Day 3: Male, 58. Victoria School (PC)

58 year old male presents with reduced VAs distance and near. LEE was 13-14 years ago. He was a light hyperope then so he probably didn't need glasses 13-14 years ago, as he could just use his accommodation to see infinity. Now however, with the onset of presbyopia, his accommodation is gone and can no longer help him in focusing the image on his retina. His solution? Drug-store readers: a +1.00 pair for distance, a +2.00 pair for intermediate, and a +3.00 pair for reading.

In the end, we counseled him on PALs that can replace the 3 different pairs of reading glasses with just one pair. I hope he will invest in one.

length of exam: 2.5 hours

Things I learned today:

1. Measure optic disk size by placing the slit of light over the disk and then shrinking the slit until its vertical dimensions are the same as the disk. Then read the gauge above the filter settings, units are in mm.



2. Optic disk typing. It helps to categorize what shape each disk is, as some are harder to measure than others.



3. Parks 3 step tends to over-diagnose superior obliques. Longstanding deviations develop comitancy due to other muscles compensating for the paretic muscle (deviations will appear the same on left and right gaze) Think about replacing P3S with computerized Hess plots.

4. 4 ways to treat any BV problem:

• Do nothing
• Orthoptics
• Prisms
  
• Refer for surgery

5. S.T.A.R system glaucoma risk calculators weighing factors are horribly off

6. What is the pathophysiology behind hydrocephalus and sunset eyes?

7. Reminder: Pencil trick, if px talks too much, drop pencil and "as I was saying....". Don't let px hijack your exams. Px hijacks so far: 2

8. Keep a binder full of documents that you will either refer to constantly, or frequently show pxs.

9. BV pyramid (look into this some more)

• Stereopsis
• Sensory fusion
• Fusional reserves
• Accommodation
• EOM function
• VA

10. When ordering MRI imaging, ALWAYS request contrast on imaging. Techs inject a dye prior to running MRI to make things more visible.

11. Reminder: VA charts with numbers at the end ie.

F Z B D 4 = 20/40 = 6/12
O F L C 3 = 20 / 30 = 6/9

12. Smith's technique on ant. chamber depth

• slit and eyepieces at 60 degrees
• rotate slit to horizontal position
• illuminate the cornea, see the reflection of the light on the cornea and on the lens
  
• widen/shorten the slit length until the cornea bar touches the lens bar
• read gauge, apply conversion factor

13. If optometrists don't manage BV cases, then who will?

14. Pencil pushups do not work

15. Distributers for lenses for biomicroscopy often talk about magnification and field, but what does it really matter when a) the only field you see is the slit width and b) magnification can be toggled on the slit lamp? Get a lens you're comfortable holding in your hands that allows you room to move around and view periphery as well.

16. The only way you can see periphery in high mag is by doing biomicroscopy in various gazes, BIO will not give you such magnification.

17. When trying to neutralize a difficult cyl on ret, try pushing the collar all the way up. This will turn the cyl reflex into a "with" instead of "against", making it easier to neutralize the axis and power.