Here are three things we used to get in trouble for doing in the consulting room, that these days, we just can’t live without.
This year is my 20th year in the optometry profession. When I look back at the evolution of optometry over that time, it humbles me to see how much our eye care profession has evolved and improved.
As a profession, acknowledging the support of forward thinking fellow professionals and ophthalmologists to increase our knowledge base, we have made huge inroads in our capacity for scope of practice and ability to help our patients.
Our profession started with a modest refraction, a slit lamp, a direct ophthalmoscope and a tonometer. Fast forward and the breadth of modern practice today entails so much more. There are new takes on old school techniques, and new technologies fleshed into even new techniques.
Photo documenting slit lamp images certainly helps maintain clinical records, but the most useful effect of photo documentation is utilising the images as a communication tool
Fun and Games
When doing children’s eye tests, we all know to make as many of the tests as possible into a series of fun games to keep a child’s short attention span. Humour and play in clinical testing fast tracks rapport and comfort for our paediatric patients, and gets them ready to engage and cooperate.
Taking visual acuity via Illiterate E can be made into a game about ‘Make Your ‘E’ Copy Me!’. Give everyone in the room a paper E, ask your patient to identify some easy ‘E’s in free space, and then move the game to the letter chart, to make for an engaging and fun eye test. With everyone having fun, it will be it easier to get the clinical results you need.
‘Pretend to be the Doctor’ is another one of the small games you can play. Ask a parent or sibling to ‘Pretend to be the Doctor,’ to be ‘Dr. Mummy’ or ‘Dr. Daddy’. Get them to stand as far away as possible to get a distant focal target for the patient and ask the ‘Doctor’ helper to show flash cards to the patient on a phone/iPad.
Figure 2. ‘Good’ uninjured eye. Figure 3. Injured eye repaired a few years ago with a corneal tattoo. Figure 4. A slit lamp microscopy photo of the hand painted prosthetic lens with normal room illumination in situ.
Figure 5. Before and after photo of the prosthetic hand painted Capricornia CL with decentred pupil to compensate for exotropia in situ.
Figure 6. RE Baerveldt tube and prior severe cutaneous uveitis in both eyes. Figure 7. Significant central, fine, vertical lines showing Vogt’s striae on his RE as a sign of keratoconus.
Figure 8–10. NaFl staining inferiorly LE to indicate severe dry eye LE.
Figure 1. Baby Flash Card Lite
Figure 11–12. Customised RoseK2 XL CL RE; note corneal stitch and Baerveldt shunt
Although the target isn’t quite at optical infinity, the patient may be slightly accommodating, and you need to take your working distance into account, overall, this makes for a really good distraction so you can do retinoscopy at leisure. You can then get quite an accurate guide for a young patient’s objective refraction.
Using the patient’s sibling(s) as ‘Dr. Big Sister’ or ‘Dr. Big Brother’ will keep them distracted and feeling engaged – while they show the patient lots of flashcards to keep them guessing, you can ret at ease to obtain a confident objective Rx.
Neat free apps from the app store that can be used for this purpose are flashcard apps such as Baby Voice Card Lite or Baby Flash Cards Free.
Take Discreet Photos
Photo documenting slit lamp images certainly helps maintain clinical records, but the most useful effect of photo documentation is using the images as a communication tool.
I show my patient their ocular images against google images that I have pre-bookmarked. This can really strengthen communication when describing the ocular conditions in their eyes. For example, I use photo documentation to show them early stages of pathology such as corneal neovascularisation, infiltrates and ocular papillae from non-compliance, and then show them end stage pathology as part of a contact lens compliance conversation, or a discussion of how to manage their ocular pathology.
I also use photos to explain why I am able to methodically rule out particular conditions in my patients. By showing them an absence of conditions they are concerned about, patients are reassured that their ocular health is being well managed.
Even with fantastic top of the range anterior slit lamp cameras and built-in slit-lamp video cameras in my practice, I find nothing beats the efficiency, practicality, incredible autofocus and accessibility of the newer iPhones. Showing your patient a picture of their own eyes, airdropped within seconds to a nearby computer, really strengthens communication when discussing their ocular health.
More Playing with Your Phone
The clinical usefulness of the last few generations of iPhones in the consult room is impressive. I never would have imagined all the ways I use my iPhone as a consultation tool. The autofocus technology and software on the iPhone works far better than any android.
Here’s a case study to show you it’s helpfulness in designing contact lenses. The photos show the before and after images of a patient of mine with a severe penetrating childhood stick injury with resultant complete secondary corneal vascularisation and corneal opacification. It was disguised with a corneal tattoo made of india ink.
A hand painted custom made prosthetic contact lens by Capricornia was made with a decentred pupil to account for an unexpected severe ‘exotropic surprise’ discovered after I prescribed the first lens and it centred over his severely massive exotropic visual axis.
Describing these colours and the decentred pupil for the contact lens would have been impossible without the ability to efficiently take and email high resolution photos and videos.
Anyone looking to specialise in contact lenses, working in remote or regional areas where patient accessibility is challenging, or, indeed any mode of practice, will find mastering iPhone videography and photography incredibly useful.
Taking quality high resolution images and videos allows an immediate escalated expert opinion for a contact lens design, or reassurance on triaging ocular pathology.
Another case study: A recent referral for a monocular fitting for a patient, male, early 30s. Right eye 6/120 vision, left eye seeing barely light perception, severe prior cutaneous bilateral uveitis, complex bilateral glaucoma, and advanced keratoconus bilaterally. Referred for a right eye specialty contact lens fitting.
Right eye, non-responsive to topical therapy, a Baerveldt shunt lowers his intraocular pressure. This right eye has a degree of corneal toricity beyond the scope of a classic rigid corneal lens. The complexity meant it should normally have taken several refinements, though with slit lamp videos and photos and expertise, a customised RoseK2 XL corneoscleral contact lens improves his habitual vision from 6/120 to 6/6 to deliver a lens that is, ‘very comfortable and awesomely clear’. His regained vision helped him change from being on a disability pension to a good job in finance.
Helen Keller, an accomplished author, and the first deaf and blind person to earn a Bachelor of Art’s degree at university,1 once said, “I long to accomplish a great and noble task; but it is my chief duty to accomplish small tasks as if they were great and noble”.
For our patients, let’s keep doing these ‘small tasks’ with small tips that can add to be ‘great and noble.’
Margaret Lam is an optometrist in theeyecarecompany practices in greater Sydney and Sydney CBD and an Adjunct Senior Lecturer at the School of Optometry and Vision Science at UNSW. Margaret practises full scope optometry, but with a passionate interest in contact lenses, retail aspects of optometry and successful patient communication and management. She has extensive experience in specialty contact lens fitting in corneal ectasia, keratoconus and orthokeratology, and is a past recipient of the Neville Fulthorpe Award for Clinical Excellence.
