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Tuesday / July 16.
HomemicontactIt’s Time for Fine-Tuning

It’s Time for Fine-Tuning

Learning techniques from more experienced others can save valuable time for you and your patients in the clinic.

Over the years one tends to hone one’s examination techniques for maximum impact and efficiency.

One of the most valuable things one can do is sit-in with an experienced colleague while they perform a full scope optometric exam. Watch what they do and listen to what they say. There are usually many pearls of wisdom to be gleaned.

Simple tests help zero in on the cause of a patient’s symptoms, or it may involve picking the right high tech diagnostic test.

Essentially the tips and pointers come from the patient’s chief complaint

Essentially the tips and pointers come from the patient’s chief complaint. It involves careful listening and some carefully crafted questions.

Once we have our tentative diagnosis, it’s a matter of moving on to the correct tests in order to confirm our suspicions. There’s no point spending 15 minutes trying to refract through dense cataracts, a vitreous haemorrhage or corneal hydrops.


New graduates often come out of university being used to spending an hour or two doing every test in the book and dutifully noting each and every finding. Patients often comment on how tedious it was, although acknowledging how thoroughly they were examined. Some graduates are lucky to have 45 minutes or more to do an eye exam. Those who enter more commercial operations, where they are under pressure to see a patient every 20 minutes, are even more shocked. I hear the same from older practitioners. Some find it hard to streamline their exams. Few of the people I know claim to enjoy that sort of pressure.

One can, however, save a lot of repetition and time wasting by fine-tuning the questions you ask. Performing tests in an orderly fashion helps one quickly eliminate certain abnormalities and focuses us on what most patients come in for: clear comfortable binocular vision and the necessary spectacles or contact lenses that help them achieve that.

When we cannot achieve that we need to efficiently and effectively make a diagnosis and make the appropriate referral. Many of our tests – like an opening gambit of checking pursuits and cover testing – can confirm normality in seconds. We then move on. For many patients, their old spec Rx, a recent autorefraction or retinoscopy would usually be the starting point of the refraction.

LCD Rules

If you haven’t got one yet, then a LCD test chart with a decent remote is the way to go. It’s fast and efficient. One can even randomise the letters on each line so those smart aleck patients – who tell you they already memorised the letters – can be satisfied. (Do you see it or don’t you? I don’t care if you memorised them…)

It’s useful to calibrate the red and green overlays so you get maximum contrast for duochrome testing. Some practitioners dislike duochrome, stating that patients don’t respond well. It’s more likely that they didn’t understand a poorly crafted question. It’s not “which is clearer, red or green?” If you ask it that way it may allow a psychological colour preference to influence their answer. Likewise in some cultures if we ask “which is darker?”, they may tell us which one is duller. Over the years I’ve had excellent results with duochrome on pretty much every patient by simply asking, “Which letters are blacker and clearer: those on the red or those on the green?” Done deal.

Duochrome is very useful in various parts of my exam; making sure accommodation is active before performing cross-cyl astigmatism testing, making sure my end points are not over-minused and occasionally checking a patient’s old spectacles. A patient may be complaining of reduced distance or near vision or having to lift their head abnormally to see better in the distance, or near. If they’re over 40 and green best, holding up a +0.50D flipper over their spectacles can make a visible difference. We then have an immediate response. They see better. That’s why they come to us.

Finding any previously unknown and undetected pathology is fortunate as many are, at that point, asymptomatic.

They can see we’ve zeroed in on their visual problem, while appreciating our concurrent detection of a potentially sight threatening problem. This is confidence inspiring to patient and practitioner alike.

It’s also a good idea to calibrate the red and green on the LCD screen to the red and green lenses in your phoropter to ensure maximal anaglyphic effect and cut off. The specialised binocular-vision anaglyphic tests in the eye-chart software allow for very quick and successful measurement of alignment of the visual axes in high phorias, strabismus and retinal slip. It also helps show the patient how misaligned things really are. It provides an understanding of how the prescribing of prism will improve their binocular visual function, while alleviating symptoms of asthenopia.


I was fortunate to have great family and partners as optometric mentors. Each had their own way of saying things and I quickly learnt a few pearls from them. One of my fellow students passed on a useful tip to me during our clinic days early on in my career. Asking a patient to align two images when performing von Graefe phoria testing can be difficult to explain. As many of our patients are not rocket scientists, it’s best to ask the question in simple terms. My fellow student simply said, “Tell me when the two images are lined up, like buttons on a shirt”. Simple. I still use that today when doing near phorias. When testing distance phorias I use a single line of letters and ask them to tell me when the two lit-up lines are lined up over each other, one higher than the other, like an equal sign. It works on four-year-old kids as it does on 95-year olds and everyone in between. I use a Reichert Rx phoropter with a near vision Rotochart which allows me to complete a battery of near point tests, on various targets in about a minute – including add determination, phorias, amplitude, PRA and NRA etc. Although many of my mates now swear by the efficiency of electronic, motorised phoropters my experience with early versions a decade or three ago put me off.

Another very useful test is binocular crossed cyls at near, which more often than not gives the correct add for the working distance in a matter of seconds, after which we simply confirm it with ranges and a click or two up and down the sphere range. The way to phrase that question is not to say “which is clearer – horizontal or vertical?” I simply brush my finger along the lines and say, “which lines are clearer, the cross ones or the up and down ones?” You’d be surprised how many university academics and business executives still mix up their horizontal and vertical!

Something I also use on every patient is a retractable tape measure to record the patient’s working distance for reading and computer work. I simply ask them to hold a reading card in a position they would like to hold it for reading and also ask them to approximate the position of their computer screen. For complex patients I ask them to hold a piece of string at their nose bridge and then tie a knot in it for each of their computer screens, keyboard, document, smartphone and reading. It provides useful information.

So there you can see we’ve barely got started but have probably saved many minutes of frustration by getting the right answers fast.

One thing I now do is shoot a 20-second video with my iPhone – hand held to the slit lamp ocular. I scan across the patient’s cataracts and zoom in on features to show them why their vision is a little hazy and why they see starbursts on lights at night. It can save you a lot of remakes and comebacks. It also helps convince the patient a referral for IOLs is the best bet.

A picture is, more than ever, worth a thousand words.

Alan P Saks MCOptom(UK) Dip.Optom(ZA) FCLS(NZ) FAAO(USA) is a third generation optometrist based in Auckland, New Zealand and columnist for mivision. He is actively involved in the profession, having served multiple terms as president of Contact Lens Societies and arranged numerous conferences. He has also served on education committees, as examiner in contact lenses and clinical optometry examinations, lectured contact lenses to ophthalmology registrars and written several columns about eye health and the practice of optometry.