Primary Care Clinic Guidelines

Introduction

The basis of optometric practice is the general primary visual examination. The majority of optometric patients require only a visual examination with education and eyewear.   Even when specialized care is required, the primary care examination is the first step in determining the appropriate specialized service. Thus the Primary Care Clinic has two functions.

• First, to examine and deliver complete care to the majority of patients.
• Second, to identify patients who require special care and refer for proper treatment either within our clinic or to an outside source to meet the patients needs.

Regardless of whether the patient is cared for solely in the Primary Care Clinic or is referred for further consultation, the optometric student clinician, under the careful guidance of the licensed (attending) clinical instructor, is responsible for the patient’s care.

The patient receives the best care when one individual is responsible for the patient’s total care from beginning to end. Optometric service does not simply end with the writing of a prescription for eyewear but total optometric service involves translation of the prescription into spectacles, initial adjustment of the eyewear, discussion of how it will be worn, the progress evaluation to determine if the eyewear is having the desired effect and if the patient is adapting properly and any subsequent needs of the patient. Follow-up phone calls or visits are necessary, particularly with patients who have had a significant change in prescription, who are encountering a different form of prescription (contacts, spectacles, or multi-focals), or who are receiving treatment for medical eye conditions such as eye infections, glaucoma or in some cases dry eye.  It is considered good practice not to wait for the patient to seek the student clinician out, but for the clinician to follow-up and seek out the patient. The highest level of care occurs when the optometrist takes responsibility for total vision care of the patient.

Clinic Exam Form

A committee customized the present Electronic Health Record (EHR) from a commercially available medical records company.  The template for the primary care examination is detailed enough to fit the documentation needs of patients examined in not only the Primary Care Clinic, but many specialty clinics. Since the template for the primary care examination EHR is designed for a broad range of clinical situations, not all parts may need to be used for every patient encounter.  Individual clinical faculty members may advise with students the appropriate parts of the form that may be omitted for most patients.  Only clinical faculty can make final decisions as to what tests are necessary to render appropriate clinical care.

Since the EHR has the possibility to document the findings for many different procedures, students may be perplexed by what is required for a PC eye evaluation. The following information and testing sequences (e.g. procedures) can be used until the student clinician and attending clinical faculty have had a chance to determine specific exceptions:

• Case history. A relevant, accurate and complete case history should generally include:

• Determination of the patient’s chief complaint(s).
• Documentation regarding the past and present ocular history which includes present spectacle/contact lens Rxs with all parameters.  Note the state of repair of present glasses—both the frame and the old lenses. If the state of repair is poor (e.g., cracks in the frame or scratches on the lenses) record the defects.
• Recording the patient’s past and present general health status.
• Noting medications, use of illicit drugs and medication sensitivities.
• Documentation of the patient’s family ocular and systemic health history.
• Noting the patient’s visual needs and daily life including occupation, avocations and any special work environments.
• Glasses and contact lens neutralization.

• Cover test. When visual acuities are acceptable (better than 20/40), perform the cover test perform the cover test at 6 meters and 40 cm using loose prisms when necessary for accurate measurement. At 40 cm use a target with detail and ask the patient to keep it clear, thus stabilizing accommodation.

• Near vision testing.  A minimum near vision screening test includes measuring near VA, cover test, NPC (near point of convergence), near point of accommodation (if applicable) and vergences.  If abnormalities on screening tests are found and/or the patient is symptomatic, additional testing may also be needed which may include: binocular cross cylinder, fixation disparity and vergence ranges may also be considered.

• Refraction should consist of the following:

1) Retinoscopy should be performed on every patient as a first step before refraction.
2) Subjective refraction should be performed if

• a refraction hasn’t been performed in 1 year and visual acuity is less than 20/20.
• the patient is unhappy with his or her vision and/or if the patient wants an updated Rx and the latest Rx has expired.

3) Binocular balancing or binocular refraction should be done as appropriate.

• Biomicroscopy. Examination of the anterior segment should occur during every routine examination as well as any time the patient presents needing any ocular health testing.  An evaluation of ocular adnexa (lids and lashes), estimation of the angle of the anterior chamber, integrity of the cornea, conjunctiva, lens and vitreous needs to be evaluated and documented.

• Tonometry. Assuming there are no contraindications, intraocular pressure should be measured on every clinic patient with the exception the very young  (eg., under 10 years of age). Establishing baseline pressures as well as detecting high pressures is an important part of every routine optometric eye examination.

• Visual Fields. If a visual field hasn’t been performed in 1 year, a screening visual field (confrontation, screening automated fields or tangent screen) should be completed.  Visual fields should also be done in patients who have had a cerebrovascular accident or patients who present with symptoms that suggest a neurological disorder.

• Funduscopy.  If there are no contraindications (e.g., there is no risk of contraindications) in new patients and regularly thereafter, mydriatics should be used to thoroughly evaluate the ocular health.  Using a non-contact fundus lens, obtain a stereoscopic view of the optic nerve, macula and posterior pole.  In cases, where greater detail is needed or if the patient is unable to position him or herself in the slit lamp, the clinician may use a direct ophthalmoscope.   For visualization of the peripheral retina, perform binocular indirect ophthalmoscopy. The following are minimum fundus findings that should be recorded on every patient:
  • Shape, depth and size (including C/D ratio with horizontal & vertical dimensions)
  • Whether disc margins are distinct or indistinct
  • Foveal reflex (present or absent)
  • Macular integrity
  • A/V (artery to vein) ratio
  • Integrity of peripheral retina
  • Any normal variants (e.g., drusen, pigment, myelination, etc.)
  • Any abnormal findings

• Checking in with the instructor. If you have problems during the examination at any time, discuss them with your instructor in a timely manner and before all your time has elapsed. When leaving the examination room always make it safe for the patient.  Lower the patient’s chair to the lowest position, return the room illumination to full brightness, remove instruments (eg., phoropter, slit lamp and doctor’s stools) from in front of your patient, lock your computer screen and provide your patient with something to read while you are away.

• Case analysis. After your examination, write up the case under the headings: Diagnosis, Assessment and Plan.  When writing up the case, check your own data for inconsistencies. Retest if necessary or be ready to provide a plausible explanation for any discrepancies. The following guidelines will help with the case analysis:
  • Diagnosis and Assessment:
    • Refractive error: nature of refractive error, anisometropia, etc.
    • Binocular vision: significant issues with BV such as esotropia, large exophoria, convergence insufficiency, etc.  If there are abnormalities with accommodation, also include them. When appropriate, include test results such as suppression and stereoacuity.
    • Ocular health: health of the eye.
    • Significant issues with the systemic health (e.g., diabetes) may impact the eye.
    • If the patient does not achieve 20/20 vision, indicate the reason why.  Possible causes may include significant cataracts, amblyopia (be sure to indicate the type of amblyopia) or retinal pathology.
    • Plan (including treatment and advice):
      • Rx advised: which includes lens style (single vision, PALs, etc) and recommendations in terms of when to wear the Rx (eg., full time, for reading only, etc)
      • If there are significant BV issues, indicate the recommended management such as specific glasses, vision training or referral for treatment.
      • Indicate any information and recommendations which you feel would be of benefit the patient, such as what to expect from Rx, when to wear Rx, when to return for follow up care, changes that may be expected in the future, etc.
      • Recommendations regarding follow up as well as the reason and what tests should be performed at the next evaluation.

Objectives for Second Years

Optometry 200D (the didactic course) and Optometry 200DL (the laboratory course) are scheduled during the Spring Semester in the 2nd year of optometry school.  These courses assist student clinicians in the transition from class and laboratory learning to clinical care.   The focus of both courses is to analyze relevant clinical situations and solve patient problems. Often the transition from didactic and Pre-Clinic laboratory to the actual clinic setting is extremely abrupt for many students who are used to the traditional forms of study. Both courses are designed to make that transition more efficient and comfortable for entering clinicians. One way this is done is to introduce live (non-optometry students) patients. This enables students to examine a (non-student) patient who is not familiar with classroom optometric teaching – thus a patient who will provide realistic responses in terms being able to follow the student’s directions during refractions, ocular health evaluations and patient education. Pre-Clinic students will find that interacting with these patients who don’t have an optometry background to be far different and will challenge the pre-clinician into changing or modifying their mode of communication.

Optometry 200D and DL – Spring Semester

In Optometry 200DL, teams of 3-4 second year students with a supervising instructor will examine patients in the clinic. The students are expected to offer these patients the same professional care and treatment that they would receive if seen in third/fourth year clinics. An attending faculty optometrist closely monitors the teams of students and students learn the beginning portion of a clinical examination with emphasis on tests relating to the refractive status of the eyes. This includes specific techniques of clinical testing as well as the theoretical base upon which these tests were developed.

The examination procedures sequence include:

• Take a complete case history and relevant patient information including:
  • Determination of the patient’s chief complaint(s).
  • Documentation of past and present ocular history, including present spectacle Rx and all of the parameters.
  • Recording the patient’s past and present general health status.
  • Noting medications, use of illicit drugs and medication sensitivities.
  • Documentation of the patient’s family ocular and systemic health history.
  • Noting the patient’s visual needs and daily life including occupation, avocations and any special work environments.
• Measure habitual (either aided or unaided) visual acuities at distance and near.
• Perform the necessary binocular tests:
  • Cover test both unilateral and alternating at distance and near; be able to diagnose the magnitude (and if applicable the laterality) of any phoria/tropia, eso/exo, hypo/hyper deviation within 2 prism diopters.  In cases where the patient has extremely poor vision in one eye (eg. 20/200 or worse) perform Hirshbergs testing as an alternative
  • Extraocular motility or versions, including understanding the actions of the extra-ocular muscles.
  • Subjective angle of directionalization measurement of the Maddox rod at distance and near as well as the Modified Thorington.
  • Gradient and calculation of AC/A.
  • Measurement of fusional vergences ranges at distance and near: positive, negative, supra, and infra. Understanding the relationships among fusional, tonic, accommodative and proximal vergences.
  • Measurement of fixation disparity.
• Perform the necessary refractive tests
  • Retinoscopy
  • Subjective refraction, including binocular balance
• Perform the necessary accommodative tests
  • Accommodative amplitude
  • Relative accommodation
  • For presbyopes: determination of the final add utilizing the above techniques as well as the physical ranges through a trial frame, but relying mostly on chief complaint and the previous (effective) add.
• Ocular health evaluation
  • Evaluate the anterior and posterior segments of the eye, measure IOPs, and conduct visual field testing.

The students are expected to perform the above test procedures in a cohesive, accurate and efficient manner. During team care, students are evaluated on their patient communication skills and proficiency and speed at utilizing instrumentation.

In order to enter Summer Session Third Year Clinic (430A) competence in patient care is determined by passing Optometry 200D and 200DL courses.  As the final part of passing, 200DL, a Qualifying Exam is conducted to assure that the student is able to demonstrate minimum standards in patient care.

Objectives for Third Years’ Summer Session

Goal: to be able to complete a basic examination under close instructor supervision.

Although the examination is a flow of procedures and case history, orchestrated by continual thinking, analyzing and hypothesizing on the part of the clinician, it is sometimes helpful to organize the examination into the following sections: 1) chief complaint and case history; 2) confrontation tests; 3) refraction and binocular vision assessment; 4) ocular health assessment; 4) patient management and record documentation.  For different patients, the flow and sequencing will vary depending upon the patient and his or her needs. Many of these categories are inter-related and overlap. Realize that this is only a model and no examination should follow an exact template.

Case History

• Obtain the patient’s identifying information and ensure that they complete all entry paperwork
• Obtain a relevant case history
  • Identify chief complaint
  • Identify secondary complaints
  • Elicit significant systemic and family history
  • Identify vocational and avocational visual needs

Confrontation Testing

• Measure visual acuity
  • Habitual distance and near
• Perform the following confrontation tests
  • Cover test at distance and near
  • Versions
  • Near point of accommodation
  • Near point of convergence
  • Pupillary distance
  • Pupillary reflexes
  • Stereopsis (as needed)
  • Color vision testing (as needed)
  • Blood pressure

Refraction and Binocular Vision Assessment

• Perform a refraction which may include
  • Retinoscopy
  • Astigmatic testing (Jackson X-cylinder, fan dial, Paraboline)
  • Monocular subjective
  • Balance (dissociated)
  • Binocular subjective (as appropriate)
  • Keratometry
  • Distance phorias (horizontal and vertical), base in/base out vergences, supra/infra vergences
  • Near acuity, phoria, base in/base out vergences
  • Measured AC/A
  • Positive/negative relative accommodation
  • Amplitude of accommodation
  • Determine tentative add for presbyopes
  • Measure working distances of adds for presbyopes
  • Measure range of add for presbyopes
• Demonstrate the following skills
  • Ability to give proper patient instructions
  • Aptitude about proper examination sequencing
  • Knowledge about normative values for each procedure

Health Examination

• Perform basic health assessment
  • Intraocular pressure measurement +/-2mmHg by Goldmann applanation tonometry
  • Anterior segment status by slit lamp biomicroscopy including
• Anterior chamber assessment

• Grading of the anterior chamber angles within 1 grade
• Detecting any anterior chamber reaction
• Posterior segment status (by direct and binocular indirect ophthalmoscopy)
  • Quantifying C/D ratio within .2 horizontal and vertical
  • Determining cupping type
  • Determining depth of cupping
  • Assessing margins of nerve head
  • Noting A/V ratio
  • Noting crossing changes
  • Noting presence/absence of spontaneous venous pulsation
  • Assessing macular appearance including presence/absence of foveal reflex
  • Detecting abnormalities of the posterior pole (to the equator)
  • Increased knowledge of screening and threshold visual fields; improved competence in properly administering visual fields
    • Demonstrating good manners (introducing the patient to the attending instructor, escorting your patient through the clinic)
    • Always acting in a way that is mindful of patient safety (e.g, when leaving the room, fully lowering the patient’s chair and not leaving the patient in a darkened room, removing any obstacles that might impede a patient leaving the room and holding chairs in position for patients when they sit down at auxillary equipment)
    • Discussing fees with patients before tests are performed (including follow-up tests)
• Completing the examination within time limits (not exceeding 1.5 hours)
• Proper Documentation includes:
  • Noting significant diagnoses both on the diagnosis list as well addressing it in the assessment and plan.  (Significant diagnoses include any areas of concern to the patient and/or doctor)
  • Documenting an appropriate treatment plan for each significant diagnosis
  • Completing the examination record
    • by entering all important data into the EHR
    • in a timely manner—usually by the time when the patient leaves the exam room

• Detecting pressure/absence of corneal staining
• Assessing TBUT
• Detecting media opacities

Patient Management and Record Documentation

• Essential communication skills include
  • Ability to explain refractive error and treatment
  • Proficiency in being able to answer basic patient questions regarding the examination and recommendations
  • Competence in giving patients instructions regarding use and instillation of eye medications
• Professional appearance and actions of clinicians include
  • Proper attire and hygiene
  • Ability to communicate basic information to patients
  • Exhibiting concern and respect for the patient

Objectives for Third Years’ Fall Session

Goal: to build on and refine skills learned in Summer to increase confidence, efficiency and flexibility in patient care.

• In addition to being able to complete the general examination sequence with the above expectations, student will take increased responsibility and proficiency in performing follow up or urgent care eye examinations.  In this role, students will expand case history by asking appropriate follow-up questions to fully characterize symptoms.
• Identify a tentative diagnosis from confrontation testing and history
  • Qualitative assessment of source of chief complaint
  • Quantitative approximation of refractive error
• Perform refractions within the following allowances:
  • Retinoscopy within +/-0.75 D, +/-10 degrees
  • Keratometry (when indicated) within +/-0.25 DK, +/-5 degrees
• Assess binocularity and accommodative status
  • Distinguish tropia/phoria, eso/exo, vertical deviations on cover test
  • Record subjective angle and vergences within +/-2 prism diopters
  • Measure associated phoria and forced duction curve when indicated
  • Assess degree of sensory fusion, suppression, and retinal correspondence
  • Measure accommodative lag and facility when indicated
  • Indicate working add for presbyopes within +/-0.25 D
• Health assessment
  • Correctly describe abnormalities of the anterior chamber/adnexa
  • Accurately describe abnormalities of the fundus
  • Grade (within 1 unit) media opacities
  • Perform all forms of visual field testing with proficiency.  Beginning skill in visual field analysis.
  • Perform ancillary testing with competence, including Amsler grid, color vision, red cap test
  • Routine use of Volk lens for posterior pole evaluation
  • Good ability in taking photographs of the posterior pole
  • Begining competency in identifying angle structures with either 3 or 4 gonioscopy
• Contact lens examination
  • Obtain complete history
  • Describe centration, movement, appearance of contact lens
  • Perform over refraction
  • Determine appropriate fit or appropriate referral for level 3 or higher fits.  (Level 3 or 4 fits consist of lenses for CRT, keratoconus, PKP or scleral lens fits.)
• Communication
  • Feel comfortable discussing all refractive errors and basic binocular, accommodative, and ocular health problems
  • Respond to individual needs of patients
  • Be able to assess the patient and establish effective rapport.

Objectives for Third Years’ Spring Session

Goal: further refinement of all skills and techniques from prior clinical experiences leading to greater clinician independence and improved patient management

• Continue to expand case history taking skills by probing the patient’s unique problems and identifying a tentative diagnosis and treatment from the case history.  In addition to the skills described above, the third year will have the following skills:
• Refraction
  • Binocular refractive techniques (Humphriss/Polaroid)
  • Retinoscopy accurate to +/-0.50 D, +/-5 degrees
  • Subjective accurate to +/-0.25 D, +/-5 degrees
  • Proficiency in alternative refractive techniques (paraboline, Humphriss, etc.)
• Assessment of binocular and accommodative status
  • Binocular X-cylinder testing for near add determination
  • Proficiency in alternative techniques
• Health assessment
  • Correctly diagnose abnormalities of the anterior chamber/adnexa
  • Accurately diagnose fundus abnormalities
  • Able to perform scleral indentation
  • Good ability in taking photographs of the posterior segment
  • Increased competency in identifying angle structures with either 3 or 4 gonioscopy
• Contact lens abilities include
  • being able to interpret information from the case history and how it relates to the contact lens wear
  • identifying health care concerns that are related to contact lens wear and corneal physiology
  • being able to compute optical relationships between spectacle refraction, K readings, base curves, tear lens, contact lens power and over-refraction
  • having accurate evaluation skills related to
    • Tear film
    • Fitting patterns
  • drawing appropriate conclusions regarding successful lens fitting or the need for referral
• Communication
  • Being able to discuss findings concisely to the patient’s satisfaction
  • Having good rapport and gaining patient trust
  • Inspiring confidence and compliance with recommended treatment plans

Objectives for Fourth Years

Early in the fourth year, the student will be expected to have achieved proficiency in all of the clinical skills/tasks as outlined for the previous three years and then the during the forth year will be introduced to advanced clinical knowledge while rotating through the specialty clinical services and external clinics.

Each graduating student

In Primary Care will:

• be able to quickly identify the patient’s chief complaint and any secondary complaints and come up with a differential diagnosis list that helps the clinician determine the appropriate diagnostic procedures during a primary care exam.  As needed, students will be able to appropriately utilize the state-of-the-art instrumentation.
• be able to formulate a treatment plan to meet the patient’s primary care needs in a timely manner (in sixty minutes or less).
• be knowledgeable regarding contemporary ocular and general health care, including familiarity with common systemic diseases.   In order to care for and counsel patients effectively, clinicians will appropriately refer patients to other disciplines as indicated.
• have an in-depth understanding of the practical management of ocular and non-ocular diseases, including urgencies and acute emergencies.  Examples of managing cases may include ocular, systemic and psychiatric emergencies.  In each case, the graduating clinician will be familiar with the appropriate professional to refer patient to for consultative care.
• Be knowledgeable about vision care and medical insurance coverage as well as be familiar with medical coding.

In Specialty Clinics:

1) Pediatrics and Binocular Vision

• Be knowledgeable about pediatric vision care, including genetics and the development of the visual system from birth to adulthood.  Clinicians will also have an understanding of the special techniques and procedures that can be incorporated in the examination of infants and children.
• Be able to identify and manage children who display substandard school achievement that is related to factors falling within the scope of the optometrist.  Management may include referrals or reports to other disciplines such as physical and occupational therapy, special education and educational psychologists.
• Be knowledgeable in the binocular function of the visual system, including unique visual demands such as computer eye and sports vision care.

2) Geriatrics and Specialty Vision Care

• Be familiar with the changes in the visual system with age as well as the special techniques and procedures in examining geriatric patients
• Be knowledgeable about the management of patients with vision impairment.  Clinicians should not only be familiar with vision rehabilitation options but also be familiar with other professional services available such as specialists helping with mobility and orientation, rehabilitation specialists and support groups.  Assisting patients with vision impairment requires that graduating students be part of a multi-disciplinary delivery of care and be able to work and communicate with other care professionals.
• Be knowledgeable in electro-diagnostic services to patients with retinal or neural anomalies.
• Be proficient at understanding both the treatment and management of patients with ocular disease and understand treatment options for the care and delivery of medical eye care.

Will Maintain Professional Obligations

• By continually performing a careful and critical analysis of current literature to improve patient care.  Clinicians will assume responsibility for their own continuing education and professional development throughout his or her professional career.
• Assessing community vision and eye care needs.
• By establishing appropriate interactions between themselves as providers, patients and ancillary office personnel.

Clinical Entrance & Proficiency Examinations

Clinical Entrance Examination (CEE)

In the Spring semester of 2015, a change was implemented to the 200D Lab course. The final practical exam was converted to include most elements of a full eye exam. In addition to performing the tests, the students were required to enter the data they obtained into a mock electronic health record (EHR) on an assigned computer rather than handwriting their results as done previously. A supplemental Qualifying Exam was administered by the Clinic Administration to test the students’ proficiency in using Compulink, the Clinic’s EHR. The Qualifying Exam tested the ability to enter and print prescriptions (spectacle, contact lens, and medicine) in addition to choosing correct diagnoses and procedure codes. A passing grade in both the 200D Lab course as well as the Clinic Qualifying exam are required in order to start patient care in the Summer Session.

The CEE has several benefits to the Clinic. It will:

• Allow the entering third year student to understand what is expected in Clinic.
• Give third year students additional experience taking practical exams under high stress situations, very similar to state and national licensing.

Clinical Proficiency Examination (CPE)

During the third year Summer Session Clinic rotation, specific tests and goals will be presented to the students, giving them a clearer understanding of the upcoming Clinical Proficiency Examination (CPE). The CPE will be:

• Administered to third year students at completion of Summer Session Clinic.
• To ascertain that the student clinician has grown and developed proficiency in the clinical skills presented to them during their first session of third year Clinic.
• Administered again at completion of Fall Session to ensure student has been developing in clinical skills.
• Very similar to the test given during the NBEO Clinical Skills, Part III.
• Designed to test a minimum proficiency in the areas of:
  • Primary Care
  • Case analysis
  • Ophthalmic optics
  • Ocular health
  • Binocular vision

It is recommended that students review the candidates’ exam book that outlines detailed procedures standard during that test.

The CPE has several benefits to the Clinic. It will:

• Allow the Clinical Faculty, who will be working with these students, to gain a clear understanding of their skills.
• Identify students with fundamental weaknesses so they receive additional help to prepare for clinical learning.
• Help assure quality of care for patients.

During third year Spring rotation, a second group of expectations and goals will be issued to the students. Competency in these procedures, as demonstrated by passing a CPE, is mandatory for continuing in the program.

Both the CEE and CPE are important ingredients to ensure student clinical competency. Students demonstrating significant gaps in their competence:

• Will be considered to be putting patients at risk.
• May be removed from clinical care activities and placed in an observational, non-patient clinical rotation until a re-examination can be passed, or
• May be placed into Pre-Clinic classroom and laboratory instruction until an additional CEE is passed.