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 proficiency in reading glasses: single vision torics, bifocals, trifocals, progressives, and its proper recording in a medical record.
• Demonstrate proficiency in marking the optical center and measuring the PD of glasses.
• Demonstrate measuring glasses with prism using the PCD, and calculating compound prism. 
• Discuss the significance of vertex distance.

INTERMEDIATE VISUAL FIELDS

• Review and demonstrate Amsler grid, confrontational fields, tangent screen and automated visual field testing.
• List and describe manual techniques for testing the visual field including tangent screen, and Goldmann perimetry.
• Describe the use of an arc shaped perimeter for DMV fields.
• List automated methods for testing the visual field.
• Define: false positive, false negative, fixation losses and acceptable percentage for a quality field.
• Identify the indication for the following tests with the Humphrey Field Analyzer: Full Threshold vs. SITA Standard vs. SITA Fast. 30-2, 24-2, 10-2, 60-4, Superior 36, Superior 64, Esterman monocular/binocular test.
• Describe the process of the HFA for calculating the trial lens power for the test, and the proper position of trial lenses in the lens holder.
• Demonstrate calibration of the Goldmann perimeter, including both stimulus and background.
• Describe when corrective lenses are required and for which portion of the Goldmann perimetry procedure.
• Demonstrate plotting a peripheral and a central isopter, blind spot, and static check with a Goldmann perimeter.
• Distinguish the difference between static and kinetic field testing.
• Differentiate testing strategies for glaucoma and neurological examinations.     
• Describe the procedure for confirming steps with respect for the horizontal or vertical meridian.
• Describe screening of possible malingering patient with tangent screen and expected results.

SLIT LAMP BIOMICROSCOPY

• Describe the history and evolution of the slit lamp biomicroscope.
• 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 transillumination.
• 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, and how it is documented.
• Describe when the Tear Break up Time test is performed and how it is documented.
• 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.
• Describe basic set-up and of the slit-lamp and basic procedure when scanning the eye.
• Utilize biomicroscopy to perform and document an anterior segment and ocular adnexa examination.
• Identify and document normal slit lamp findings.
• Describe the grading system to document abnormal slit lamp findings.
• Identify common terminology used to describe abnormal slit lamp findings.
• Demonstrate proficiency of estimating the anterior chamber using the Van Herick’s technique.

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, Tono-Pen, Schiotz, pneumotonometer, hand-held tonometers, MacKay-Marg, I-Care tonometer and Goldmann applanation.
• Describe the proper end point image in Goldmann applanation tonometry.
• Identify the position of the mires (overlapping, separate, uneven, too thick, too thin…) and how it relates to pressure reading.
• 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 tonometry with a tono-pen and Goldmann. 
• Describe the procedure for non-contact tonometry.
• Describe the procedure for indentation tonometry.
• Describe Schiotz tonometry including checking of calibration, cleaning and assembly.
• Describe when additional weights are required in measurement with Schiotz tonometers.
• 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.  
• Review common glaucoma drops and possible side effects.

RETINOSCOPY

• Describe the history and evolution of the retinoscope.
• 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 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 un-occluded 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.
• Review the calculation of the working distance.
• List the steps performed when retinoscoping in plus cylinder.
• Determine the cylinder axis using various phenomena: Thickness, Intensity, Break/Skew phenomenon.
• Confirm the axis using the “straddling the axis” technique.
• Review the use of the double sphere method in retinoscopy, and demonstrate.
• Practice scoping with a sciascopy lens rack and describe its indications.
• 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.
• Describe techniques to avoid reflection/artifacts when scoping.
• 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 when looking for cylinder power when spheres alone do not correct vision adequately.
• Describe the astigmatic clock and its usage.
• Describe the duochrome test and its usage in preventing over-minusing.
• Describe the principle of binocular balancing and how it is performed.
• Describe the principle of the fogging technique and how it is performed.
• Describe prism dissociation method and how it is performed to balance a refraction.
• 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.
• Describe the difference between manifest and cycloplegic refractometry and indications.
• List and review mydriatic and cycloplegic drops.

ADVANCED KERATOMETRY

• Describe the history of the keratometer.
• Demonstrate proficiency in reading K’s.
• Identify the benefits of keratometry in contact lens fittings, retinoscopy and refractometry.
• Demonstrate extending the range of the keratometer

OCULAR MOTILITY

• Collect a proper ophthalmic history on a patient with strabismus, amblyopia, new onset of diplopia (due to trauma, CN palsy).
• Describe the tests for sensory fusion: stereo tests, worth 4 dot, haploscopic devices, the red lens test.
• Define NPA and NPC
• Distinguish between ductions, versions and vergences; describe function and anomalies.
• Fusional convergence amplitudes.
• Discuss the significance of primary and secondary deviations.
• Identify 6 cardinal positions of gaze
• Distinguish between a phoria and a tropia
• Properly document ophthalmic deviations
• Describe the following strabismus measuring techniques: Hirschberg, Krimsky, prism and cover, Maddox rod.