Portland Community College | Portland, Oregon

Upon successful completion students should be able to:

1. Skillfully complete patient workup in a clinical setting.
2. Accurately perform and document the biomicroscopy and visual field examination, retinoscopy and refractometry in the clinical setting.
3. Efficiently and accurately perform applanation tonometry under supervision in a clinical setting.

At the beginning of the course, the instructor will detail the methods used to evaluate student progress and the criteria for assigning a course grade. The methods may include one or more of the following tools: examinations, quizzes, homework assignments, research papers, laboratory modules, student participation and demonstration of competency.

LENSOMETRY

• Demonstrate the lacoation of the optical center of the lens.
• Demonstrate measurement and proper recording of single vision and multifocal spectacles.
• Demonstrate two methods of measurement of spectacles with prism.
• Discuss the significance of vertex distance.
• Demonstrate usage and measure base and power curves of spectacle lens using the Geneva lens clock.
• Convert Geneva lens clock measurements into a plus cylinder spectacle prescription.

INTERMEDIATE VISUAL FIELDS

•  Review and demonstrate Amsler grid, confrontational, tangent screen and automated visual field testing.
•  List and describe manual techniques for testing the visual field including tangent screen, and Goldmann perimetry.
• Demonstrate calibration of the Goldmann perimeter, including both stimulus and background.
•  List automated methods for testing the visual field.
• Describe when corrective lenses are required and for which portion of the Goldmann perimetry procedure.
• Distinguish the difference between static and kinetic field testing.
• Differentiate testing strategies for glaucoma and neurological examinations.     
• Define minimum criteria for testing for Armaly-Drance glaucoma screening examination, including blind spot screening methods.
•  Describe the procedure for confirming respect for the horizontal or vertical meridian.
•  Describe screening of possible malingering patient with tangent screen and expected results.

SLIT LAMP BIOMICROSCOPY

•   Describe two major styles of slit lamps.
•   Define “coaxial” as it relates to the slit lamp.
•  Differentiate “magnification” vs. “illumination” in isolating pathology with the slit lamp.
• Describe the procedure for properly setting each eyepiece of the slit lamp microscope.
•  List 6 “direct” and 6 “indirect” forms of illumination with the slit lamp.
• Describe the use and technique for each of the following forms of illumination: diffuse, parallel piped, optical sectioning, tangential, conical beam, specular reflection, proximal illumination, sclerotic scatter, direct retro-illumination from the iris, indirect retro-illumination from the iris, retro-illumination from the fundus and iris tranillumination.
• List the different filters available on the slit lamp and their usage.
• Describe the vital dyes and their usage when used with the slit lamp including: Fluorescein, rose Bengal and lissamine green.
• Describe when the Seidel test is used and how it is performed.
• Describe accessory lenses available to use with the slit lamp microscope; why and how they should be used.
• Differentiate between direct and indirect gonioscopic lenses.
• Utilize biomicroscopy to perform and anterior segment and ocular adnexa examination.

  INTERMEDIATE TONOMETRY

• Describe the differences in tonometers.
• Outline the advantages and disadvantages of each kind of tonometer.
• Explain how to use each tonometer.
• Decide which instrument to use to accomplish the measurement with greatest accuracy, efficiency, and least amount of discomfort to the patient.
• Discuss proper methods of cleaning and list 3 acceptable methods for disinfecting tonometers.
• Discuss technique for each method of tonometry: non-contact, TonoPen, Schiotz, pneumotonometer, hand-held tonometers, MacKay-Marg and Goldmann applanation.
• Describe the proper end point image in Goldmann applanation tonometry.
• Describe interpretation of the measuring dial of a Goldmann applanation tonometer in recording intra-ocular pressure.
• Describe and give the proper abbreviation of the units measured in tonometry.
• Describe the intra-ocular changes during the systole and diastole of the heartbeat.
• Describe the proper rotation of the tonometer prism head for patients with corneal cylinder of more than 3 diopters.
• Demonstrate the process of checking calibration of a Goldmann applanation tonometer in all three measurement ranges.
• Demonstrate checking calibration of TonoPen and proper measurement technique including replacement of OcuFilm tip covers.
• Demonstrate disinfecting each instrument.
• Perform and document applanation, non-contact, and indentation tonometry.
• Describe how central corneal thickness relates to measurement of intra-ocular pressure readings.
• Describe how intra-ocular pressure readings are converted for thick or thin corneas.
• List 3 types of patients contraindicated for tonometry.  

RETINOSCOPY

• State and explain the principles of and indications for retinoscopy.
• Describe the mechanism and functioning of the streak retinoscope.
• Describe the various types of behavior of the retinoscopic streak.
• Explain the recording of retinoscopic results and transpose those results into sphero-cylinderical form.
• Perform retinoscopy on the schematic eye.
• Perform retinoscopy on the human eye.
• Demonstrate appropriate maintenance of various retinoscopes.
• List at least 3 types of patients for whom retinoscopy is critical because refractometry cannot be performed.
• Describe the proper setup, with both phoropter and trial frames, for performing retinoscopy.
• Describe the reasons for both “fogging” the fellow eye and having the fellow eye unoccluded during retinoscopy.
• Describe proper sleeve position for both the Copeland type and Welch Allyn types of retinoscopes.
• Describe the purpose of using a “working lens” or subtracting “working distance” from the patients retinoscopic findings.
• List the steps performed when retinoscoping in plus cylinder.
• Explain the use of the “double sphere” method in retinoscopy.
• List the types of motion observed in patients with emmetropia, myopia, hyperopia and astigmatism.
• List the types of lenses used to neutralize motion in myopes, hyperopes and astigmats.
• Describe a method of confirming that neutrality has been achieved in retinoscopy.
• Give estimated spherical refractive errors for patients with visual acuities of: 20/80, 20/200, 20/400, and worse than 20/400.
• Explain how keratometry findings can help in finding proper correction of axis in retinoscopy.
• Describe a retinoscopic reflex in patients with high refractive error.

REFRACTOMETRY

• Differentiate between refraction and refractometry.
• Define emmetropia, ametropia, hyperopia, myopia and astigmatism.
• Describe symptoms of myopes, hyperopes and astigmats.
• Identify all knobs, dials and parts of the phoropter.
• List the five main steps in refractometry.
• List at least 5 “rules” to use during refractometry.
• Describe the proper use of the Jackson Cross Cylinder in testing both cylinder axis and power (in plus cylinder).
• Describe the “4-Step Test” for looking for cylinder power when spheres alone do not correct vision adequately.
• Describe the astigmatic clock and its usage.
• Describe the duochrome test and it’s usage in preventing over-minusing.
• Describe the principle of binocular balancing and how it is performed.
• Define “aphakia” and “pseudophakia”.
• Describe techniques to use with aphakic patients.
• Describe trial frames and loose lenses – distinguish how refractometry with these is different than that with a phoropter.
• Define vertex distance and explain when/how it is measured in performing refractometry.
• Define “Halberg Clips” and explain when/how they are used when “over-refracting”.
• Define presbyopia and list common symptoms.
• List estimated “adds for each age” for each group of presbyopes.
• List the process for checking the patients “near range” with “adds” in place.
• List three methods of measuring amplitude of accommodation.
• Describe subjective and objective methods of measuring refractive error.
• Explain the refinement technique using a cross cylinder lens.

OCULAR MOTILITY

• Demonstrate motility screening tests including cover/uncover, alternate cover tests.
• Demonstrate phoria and tropia.
• Demonstrate Krimsky and Hirschberg estimation.
• Demonstrate the use of the Maddox rod, Worth 4-Dot, red glass, duction and version testing.
• Demonstrate near point of convergence/accommodation.
• Demonstrate vergence amplitudes.
• Demonstrate use of the Risley rotary prism.

ADVANCED KERATOMETRY

• Demonstrate extending the range of keratometry