-____M print.

-*20/20* -*20/50 (.4/1M x 10 = 40/100 = 20/50)* -*.16M to .5M * -*Doubles, 1/2* -*0.5, 2-3*

Legal Blindness: -General Definition: Best corrected VA of ______ or less in the better eye. -Updated Definition: Patient cannot read any of the letters on a _______ equivalent line with low vision distance acuity chart testing* -Or visual field defect such that the widest diameter of the visual field, in the better eye, subtends and angle no greater than ____ degrees.

-*20/200* -*20/100* -*20 degrees*

Fitting a Fresnel Prism: -Pt. VA should be better than _______. -Good ______. No neglect/imperception/inattention. Prism on the temporal field loss (left nasal VF compensated by right nasal VF). -Can you do it on both eyes? -Patient should return to you office in _____ weeks. What should they notice (Cut back a mm, come back, training patient to scan and eventually wont need it anymore). Smooth side goes on back of glasses. -Move prism 2 mm temporal, why?

-*20/200* -*Cognition* -*Yes, but less successful* -*2 weeks* -*B/C don't want inside vision (use as side mirror)*

What should my goal acuity be: -Most things we view in real life are around what? -If a patient sees 20/80 and you want them to reach their goal what power would you start with?

-*20/40* -*2x (20/80 / 2 = 20/40)*

Snellen Chart: -Not recommended for low vision unless VA is ______ or better. -Chart luminance is _____. -Poor ______ (Varies with age of bulb, system, or if mirror is used). -Large _______ in optotypes result in poorer VA (20/200 to 20/100) which may cause a patient to fail requirements. -What is the largest optotype? Good for what type of acuities? -Start with ____ or _______ chart (but these are not callibrated for higher acuities). -Mirrors can cause loss of illumination, why?

-*20/40* -*Fixed* -*Contrast* -*Gradations* -*20/400* -*Finer acuities* -*Feinbloom or ETDRS* -*Due to prism effect*

Low Vision = Visual Disability -Visual Impairment is best corrected vision of ______ or worse. -What is important about this? -Many diseases are _____ and can take years, so starting early produces the best outcome. Low vision is not a one time fix, it is rehab and requires multiple and prolonged visits. Low vision is functional vision loss that causes personal impairment. -In order to function in the real world what type of vision do you need?

-*20/50* -*Best time to begin intervention* -*Progressive* -*20/200*

A low vision patient is given a 20D IHHM with a lens diameter of 75 mm. Calculate: -Regular Magnification of IHHM: -Apparent Magnification WD from 25 to 40 cm* -Size of FOV (z = 25 cm) -Size of FOV (z = 40 cm -Size of FOV (+2.00 Add, Z = 15)

-*20/5= 4 x* -*40/5 = 8 x* -*7.5 (5/25) = 1.5 -*7.5 (5/40) = 0.9375* -*Fe = +2.00 + 20 - (2 x 20 x .15) = 16D; 7.5 (6.25/40) = 1.17*

Low vision and Life Changes: -Driving Laws in Texas: _______ in better seeing eye; unless one eye is ______ or worse (in which case the better seeing eye must be ________).

-*20/70* -*20/200, 20/40*

Snellen Chart: -Not recommended unless vision is better than _______ (always use if VA ____ or better or use ______ chart). -Why?

-*20/80* -*20/40 ETDRS* -*Because Feinbloom is not calibrated for finer acuities.*

Why does the mag on screen not match my numbers? -Remember, like the X value used for magnification it is based on what reference distance? -Key points: as working distance changes what also changes? -As ER increases, FOV _______, b/c less print is viewable the closer you get.

-*25 cm* -*System magnification* -*Decreases*

Mystique of stand magnifier: They are labeled with a D power of the lens, the magnification (x) and where the image forms. Problem: Consider the difference between manufacturer labels and true magnification a patient receives. -Some use a reference distance of ____ others assume object is inside of F requiring accommodation (F/4) + 1 (conventional mag). -How do you find the true values: use what? Conventional mag: Put focal point within magnifier so add +1

-*25 cm* -*Use published parameters from the manufacturers*

Conversions: -20/40...what is MAR? What is log mar? -0.96logMAR...what is MAR? What is snellen?

-*2; 0.3 (3 line jump)* -*2, 20/40*

PRL Recording: Always record as the patient sees it, think of the chart like a clock hour. If the patient views the chart to the left of the doctor record as what? If the patient views the chart below the doctor then record as what? The clock points to where the eye goes. Example: FeinBloom Chart 10/50 OD PRL 3 O'clock

-*3 o'clock; 12 o'clock*

Opportunity for Optometrists: __________________ people over age of 40 are visually impaired and do not receive proper care; become unable to work and/or care for themselves; early entrance into skilled nursing facilities or assisted living. Very few optometrists receive adequate training in low vision care resulting in ____ loss, loss of huge patient base, and loss of the rewards of providing care that transforms a patient's life.

-*3.3 million* -*Financial*

An object 3mm tall is placed 15 cm to the left of a +10D lens. -Calculate the image location -Height of the image -Lateral magnification of the system.

-*30 cm to the right* -*1.5 mm* -*-2x*

When given: 4x12. -What does 4x stand for? -12 stand for? -What would the exit pupil be? -What is entrance pupil diameter?

-*4 = Magnfication* -*12 = Objective lens diameter* -*Exit pupil=12/4 = 3 mm* -*Entrance = 4 = EP/3mm = 12 mm*

Clinical Usage of LogMAR Charts: -May be used at any distance...but usually what two are most common? -There is a three line increase in this chart. For every 3 lines there will be a _______ line increase in acuity. -Isolate lines for ________ effect to help aid acuity.

-*4m and 2m* -*2* -*Crowding*

M Notation: -A 1M letter subtends an angle of ____ MAR at _____ meter. -Linear size is ______mm meaning this is the size no matter what distance you measure. This is why we record Test distance (m)/Letter Size (M).

-*5 MAR, 1 Meter* -*1.45 mm*

Snellen History: -Using a single vision letter calibrated to the standard distance that letter subtends _____ MAR. -Each stroke width subtends ____ MAR. -Acuity is measured as _________ /_______*

-*5* -*1* -*Test Distance/Standard Letter Distance (or letter size)*

Reduced Snellen Card: Snellen introduced chart in 1866. -20/20 letter subtends a ____ MAR usually at 40cm. Recorded as 20/acuity assumption tested at 40 cm. -Is this a good or poor way to measure near VA and why?

-*5* -*Poor way to measure near VA because patients are rarely reading at 40 cm*

Hemianopsia: Can be complete or incomplete. -Can improve within 1st ____ months of loss. -Can exhibit visual _____ or _____ (this can occur without a field cut when patient tries to squeeze all things on one side). Need to treat the neglect prior to treating field loss. -T/F. Cannot be rehabilitated with prism/telescope bc inattention and must do VT first.

-*6th* -*Inattention/Neglect* -*True*

Dazzling Glare Treatment: Make sure to address the other two types first. Assess for overcast and sunny days. -Let patient adapt for ______ minutes to lighting conditions before you test. -Solution is ______ CL or _____. -Goal is try to keep total light transmission as ______ As patient can tolerate (plum, gray, and amber). -Which lens tint is not recommended for driving?

-*7* -*Opaque, tint* -*High* -*Amber*

What print size is equal to 1M? -Use _____ print, _____ spaced, and ________. -Example: If can read 2M print, what print size do you need?

-*8 points (M=point size/8; important because gives value to your testing)* -*Helvetica, double, bold* -*2M=____/8 => 2(8)= 16 point font*

HHM: Relative mag is unchanged but apparent magnification changes with viewing distance. -A +8D IHHM has a conventional mag of what? What is the apparent mag equation?

-*8/4= 2x* -*Apparent Mag: Mag x (VD/WD) (OR: VD/WD)*

Clinical Experience: Typically there is a device that will help: ________% of patients with vision loss have some form of usable vision. _______ status may be a major problem (patient can't learn to use it). -When should you talk about cost?

-*80%* -*Cognitive* -*At the end of the exam when plan is in place*

-Most common causes of visual impairment include what four diseases? -What is an additional disease? -What is the biggest impairment that is often not caught?

-*AMD, DR, Cataracts and glaucoma* -*Stroke* -*CS*

Stargart's: FA: Silent FA prominent vessels on dark background, RPE atrophy shows hyperflurescence, yellow flecks do not hyperfluresce. Full field ERG is normal. -EOG is _____. LV Mgmt: Refraction. EV training. Magnification. Direct illumination. Filters and sunglasses. Prognosis stabilizes at 20/200. Legal blindness letters. -Can consider ______ telescopes.

-*Abnormal* -*Bioptic*

-__________ is a hereditary condition in which cones do not develop properly and result in absence of color discrimination. Two Types: -_____ monochromatism: True CB -____ cone monochomat: Loss of R/G cones. Most common. -What is the inheritance? VA Range: 20/60-20/200. Better at near and in DIM illumination. Worse in bright (think about it: patient has lost CONES! Rods work better in dim)

-*Achromatopsia* -*Rod* -*Blue* -*AR*

How to Prescribe CCTV: Test reading acuity with current ____. Calculate EVD and EVP (done by using ratio TD/LS = TD/LS). -Bring patients to CCTV with their current add, have them sit at this ____ ____ (or use a trial frame)...commonly what two distances? -Determine the _____ and set the print size on screen accordingly (height or width). Confirm system magnification (if were not able to get patient successful with the ER that you calculated based on EVD). Begin Evaluation.

-*Add* -*Working distance; (15 cm/40cm)* -*ER*

What are three ways of correcting the effects of ametropia?

-*Adding the full relative correction to the eyepiece* -*Adding a partial refractive correction to the objective* -*Changing the telescope length (focal).*

-What is an advantage of testing poorer eye first? -Disadvantage? -Advantage of starting with right eye first?

-*Advantage: Prevent memorization* -*Disadvantage: Frustration* -*Won't forget which eye was tested first*

Telescopes: -Advantages include what three things? -What are three disadvantages?

-*Advantages: Light, Inexpensive, quick spotting of tasks* -*Disadvantages: Restricted FOV, Requires some training, Not used while mobile*

How to Find Power of SM Vergence Amplification Method: Place stand magnifier on clearly printed material. -Hold an ___ telescope in front of your eye and view material under stand magnifier with telescope. It will most likely be blurred because of the divergence of stand magnifier will be amplified by factor of M squared. Insert ____ lens on top of stand magnifier until material is ___. The first image that provides a clear image is approximation of divergence.

-*Afocal* -*Plus, Clear*

Full Field Doublets: -Two lenses separated by what? -Allows for high magnification with less what? -Available in magnification from 2-20x but especially useful in powers of _____x and above. -Advantage: uses _____ of _______ and lens to maximize the power of the lens. Reading material looks good though whole lens. Can be tinted. -What is a disadvantage of this lens?

-*Air space* -*Less peripheral distortion* -*5x* -*Index of refraction* -*Expensive*

-_________ is a congenital condition caused by body's inability or lack of pigment in skin and eyes. -______ albinism: X linked recessive (males). Reduction of number of melanosomes. Carriers of hypopigmentation scattered among areas of normally pigmented areas. -______ albinism (AR/AD) reduction in amount of pigment in each melanosome. -____ ___ (fewer symptoms and has more pigmentation). -____ _____ (classic presentation). Tyrosinase parents can only have pigmented children.

-*Albinism* -*Ocular* -*Oculocutaneous* -*Tyrosinase Positive* -*Tyrosinase Negative*

-_____________ is amount of light emitted from a light source measured in lumens. -This follows the ________ ______ ______ which states that a light source emits luminous flux to illuminates a work space set at a certain distance. Illuminance of that object is inversely proportional to the square of the distance the light source is from the object. -How do you maintain maximum luminance? -If you have a light at 50cm and you go to 25 cm it is the square of that so...._____x brighter.

-*Lumanous Flux (Illuminance)* -*Inverse Square Law* -*Bring it as close as possible* -*(2 times closer)^2 = 4x*

Telemicroscope System Mag: -What is the equation for magnification of telemicroscope system? -If you are given a 4X TS with a +2.50 add what is the magnification of the telemicroscope?

-*MT = MTS x (Reading cap/4)* -*MT = 4x x (2.5/4) = 2.5X*

-___________________ is an age acquired disorder where changes in RPE occur with degeneration of the rods and cones in the area involved. Atrophy, fluid, bleeding and scarring can result. -Defects in the processing in the photoreceptor _____ segments. -Deposits in the RPE and ______ membrane. VA is 20/20 to >20/400. -Garbage man not properly taking out the garbage.

-*Macular degeneration* -*Outer* -*Bruch's*

CCTV: Pros -Large options of what? -Can enhance what? -Uses system magnification to give the patient a longer what? -Can be used as a ____ _____ device. -What is maintained? -Can go up to what magnification? -Patient can pick-up usage quicker because more real world (< 1 1/2 VA difference). VA patient can purchase these. -How many hours of training are necessary?

-*Magnification* -*Contrast* -*Working Distance* -*Hands Free* -*Binocularity* -*60X* -*8 hours*

-VA is Essential for ______ Determination and choosing appropriate low vision devices: -Not taking the time to get good acuities can result in poor ________ of optical device and _______ an already long exam. -You want a functional acuity rather than a true acuity. Taking poor acuities may also cause problems with prescribing their devices because vision is too poor or too good. We usually like to read ___-____ lines above our threshold (so more like 20/40).

-*Magnification* -*Selection, prolong* -*2-3*

What is a CCTV: -____ device using a camera with a zoom lens, ____ table, light and a TV screen It is the "cadillac" of low vision devices Available in black, white, and color. Can be mounted, portable, or a variation of two (goggle system or text to speech).

-*Magnification* -*X-Y Table*

Dislocated lens: Can be hereditary or due to systemic abnormalities or ocular trauma or inflammation. VA: Normal to severe impairment VF: loss due to secondary glaucoma Symptoms: blurred vision from RE, mmonocular diplopia, loss of acommodation, secondary glaucoma, phacolysis, iridoenes -______: upward displacement, blue sclera, strabismus, myopia, RD. Arachnodactaly, tall stature, hyperextensibility, hyperelasisty, and aortic valvular disease -_______: downward lens displacement + osteoporosis -Weill Marchesani: microspherophakia, _________ dislocation of lens, short stature, stubby digits Treatment: Pupillary block (LPI); lensectomy if poses a threat

-*Marfan* -*Homocystinuria* -*Anterior*

Veiling Glare Treatment: -Fix the ______ problem. -Wear the _______. -_____ lenses (What color and why?) -____ lenses. Amount of tint depends on squint reflex.

-*Media* -*Visor* -*Tinted (yellow because it is medium wavelength that blocks out blue short wavelength)* -*Polarized*

JCC: Same as phoropter. -Red lines replace red dots in phoropter, represent the _______ cylinder axis. Black lines are black dots. Align lines with cyl. -Do we do binocular balance in low vision?

-*Minus* -*No because most patients have asymmetric acuities and/or are presbyopic*

Galilean Telescopes Myopes: -Borrow _____; -Weaken or Strengthen eyepiece? -Reduces or increases magnification? Hyperopes: -Borrow _______; -Strengthens or weakens eyepieces? -Increased or decreased magnification?

-*Minus* -*Weaken ()* -*Reduces* -*Plus* -*Strengths* -*Increased*

Bifocals: Allow for corrected distance and near vision. -Good for what patients? -What is a disadvantage of this type over other microscopes? No full field reading with these.

-*Mobile (Active patients) with short spotting tasks* -*Smaller field of view*

Hand Held (Why...): -Monocular or binocular use? -Enhance ______ travel -Watch TV for (short or long?) periods -______ Tasks See blackboard in school (Depending where seated) See baseball game -______ someone across the room Can also be used to introduce the system type

-*Monocular* -*Independent* -*Short* -*Spotting* -*Spot*

Clip On (Why...): -Monocular or Binocular use? Slipped over rim of glasses when needed to view -Used for (long or short term) when a specific hands free task is needed (copying, watching TV, hand tremor) -What is a big disadvantage of these? -What is a big advantage of these?

-*Monocular* -*Short* -*Cosmesis is poor* -*Hands-Free*

-______________________is a demylinating disease where fibers have an impaired ability to conduct impulses at physiologic frequencies. Lesions infiltrated by T lymhocytes and macrophages that result in release of lymphokines and monokines. Scarring and edema. 10-59 year old female (30 years old) VA: Normal to severely impaired -VF: _____ and ____ or _____ -Seizures, decreased sense of touch pain and temp. Uhthoff's sign. General weakness. Blurred vision. Lhermitte's sign. Optic neuritis. Papillitis. APD and color vision. Cranial nerve palsies. Uveitis. Treatment: High dose steroid therapy for acute episodes. Prognosis gets worse when episode occurs and then gets better. Waxes and wanes. Adjunct therapy: MRI T1 and T2. VEP to test optic nerve. -What LV device may be best for this type of patient?

-*Multiple Sclerosis* -*Central, Centroceccal, Altitudinal* -*Glasses*

-_______________: Increased axial length with thinning of sclera, choroid and retina. 20/20 with gradual decreased. -What type of VF defect? Down syndrome, marphans, stickler's syndrome. RPE thinning creates tesselated fundus and peripapillary scleral cresents. -LV: ___ correction (small frames with round AR); direct light; -Remove ___ for near or microscopes; sun filters; flashlights Prognosis: 4D change a year; stabilize around year 20 years old. Medical: CNVM if present. Tx retinal tears and breaks.

-*Myopic Degeneration* -*Ring shaped scotomas* -*RE (minimize prismatic effects) -*Glasses*

Cataract: Opacification of crystalline lens. Can be caused by trauma, metabolic, toxic, pharmacological, inflammatory, hereditary and age. 95% of people > 65 have some form of cataract. VA: Not generally affected by early NS. -_______ shift usually occurs when lens starts to be come sclerotic (second sight). PSC can cause severe acuity loss. -VF: ____ depression on central and peripheral field testing

-*Myopic* -*Generalized*

Glaucoma: -Can have various field loss, but what is often the first type of defect? -_______ is definitely more affected in these individuals (more than RP) -______ progression Happens later in life usually. People want what the accustomed to and can be difficult to train because they can't do that anymore. Sometimes harder to rehabilitate because they want what they have lost. -___________ affects can vary depending on stage of loss and contrast impairment. If problem on daily basis refer to LV.

-*Nasal Step* -*Contrast* -*Slow* -*Mobility*

Macular Degeneration Symptoms: Blurry vision, metamorphopsia, micropsia, and central vision loss. Problems reading, needing more light to see, vision comes and goes or fades. -Easily fatigued with ____ work. Visual hallucinations (Charles Bonnet syndrome). Adjunct Testing: Map scotomas with amsler grid. OCT and FA. Important to co-manage with retinal ophthamologists to help patient during their treatment. Low Vision: -_______ education. Good trial frame refraction. Map scotomas. -Increased _____ illumination for near goals. -______ glasses for near and distance. Filters and tints. -____ blocker lenses and typoscopes. No amber. -Prognosis: Educate AMD will not cause blindness (maintain peripheral vision). Recommend support groups.

-*Near* -*Vitamin* -*Direct* -*Separate* -*Blue*

Ophthalmological Office Codes (92004, 92014, 92002, 92012): -Do services have to be completed in one visit? Dilation is not required unless required by state. -Following ____ of ___ is most important which often requires DFE Following state laws regarding minimum exam requirements typically exceed Medicare. -*92004/92014: Optometry School CEE -*92002/92012: Specific problem

-*No (as long as you bring patient back) -*Standard of care*

Treatment for Overall Peripheral Field Loss: -Does stroke affect central vision? -Sector prisms for overall constriction (Read p. 711) -Reverse Telescope: gives a ______ view of the world. Vision decreases by the power of the TS (give highest power tele w/o reducing more than 20/200). VF enhances by the power of TS. -Goal : Highest power that does not reduce VA more than ______. Can measure how much field the patient is getting by using the arctan formula. -Refer to _____ to help with training of TS. -Should you use a reverse telescope with a stroke patient?

-*No* -*Miniaturized* -*20/200* -*O&M* -*No*

Hand Held Magnifiers: -Made of _______ lens. -Magnification _____ regardless of eye position (only effects field of view). Object is placed a primary focal point. -Is an ADD required? Some will include a light to help illuminate reading material. Main thing is it must be held at focal point (where light is leaving parallel). -It is also called what type of magnifier? As the eye moves back and forth the image size will stay the same but relative to print side on outside will change due to apparent magnification. As you move further away apparent magnification will look like its increasing because print around it is smaller central image.

-*Plus* -*Same* -*No* -*Collminating*

How to Find Power Of SM Plus Lens Method: Place the stand magnifier on clearly printed material such as a visual acuity chart. Place your best corrected dominant eye as close to lens as possible. -Insert a ____ lens until you first experience ____. -The highest plus lens which still allows for clear vision is an approximation of the _____ exiting the SM. -What is downside to this method?

-*Plus, Blur* -*Divergence* -*Accommodation*

Lighthouse Game Card: -VA with this chart may be _____ than obtained from an ETDRS because of increased contour between letters of each word. -As word decreases in size, _______ or distortion of part of the word or losing place while reading can occur in some patients with _______ scotomas.

-*Poorer* -*Dimming* -*Central*

Amsler Grid: -Good for measuring patient's ____ for using a near magnifier for reading/writing. -Testing ________. -_______ scotomas (>___ degrees patient is usually EV and are not giving you a true measurement). -Where do you want to move the scotoma? -Each line is ______ mm apart subtending ___ Degree when held at 13 inches. -What happens if you test OU amsler?

-*Potential* -*Metamorphopsia* -*Small (>5 degrees)* -*Above (increase reading speed)* -*0.5mm, 1* -*Rivalry (other eye will replace missing info)*

Treatments: -Just like we defined the different etiologies for the field losses, we can identify the treatments into 2 categories as well....what are these? -What are three things to consider? -Glaucoma vs. Stroke; Absolute vs. Gradual

-*Prisms & Reverse Telescopes* -*Pt. cognition, motivation for rehab, type of loss (progressive, stable, absolute, etc)*

Color Vision Testing: Helpful in confirming ocular diagnosis and monitoring _______ of disease. Help determine how difficult a time patient will have with ADL. School age children who may need to discriminate colors. -Farnsworth D-15: Done monocularly when any color vision defect is suspected that is not due to classic deutan, protan or x-linked blue cone monochromat or rod monochromat. Large version available. Good for differentiating _____ pathologies. -DM, HTN, and AMD have _______ Defects -Dystrophies have ________ Defects Test performance can be affected if wear filter

-*Progression* -*Macular* -*B/Y* -*R/G*

In what four cases should a CCTV be considered?

-*Prolonged Reading* -*Writing* -*Viewing pictures, cards* -*Someone who has poor contrast or glare reduction*

Aniridia: Medical MGMT: Glaucoma surgery/mgmt. Corneal Transplant. Cataract extraction Low Vision: -_____ blocking contact lenses (Decrease nystagmus and improve VA. -CL's contraindicated when? - ______ lighting, filters and sun lenses. Magnification devices for distance and near. Genetic counseling. Prognosis: Secondary glaucoma is hard to manage and can lead to blindness.

-*Pupil* -*Cornea is involved* -*Direct*

Acuity measures visual ________ Contrast measures ______ -We do not function in a high contrast world. So why do we test patients with high acuity charts?

-*Quantity* -*Quality: a more complete measure of functional vision. Important test to aid in devices prescribed* -*Because it's the way things have always been tested*

Bioptic (Why...): -(Quick or extended?) spotting tasks (playing cards) and driving -Hands free or not? May have patient say state says suitable to drive -_____ lens system

-*Quick* -*Hands Free* -*2*

Coloboma: Treatment: RD and breaks require surgery Prognosis: usually stable, but need to watch for RD Low Vision MGMT: -Treat _____ __; -CL occluding iris or aperture; _____ ______ (photochromatic); -Perform better in (dim or bright) illum?; -______ field loss can teach scanning techniques; distance and near magnification

-*RE* -*Corning Filters* -*Dim* -*Superior*

-____________ is the proliferation of developmental BV in newborns with retinal vascularization is incomplete. Low BW with oxygen therapy (<1500 g or 30 weeks). -Stage 1 (sharp demarcation line between vascular and nonvascular) to stage 5 of RD. Location is divided into 3 zones with ONH in center. Extent is clock hours. -High _______. 20/20 to NLP. -____ field defects most common Tx: Cryotherapy to scleral buckle. Large doses of vitamin ___ Are thought to reduce severity. LV: Rx RE with AR coating or CL. Magnification. Filters and tints. -Direct ____ illumination. Field awareness systems and mobility. -Prognosis: complications including glaucoma, cataracts and RD.

-*ROP* -*Myopia* -*Nasal* -*E* -*Nonglare*

Illumination: -What are two eye conditions that perform optimally under bright lighting that is glare free? -How about less illumination? -Most patients prefer _______ to ______ watts in illumination. Place lamp behind patient over reading material and vary the intensity until patient is comfortable, document. -A lot of patients like _______ the best. The closer you can bring the light to the patient the more you change the _______. You can't read for long periods with intense magnification.

-*RP and AMD* -*Cone abnormality* -*60-100* -*LED, luminance*

Telemicroscopes: -____ ______ + Telescope for intermediate distance viewing. TS power required for equivalent viewing distance. -Advantage? -What are 2 disadvantages?

-*Reading Cap* -*Increased WD* -*Deceased FOV; training*

Device Options: What are three options?

-*Reading add (effective add) microscopes* -*Stand and HHM* -*Electronic Magnification (if contrast problem)*

Communication: Be _____ and ______, but optimistic. Explain the difference between what?

-*Realistic* -*Honest* -*Blindness and Visual Impairment*

What are three types of single letter charts?

-*Reduced Snellen* -*The M system Lighthouse Near Acuity Chart* -*Reduced ETDRS chart*

Albinism: Adjunct Testing: Hair bulb test for Tyrosinase (+ or -). Low Vision Mgmt: -Correct _____. Control illumination (filters, tints, hats, CL/opaque lenses, visors hats. -What are advantage of CL?. Magnification. -Would these patients have oscillopsia? Genetic counseling. Consider tilting paper to read. -What type of pencil? Prognosis: Non-progressive condition. Tyrosinase patients can get some improvement as pigment increases with age.

-*Refractive error* -*May dampen nystagmus due to pressure on li* -*No, congenital condition* -*#1*

How the CCTV Provides Magnification: -Uses a combination of what two things to create system mag? -What is the equation for EVP? -What is the equation for ER? -What is the equation for EVD? Remember when yo know EVD and EVP you can prescribe any device.

-*Relative Distance Mag & Relative Size Mag* -*EVP = Add x ER* -*ER = Size on screen/Size on page* -*EVD = WD/ER*

Distance LogMARChart (Bailey-Lovely): -Great for what type of applications, because it is calibrated? -Geometric progression of letter size by a factor of _____ times. Each row is ____ Difficult (5 letters each = ______ logMAR step). -Letter spacing is _____ (Good for what two things?). -______ and _____ is same on each line. -Each letter is scored in _____ logMAR units.

-*Research* -*1.26* -*Equally, 0.1 (0.02 x 5 = 0.1) * -*Proportional; scotomas and finer VAs* -*Task and spacing* -*0.02 (For each letter read correctly, subtract 0.02 from logMAR line. For each letter read incorrectly add 0.02.)*

-When you are stumped by etiology perform an ERG which measures the electrical potential of the _______. -It is a ________ Dominant test. -Patient is tested under what conditions? -Good for what three things?

-*Retina* -*Rod* -*Light and dark* -*Family History with suspicious retinal finding, Unexplained Field Loss, and Prolonged Dark Adaptation*

RD: Fluid collection between sensory and retinal and RPE. -Most common cause of rhegmatogenous? Exudative: blood vessel or RPE damage Tractional: Vitreous membrane or proliferative retinopathy pulling on retina VA: severe if macula off VF: correspond to site of RD -Flashes, floaters, curtains, ______ _____. Ehler's danlos, marfan's, sticklers. B scan. Tx: scleral buckle, retinalplexi, silicone oil. PPV with membrane peel.

-*Retinal Break* -*Tobacco dust*

What are some common culprits of peripheral field loss: Key is to think about the disease and how the disease functionally would impair the patient. -*What are four peripheral diseases that can cause peripheral field loss? -*What is an attitudinal disease? -*What is a hemianopic/sectoral disease?

-*Retinitis Pigmentosa, Glaucoma, DR, and Retinal Detachment* -*AION* -*Cerebrovascular Accident*

How do you get a baseline for Refraction: -Current Rx (not really in low vision), ________ -____ measures amount and axis of corneal toricity to estimate the amount of astigmatism (topographer and keratometer). -Real world: likely use an ________. Retinoscopy can be done anywhere. -_______ retinoscopy: no reflex when you have a patient with congenital cataract or other problem that means you move closer to patient and remove working distance based on that.

-*Retinoscopy (in phoropter, outside phoropter, radical retinoscopy, and over retinoscopy)* -*Keratometry* -*Autorefractor* -*Radical*

Retinitis Pigmentosa: -Causes a ____________ VF defect? -______ progression (30s and 40s). Y-ou could miss this doing CVF, why? -Treatment options: ____ ______. Usually reserved when patient has ____ degree field loss or less. How much is 20 degree field or less?

-*Ring scotoma (vision in the periphery then missing in the mid-periphery then vision returns centrally)* -*Slow* -*B/C hands too far out (need to bring in); ie. you could be past defect* -*Reverse Telescope* -*20 (B/C minimum amount of field to function may not help patient)* -*Shoulder Width*

Recording Acuity: -Test vision with current reading ________ and any low vision aids they have brought with them. -Make sure to write the working distance. Record as what? Record whether the patient consistently loses their place, omits sections of the chart/letters/words etc. Test single letter acuity and paragraph acuity. Eccentric fixations positions should be recorded. -Where should you have the patient hold the reading material? -A ________________ helps minimize confusion and increase localization it is a good tool if skipping lines or moving around. -This type of filter is good for AMD or problems in macula.

-*Rx* -*Test Distance/Letter Size* -*At the focal point of the lens* -*Typoscope* -*Yellow*

Ocular Diagnosis: Many patients do not understand their condition: _________ can play a role; may believe misinformation they have been given ("There is nothing more that can be done for you"); ______ is crucial and can help psychologically (AMD pts thinking they go blind; take time to explain). Even after a thorough discussion you may have to review it again and again. Sometimes you are the first person to talk to them.

-*Selective hearing* -*Education*

Discomfort Glare Treatment: -Translucent side _____ on frames. -Are sunglasses a good option, why or why not? -Visor with good brim positioned low the brow. Rim should extend _______ inches minimum. Bending sides can help with lateral discomfort glare in superior and temporal visual fields.

-*Shields* -*No because it make darker areas even harder and darker to see* -*3*

How To Speed It Up: -Use ______ low vision chart, patient holds card comfortably WD, measure, if not at focal point redirect patient. Record OD, OS. -Use _________ chart, read OU then test worse eye occluded to determine improvement in reading speed. -Focal point will increase _______ of card/material. If improvement in reading speed when eye is occluded then there is likely a problem with ________. -This can be tested with what?

-*Single letter* -*Continuous Text* -*Clarity* -*Rivalry* -*Amsler Grid*

In office training with the prism: Locate the object with the prism and touch it. Show jack in the box effect and image jump (image disappears and then becomes clear). -Locate stationary object while patient is _______. -Locate stationary object while patient is ______. -Locate moving object while patient is _____. -Locate moving object while patient is ______.

-*Sitting* -*Walking* -*Sitting* -*Walking*

Explanation of Exam Procedure: Use good judgement and proceed _____ and with ____. Make sure they know you are trying to ______ their vision, not fix it.

-*Slowly* -*Caution* -*Enhance*

Reduced ETDRS: Like distance chart version, it maintains 5 letters in each row and can be used at any distance. -Get small _____ at higher acuities which gives the chart a ___ Effect (so not good to use with what problem?). -Each line of optotype has _____ log unit (25%) larger than the previous line. Every 3 rows will have a double or halving effect at any viewing distance. -Would you use with a macular degeneration patient? -Will you use with RP patient?

-*Spacing, Crowding, Central scotoma* -*0.10* -*No* -*Yes*

-Microscopes are also known as what? -They are __ lenses that use __ ___ magnification. -What are the only two things you can do in low vision?

-*Spectacle Magnifier* -*Plus, relative distance* -*Make it bigger or bring it closer*

Discomfort Glare: Worse usually in late morning or late afternoon. -Patient may ______ or use their hand to cover as a visor. -Need at least _____ Degree radius of ______ or ____ VF before you will notice problems. We experience this.

-*Squint* -*10, superior or temporal*

What are four types of VMS (Video Magnification Systems)?

-*Stand alone or desktop style* -*Handheld* -*Portable* -*Wearable*

HVF: -_______ perimetry. Can test variety of points, intensities. Fixation monitoring available -Goldmann: ______ perimetry. Can test variety of points, intensities, sizes and speeds. Initial testing target can be smallest target seen 15 degrees from fixation. -What is used for legal blindness? -For driving? Can watch patient through telescope to make sure EV position is steady. -Which of the two is the gold standard of fields?

-*Static* -*Kinetic* -*III4e* -*IV4e* -*Goldmann*

Keplerians: Myopes: Borrow minus. -Strengthen or Weaken eyepiece? -Increases or decreases magnification? Hyperopes: Borrow plus. -Strengthen or reduces eyepiece? -Increase or reduce magnification

-*Strengthen* -*Increases* -*Reduce* -*Reduce*

Disease Process in Low vision (Stroke/Brain Injury): 795,000 Americans will have a _________ this year. #4 Killer in the US (HA #1 and cancer #2). It is the leading cause of what in the US?

-*Stroke* -*Visual Imperception (or neglect)*

Lighting: -It is important to have good lighting, but sometimes too much is a bad things. Lighting is patient ________. -When you have too much lighting you lose CS, which your patient would describe to you as_____________

-*Subjective* -*Glare (wash out)*

Coloboma: Keyhole shaped pupil if iris involved (inferior) can cause glare. Optic nerve excavation within ONH, 50% of patients get a nonRheg RD. Retinochoroidal appear white/yellow with pigmented borders inferior to ONH. -Sensory retina is present so what can possibly form? Strabismus and nystagmus can occur due to sensory deprivation. -Associated symptoms: Trisomy _____ (100% of cases); -Aicardi's Syndrome; Goldenhar's Syndrome; ______ syndrome.

-*Subretinal neo (due to potential space) -*Trisomy 13 -*CHARGE*

Binocularity: Not often done in low vision. Good mentally for patients so they know they can use both eyes. -Binocular vision offers _______ and can have a larger ______ _____. Depth perception and stereo are also possible. -Done when acuities differ no more than _______. -Binocular summation improves vision ____-_____ lines. A lot of times we can teach monocular depth cues

-*Summation, visual field* -*1.5* -*1-2*

-AION produces what VF loss? -Can affect mobility if ______ and especially in dominant eye. An old AION will have atrophy (pale, thin)

-*Superior altitudinal defect* -*Inferior*

Patient Ocular and Medical History: -Important to learn of any ________ interventions in the past or currently. -Medical History is important. ROS/Meds/ALL/Physical Impairments. Social History, ETOH use, Smoker and mental status are all important, why?

-*Surgical* -*Because you want to be paid for your visit by insurance*

EVD: Equivalent Viewing Distance is the distance that a patient needs to hold their material to meet their goal. -It is represented by what equation? -EVP: Equivalent viewing power is what equation?

-*TD/LS = TD(EVD)/LS(M)* -*1/EVD*

The low vision population is growing daily; there are many patients who need quality care; -______ approaches to vision loss (as with any rehabilitation program) is vital to maximize success). -What is considered the art of optometry?

-*Team* -*Low vision*

8 things you need for near acuity measurement:

-*The eye tested* -*The device name and whether it was used with or without correction* -*Size of letter/words seen* -*Test distance measured (never eyeballed) in meters* -*Type of target* -*Description of reading* -*EV position if any* -*Illumination level*

Galilean: The system is considered a _____ lens system separated by a tube length (f1+ f2). -Example: What would the lens separation (d) in cm for Galilean TS be for a +10 Objective and -20 Ocular?

-*Thin* -*1/10 + -(1/20) = 5 cm*

-E and M Codes are billed by _____ instead of by complexity. -If counseling time is greater than ______ % of the entire time that you spend with the patient minus refraction you can bill based on time. Drawback is that you have to record how much time for each and make documentation of refraction time.

-*Time* -*50*

Most common chorioretinits in western world. Prenatal or by inhaling from cat feces. VA: Severe or not depending on location VF: Depends on location Ocular: strabismus, blurry vision, floaters, white elevated lesions, necrotizing retinitis, multifocal gray white lesions, vitritis, iritis, periphlebitis, optic neuritis, inactive lesions are large scars, encysted organisms remain latent in retina Adjunct: indirect fluorescent antibody test Tx: Steroids or antitoxoplasmic agents LV: RE correction, magnification, EV training, direct illumination, -_____ lenses for glare, non-optical aids

-*Toxoplasmosis* -*Absorptive*

Limitations of microscopes: -_____ of device (can't work like they always have) -___, ____ and ___ position can cause fatigue* -______ of peripheral fields* Nausea (especially if looking around) Patient's limitations (FOV and elbow resistence)

-*Training* -*Arm, neck and shoulder* -*Distortion*

Referring Specialist Report: -Gives a rough sketch of patient's ______ and ________. -Often, acuities may be ______ (Don't make assumptions of patient's rehabilitative potential). -Check if future treatments or surgeries are planned. Get name of doctor...why? -Why would "counting fingers" be a problem?

-*Treatment and diagnosis (condition)* -*Inaccurate* -*Allows for communication back with the doctor (you get to build a rapport for referral and another reason is insurance communication)* -*Because contrast issue with light color skin or light colored clothing.*

Art of Prescribing CCTV: -T/F. Bigger is not always better. -Education of what size they "_____" need. -Remember what are the five things that make up magnification? -Determine by size of EVP. Teach them from the _______ of the evaluation. Balance critical print size + Threshold acuity. Noise n D-15 = contrast issue.

-*True (Reading speed and retention will be reduced if print is too large.)* -*Should* -*Color, contrast, FOV, magnification, lighting* -*Beginning*

Albinism: VA: 20/200 -20/400 (T.negative) (T.A is better acuity) VA: 20/25-20/100 (ocular albinism) -T/F. VA does not improve much with age. Visual fields: full in all forms Signs and symptoms: skin damage, usually high hyperopic, myopia or ATR Poor stereo 2/2 (abnormal chiasmal nerve deccusation therefore high strabismus) -Fundus: _______ fundus with prominent choroidal vessels and no foveal reflex -Macular _______ resulting in decreased VA and pendular nystagmus Oculocutaneous: White eyebrows, eye lashes, blue transilluminating iris with photophobia

-*True* -*Blonde* -*Hypoplasia*

T/F. For distance acuity you should never use finger counting. -For near you should use ___________ notation? -Is working distance important?

-*True* -*M Notation* -*Very*

Options for Low Vision: -T/F. If device is mounted you won't be able to walk around with it. -What are two options for distance? -What is an option for intermediate (gives mag with increased working distance)? -What are three options for near? -What are two types of non-optical aids (help to block out noise)? -What are two types of periphery field enhancements?

-*True* -*Telescopes and Bioptics* -*Telemicroscopes* -*Microscopes, Magnifiers, Projection (CCTV)* -*Typoscopes; Filters* -*Prisms; Minification*

Field Assessment Techniques: Poor fixators may require alternate tests. May require changing your testing methods. -______ person visual field testing (using different targets to grab attention). -Important to ______ how you test the patient (note head turns, posture, attention lighting, etc). -Low vision is the ____ of optometry. -What is the preferred method? If reduced acuity use different target sizes. Changes to HVF: Size 3 is standard may need to change to size 5.

-*Two* -*Document* -*ART* -*Automated Perimetry*

Half Eye Microscopes: -Provide ______, _______ distance viewing. -Good for patients who want what? Prismatic half-eyes available from +4.00 to +12.00. -________ prism is usually incorporated into the lens in order to maintain binocularity -(amount of prism diopters is ____ more than dioptric power of the lens.) -Ex: If a +6.00D lens is given. What is prism in each eye and combined?

-*Unobstructed, uncorrected* -*Mobility* -*BI* -*2D* -*6 + 2= 8PD BI/eye or 16BI Binocularly*

Or perform a VEP which measures the electrical activity of the ______ _______. Emphasizes patient's what three things? Good for what three things?

-*Visual Cortex* -*Central vision, ON and cortical processing* -*Unexplained VL, ONH pallor and suspicious ONH changes*

VA's are not just about central VA's: -_____ ___ status* -Techniques in measurement (patience) -You want to find a _____ piece of the eye and rehab, not something that cannot be helped. _______ illumination of VAs may be a problem because some diseases can cause problems at night -Name a disease that causes problems at night. -If the letter is too ____ it may occur outside their field. -It can take up to ________ minutes to get acuity.

-*Visual Field* -*Functional* -*Dim* -*Retinitis Pigmentosa* -*Large* -*10*

Types of Patients: Decreased ________, decreased _________, and decreased ____________

-*Visual acuity* -*Visual Field* -*Contrast sensitivity*

Trial Frame vs. Phoropter: -_______ lens to view through. You can dampen ______ with head position. Make large lens changes (phoropter +/-0.25D), JCC in _____ power so patient can appreciate a distance; check near acuities in more natural position; compare TF Rx with old Rx.

-*Wider* -*Nystagmus* -*Higher*

Aniridia Signs and Symptoms: -______ tumor, genitourinary abnormalities and mental retardation. Ocular signs and symptoms: Photophobia, microcornea with corneal pannus, congenital polar cataracts, lens dislocation, macular hypoplasia, _________ hypoplasia (Due to smaller number of neurons), -28% develop progressive ____. Associated syndromes include Miller's syndrome or WAGR syndrome (Willms, aniridia, genitourinary, retardation)

-*Wilms* -*Optic nerve* -*Glaucoma*

Determine Angluar FOV: Tangent = Opposite over adjacent. -Adjacent = ____ ____ (m). -Opposite = ______ the visible computer screen. ARC TAN = Half of the computer screen. Multiply by 2 to give you the angular FOV.

-*Working Distance* -*1/2*

CCTV Eval Continuation: Record on Exam Form: _________, glasses used (bifocal, FDMS, Trial Frame), Document EA used, _____, contrast, ________, system ______, reading _____ and ________.

-*Working Distance* -*ER* -*Polarity* -*Magnificaiton* -*Accuracy and speed*

Fresnel Prism: Idea is that it is used as a side view mirror to help patient what is coming before they hit it. -Prism Basics: Uses series of _____ that are separate prisms arranged in a circular fashion. -Allows for substantial reduction of _______. -Results in poor _____ quality. -Is it economical or not? -The image is shifted towards the apex. If you have a LHH where would you put the base of the prism? -Usually uses _____-____ prism diopters. -1 Diopter = 0.57 degrees, so 20 PD = what degree shift? Want a huge jump for patient appreciation.

-*Zones* -*Thickness* -*Optical* -*Economical* -*Toward defect (left)* -*15-30* -*20 (.57) = 10 degrees*

Central Visual Field Testing: RP patient looks at center of grid and has a field 4cm to the right of fixation horizontally. WD is 0.22 m what is the visual field in degrees?

-*tan (0.04/.22) = 10 degrees*

FOV and Stand Magnifiers: -The field of view for a SM is calculated differently from HHM. -The separation between the eye and lens (_____) is measured in same units as EVD. -Af = Al (length of lens) (EVD/z) or FOV = A (f/z) -Because EVD is dependent on z, when z decreases, EVD ______. -However as patient moves closer to the SM, Af becomes _____.

-*z* -*Decreases (decrease z = decrease EVD)* -*Larger (decrease WD = Increase FOV)*

Example : -New patient presents for CEE. Blurred vision. Treated for glaucoma, but just moved to the area and needs a new doctor. Was diagnosed with cataracts. -(Score the History): HPI: 5 points ROS: 12 points Medical, Social, Family: All 3 areas* -(Score the Physical Exam): All elements of eye exam were performed -(Score the Complexity): Same patient brought in 5 years of records from old OD documenting treatment and glaucoma management (VF, OCT, IOP). Number of diagnosis: Limited (2-3). Amount of data reviewed (Moderate 4-5). Risk (Moderate). You Rx Travatan. -Using the table of code and given that History was level 4, exam was level 4, and decision making was a level 3 what code would you use? -T/F. If you forget mood and orientation you decrease the code you can bill for?

-Score: Level 4* -*Score: Level 4* -*Score: Level 3 (2/3 elements on table were met = Rx given and moderate decision making)* -*Code: 99204* -*True*

Keplerian: -Both lenses are _____ -Exit pupil (inside/outside) telescope? -Image is ______ -Requires what?

-*Plus* -*Outside* -*Inverted* -*Erecting prism*

Albinism Associated Symptoms: Yellow Mutant Oculocutanoues: Common among amish. Gradually accumulate pigment, yellow red hair with creamy yellow skin. Dark skin patients have this form and have dark cream color skin with hair and dark yellow to red eye. Pigmented nevi -_____ : lighter complexion; sunburn easily, good VA and no nystagmus. Iris transillumination and fundus hypopigmentation with a dull foveal reflex -_______ _____ syndrome: common in PR population. Albinism, bruise easily, and serum platelet defect with epistaxis. Must avoid all medication that block prostaglandin synthase needed for platelet aggregation Chediak Higashi Syndrome: Rare metallic gray hair and skin color. Progressive peripheral neuropathy. -Increased susceptibility to _____.

-*Albinoidism* -*Hermansky Pudak Syndrome* -*Infection*

-Vergence is _________ when passing through the telescope. Users acommodation is insufficient to clear retinal image thus focusing is required. -What is the equation of the vergence leaving given magnification? -What is the equation for actual magnification?

-*Amplified* -*L'=L + M^2 (+ Galilean, - for Kep)* -*Mag^2 x expected accommodation*

Telescopes and Brightness: -_____ the brightness of point sources -Transmit nearly all the light from ______ sources (little is lost within the telescope, especially with many mirrors and prisms) -Brightness of the extended source depends on whether the exit pupil of the telescope is ______ than the eye pupil -If exit pupil is equal or larger than the eye pupil what type of change in brightness occurs versus without the telescope? -If exit pupil is smaller than eye the image appears _____ than without the telescopes? Older patient: Limitation is pupil Young patient: Telescope is limitation

-*Amplify* -*Extended* -*Smaller* -*No change* -*Dimmer*

Magnification of Telescope: Uses what type of magnification? Enlarges something only in ______ (not physical size). Angle subtended by the object of the focal point. How do you find the magnification of a telescope given the power of the lenses?

-*Angular* -*Appearance* -*MTS = -Fe/Fo*

Telescopes: -Use what type of magnification? -What are three challenges for using these?

-*Angular* -*Movement of viewed objects is exaggerated; Stronger the TS the smaller the FOV; Disruption of spatial judgements (appear closer than they are)*

-_________ is a bilateral condition where iris is absent, sometimes leaving only a small stump (can cause PAS). -Should monitor for what? Etiology: 12 weeks gestation. 2/3 are AD. 1/3 are spontaneous. Male or female. Incidence: 1/100,000 -Acuity: 20/100 to 20/400 because of associated what? Visual field: can be restricted due to secondary glaucoma Teach visors, hats, opaque CL.

-*Aniridia* -*Secondary glaucoma* -*Macular hypoplasia*

Full Field Telescope (Why...) -_________ distance activity that is done _______ or _______. -Person needs ___ vision for extended period of time (movie watching; bird watching) Increased light and increased FOV

-*Any; Sitting or Standing* -*Binocular*

Patient has an EVD of 10cm but wants to move back to 40cm. What power reading cap is required?

-*At 40cm you would need a +2.50Add* -*A 6x TS with a +2.50 ADD*

Hyperopes: Take _____ power from microscope. -An uncorrected 6D hyperope needs a 10D microscope to read print. What power will you Rx? -What working distance do they need to hold their material? Working distance is the reciprocal of power needed to focus print (EVD = 1/EVP)

-*Away (need to add it back)* -*10 + 6 = 16D* -*1/10D WD = 10 cm*

CCTV:Cons -Portable option has short what? -What is the biggest con? Not always portable (HEAVY) -Requires extensive _____ to be used to its potential. -LV devices are or are not covered by insurance?

-*Battery Span* -*Cost* -*Training* -*Not*

Avoid Vague Goals: -"I just want to see better" must be narrowed down to a specific goal..because you want to be careful with what? -"They told me you could give me new glasses" often an explanation of the _______ of low vision must be needed. -Position yourself _____ your patient and sit _______ than them.

-*Be careful with false expectations* -*Purpose* -*Towards, lower*

Spherical Full Field Microscopes: -______ or _____ ____ lens -What is a disadvantage of this type? Have reading material in front and scan across like a type writer. -Used in powers up to ______

-*Biconvex or plano convex* -*Lens power increases, peripheral distortion increases* -*+8.00*

Corneal Dystrophies: -Bilateral or unilateral? -Starts early in life and usually (progressive or nonprogressive?). Many different types. VA: 20/20 to LP. Visual field generally unaffected but can show generalized depression. Systemic Signs and Symptoms: Lattice (Amyloid deposits); central crystalline dystrophy of schyder (ring shaped crystalline opacities in central cornea ossibly from systemic hyperlipidemia). Ocular signs vary and include opacification, RCE, astigmatism, nystagmus, strabismus. Symptoms include lacrimation, photophobia, monocular diplopia, foreign body sensation, pain

-*Bilateral* -*Progressive*

Ways to enhance contrast: Create high contrasting spaces. ________ print on white or yellow paper. CCTV in negative polarity. Enhance ________. Cut glare by window treatments, position light away from line of sight or use a ______.

-*Black* -*Lighting* -*Typoscope*

DR: Low Vision: Check refractive error. Contact lenses. -___ and sun filters that block _____ wavelengths. Direct illumination. O and M training. Glucose monitor/insulin syringe with adaptive aids. Support groups.

-*CFS -*Blue*

What are four more advantages to a trial frame?

-*Can see eccentric viewing* -*Can see if there is search behavior* -*Can see facial expression* -*Can make larger lens change*

General Appearance: -Provide clues of emotional status (relationship with accompanying _____). -Watch how the patient moves from the exam room provides valuable information (_____ issues secondary to field loss or possible neurological problems). A lot of times a stroke patient will walk _______ or not in a straight line.

-*Caregiver* -*Mobility* -*Diagonally*

Eccentric Viewing and Eccentric Fixations: -Used when _____ scotomas are involved. Patient may have more than 1 spot (1 for distance and 1 for near). -Look for ______ of the position. -Usually do better with ________ acuity than paragraph. Document on a chart as the patient sees it. -Pt. looks at your right side to see the chart...what is their PRL? -How about if patient looks down?

-*Central* -*EV* -*Single Letter* -*9 o'clock* -*6 o'clock*

CCTV Evaluation: Show patient how to turn on CCTV. Ask them to scroll through different colors and choose one is most comfortable for them. -Demonstrate that the larger the letters, the less _______ patient will have and find balance for them for easy reading ability. -Document this and determine if this is close to your calculations if not why (may require more _________ b/c see less). May need to find less ER than you calculated because 5 things (mag, contrast, FOV, lighting..) Show them how to make the print larger and smaller, and what size is best for them. -Place reading material at the top _____ corner of X-Y table and have patient bring all the way towards them and over to the right so they know that they are stating at the top of the page. -Demonstrate the _______ method of reading (Roll, back, scoot away) Show them how to find their place if they get lost. -Demonstrate how to ______ table. -Show them how to ______ under CCTV.

-*FOV* -*Memory* -*Left* -*Typewriter* -*Lock* -*Write*

Two Sides of Case History: -Medical side: the ____, ____ and _____ collection. -Will lead more toward ______ to specialists and guide how you will proceed with exam testing. -Psychological side: emotional feelings and observations; will lead more toward appropriate ______ to the rehab team.

-*Facts, tests, data* -*Referrals* -*Referrals*

What are the two most popular distance low vision charts?

-*Feinbloom Chart* -*Modified ETDRS (Bailey-Lovely) Chart*

Patient's Goals Can Change: -Be _______: once a patient realizes that vision can be improved with low vision device, other goals may surface -Patients must understand that _____ visits are usually required -Sometimes if something is not working it may just be that they are not motivated to do the task. Studies show that patient requires ______ hours of training with a low vision device to improve.

-*Flexible* -*Multiple* -*8*

Types of Microscopes: -__________ (spherical, aspheric, doublets), ________, ____ and _____.

-*Full Field* -*Half Eyes* -*Loupes* -*Bifocals*

Patients Homework: -Wear prism ____ time. -Teach them how to ___ if falls off (wet and reattach). -Have them remember to ____ into the prism (Always scan into area not seeing). -Work on finding objects on a ____ . Education that this does not expand their field loss (not giving back vision that has been lost). -Should these patients drive? a

-*Full* -*Replace* -*Scan* -*Table* -*Possibly*

Definition of Low Vision: Significant reduction of visual ________? Cannot be fully ______ by ordinary glasses, contact lenses, medical treatment and/or surgery. It affects people of ALL ages, in the home, on the job, or at school.

-*Function* -*Corrected*

MNRead Card: -Combines reading _______ and acuity assessment. -Printed in high contrast (_____%). Each 3 line sentence has identical number of letters and spaces. -Each sentence has 60 characters printed in 3 lines, even L and R margins and uses a _____-____ grade reading level. -Also available in what? -Reading speed can be graphed to obtain _______ reading speed and _______ print size. -Why would a chart like this be useful?

-*Functional Performance* -*85%* -*2nd-3rd* -*Negative Polarity (Reverse Contrast)* -*Max, critical* -*Normally used in research; negative chart may aid in patients sensitive to glare can compare how they read with a device prescribed and if the new device is hurting or helping reading speed*

Tests for Binocularity: -Worth 4 Dot (Good for Children): use at any test distance, use best correction, use normal room illumination, jumbo versions are available. 4= what? -Red Filter and Maddox Rod Test: Any test distance. Red lens over ________ eye. View transilluminator with both eyes and tell if light is white, red or pink. Pink suggests what? -Prism test: Use at any testing distance, use in standard room illumination, ______ diopter prism over 1 eye and rotated while viewing a distant target; binocularity if ______ is reported.

-*Fusion* -*Poorer seeing (non-dominant)* -*Four* -*Diplopia*

Near Magnification: -When considering options for near the first thing that should come to mind as an optometrist is what? -Need to take into account patient's goals, limitations and ____. -Then think what four things? -Best quality optics are in a good pair of glasses.

-*GLASSES!* -*Expectations* -*Loupes, hand held magnifiers, stand magnifiers and electronic aids*

-__________ telescope is also called a Terrestrial Telescope. It is a 2 lens system with a (+) objective lens and a (-) ocular lens. Posterior focal point of objective lens coincides with posterior of ocular. -Creates what type of image? -Smaller or larger? Lighter or heavier? High mag or low mag?

-*Galilean* -*Erect* -*Small, Light, <4X (lower)*

Final Thoughts -When possible use _____ as first line for near goals* -Understand patient's ____ VL will aid in good fit for low vision aids* -*Understand ______ _______ magnification Be creative in customizing for your patient Have fun Make it bigger or bring it closer

-*Glasses* -*Functional* -*Relative distance*

Physical Health: Important when determining realistic _______, ________ low vision devices, and making appropriate ______.

-*Goals* -*Prescribing* -*Referrals*

Notes on Tints: -To be used as a ____. Little research shows which tint correlates with eye disease. Trial and error with educated demonstrations. -What are three tints that enhance contrast.

-*Guide* -*Yellow, Orange and Plum*

What are five types of Telescope options? Which of the five has the best option for walking around?

-*Hand Held* -*Clip On* -*Full Field* -*Bioptic (Best for walking around)* -*Binoculars*

Distance goals of individuals include driving, television, seeing faces, reading signs and marques. -Types of telescopes include ___-____; ____ (spectacle mounted) and ______ for intermediate distance.

-*Hand-Held* -*Bioptic* -*Telemicroscopes*

When to consider a microscope: -Need a ______ free system -______ and flexibility -______ Field of vision -_____ term reading (still only 15-20 minutes max at a time. Consider rewetting drops and educate on headaches) -______ Reading speeds* -Complete _____ tasks (writing) Reading receipts* Hobbies (needlework)

-*Hands* -*Portability* -*Wider* -*Long* -*Faster* -*Near*

Dislocated Lens: Low Vision MGMT: -_____ lenses for aphakic situation; magnifiers; UV coatings; filters and sun lenses; -Diplopia can be treated with ___ lenses, stenopopeic slits, aperture control lenses; -Recommend not to participate in what?

-*Plus* -*Pinhole* -*Contact sports*

Clinical Pearls on Charts: -Feinbloom: Perfectly adequate for most low vision evaluations; encourage patients due to large _______ of optotypes; numbers are easy if patients are ______. -LogMAR Charts: easily implemented with _____. Using it at 2 meters can help you convert to snellen equivalent if a patient asks. Easy to ______ what patient will see with low vision devices. Other notes: if you have a patient that does not know their numbers or has had brain trauma, the patient can draw it in the air or on the leg. The other way you can do it is if they can't move their hands significantly you can do matching. May also do tumbling E. Logmar chart is easy to show progress to patient and family members and allows for many cheat conversions

-*Number* -*Illiterate* -*Practice* -*Predict*

-_____________is a rhythmic involuntary oscillation of the eyes. -_____ : equal in both directions -______: faster in one direction Note: amplitude, frequency, and null point. 45 different types. Congenital or acquired (x linked recessive or AD. visuomotor problem). VA varies. Usually VF is normal. funblocs. Reversal of movement with OKN drum. -Congenital experience oscillopsia? -Lv: _____ at distance and near are beneficial. -Consider ____ devices. Consider _____. Help patients maintain null point with head position. -3-6 months of age . Persists but stable.

-*Nystagmus* -*Pendular* -*Jerk* -*No* -*Magnification* -*Binocular; Prism*

Trial Frame (Step by Step):

-*Obtain your starting point (old glasses, retinoscopy, auto-refractor, keratometry)* -*Occlude one eye* -*Check vision* -*At threshold VA, get the JND. Have patient view suprathreshold target and bracket lenses.* -*Place preferred lenses in frame and recheck acuity* -*Repeat until improvement is little or none* -*Check sphere once more*

Elements of An Eye Exam: VA EOM CVF Adnexa Bulbar/Palpebral Conj Cornea Iris/Pupil Anterior chamber Lens IOP Optic nerve Posterior segment -_______ -______/______

-*Orientation* -*Mood/Affect*

Cataract: Ocular signs: glare, decreased VA, increase in myopia, abnormal ret reflex. Distortion, monocular diplopia, alteration of color from yellow nuclear cataract. -Adjunct testing: what are three? -Low vision: ____ and _____ Treatment: Mydriatics or surgical removal.

-*PAM, B scan, Contrast acuity testing* -*Filters and visor*

Diabetic Retinopathy: -These patients will have significant field loss especially once ______ has been done. -Should do a _____ on any patient with PRP. Contrast will be an issue for these patients. Swelling, atrophy, pigment down.

-*PRP* -*HVF*

How Do you Test the Patient? -Watch the _____, not the chart -Encourage ____ ____ if necessary (if they don't move their eye, you move the chart) -Evaluate _______ to light and adjust illumination as needed -If patient has RP what chart would you use? -If patient has AMD what chart would you use?

-*Patient* -*Eccentric Viewing* -*Sensitivity* -*ETDRS (chart with finer acuity)* -*Feinbloom (move around easier)*

Why use 920xx vs. 992xx? -E and M codes typically ______ more. Ophthamology codes require ____ documentation. Sometimes you may use both (Ex: patient's chief complaint is blur, but secondary is itchy eyes. Bill 92004 first and bring back for allergy F/U and bill 9921X)

-*Pays* -*Less*

Full Field Aspheric: -Minimizes _____ _____ by reducing the power progressively towards the edge of the lens (more even reading experience and higher power). -Full diameter is appropriate for _______ to ____ powers. -Lenticular aspheric (fried egg design with flat outside and center round) is good for ______ to _______ powers. Might be easier with children because they don't know any better. Adults are more resistant because they know it is different. Pt. cannot walk with this.

-*Peripheral aberrations* -*+10 - +20.00* -*+10 - +48.00*

Accessorizing your Microscope: To maximize your speed and comfort: -Use directed lighting _____ to reading material coming from ___ the patient; -Avoid _____; -Consider a light ___; -Use a reading ______.

-*Perpendicular, behind* -*Glare* -*Tint* -*Stand*

Dazzling Glare (Third Glare): -Patient has _____ (abnormal sensitivity to light). -Due to problems with what two parts of the eye? Photophobia occurs because all the cells in the retina have to send connections back to the brain, so if the retina has cut connections then information isn't getting back to the brain with the right information.

-*Photophobia* -*Retina and iris (or iritis or uveitis)*

When to consider stand magnifier: -Preferred over IHHM when there are ______ limitations that affect ability to hold IHHM. -Problems maintaining the _______ of IHHM. -When patient wants extended reading without ______________. -_______ to prescribe unless you know tricks. -Need to know _____ ____ and image location.

-*Physical* -*WD* -*Close microscope WD* -*Challenging* -*Enlargement ratio*

Corneal Dystrophy: RCE treatment Slow progression that can be devastating if severe. Low vision mgmt: -Good trial frame refraction; _______ glasses or aperture control CL. Sun lenses. Tilt, filters, visors. Magnification (can cause problems). Non-optical aids.

-*Pinhole*

Keratoconus Low Vision: -Trial frame refraction, CL, ___ lenses, stenopeic slits, aperture control, CPFs, tints, sunglasses, avoid excessive _____, distance and near mag, CCTV Prognosis: Teenage tears, stable middle, advance rapidly

-*Pinhole* -*Light*

Depth of Focus: Important to know your devices and their limitations. -Focus TS for maximum ____. -Would this make it shorter or longer? Stand above printed material then get as close as you can until you fist notice distance blur then measure this distance. -Depth of focus: Infinity to _____ cm

-*Plus* -** -**

Stand Magnifier, What is it: -______ lens mounted in housing so that the lens is kept at a fixed distance from the page. -Good for people who want to read ____ _____, have a hand ____, poor _____ control, ____ learning how to hold a lens. -Stand height is made such that the printed material will be within the ____ point of the lens. Can be Stand magnifier or illuminated stand magnifier. -Why would we want to use something that creates a virtual image?

-*Plus* -*Continuous text, tremor, motor, children* -*Focal* -*Virtual image gives more bang for your buck (shorter WD)*

For telescopes: -Hyperopes: increasing tube length adds _______ to Feye -Myopes: decreasing tube length adds _______ to Feye

-*Plus* -*Minus*

Galilean has: -_____ objective lens -_____ eye piece lens -Exit pupil occurs (inside/outside) telescope?

-*Plus* -*Minus* -*Inside*