PRACTICE LAYOUT:

VISIGRAPH/DISPENSER OFFICE

BATHROOMS

VERTOMETER ROOM

WISE-EYE LAB

ENTRANCE

WAITING AREA

TESTING ROOM

OPTOMETRISTS OFFICE

KEY RECEPTION FRAME DISPLAY TABLE COUCH FRAME & CL CLOSET SLIT LAMP & TONOMETER PHOROPTER DESK SINK COUNTER-TOP COMPUTER COLOURIMETER

WORKFLOW MANAGEMENT: Shani du Toit (Optometrist) Examinations of patients All patient education Fitting and measurements of multifocal Ordering of frames and glasses Staff salary payments Referring of patients Stock taking Signing off orders Supervision of staff and staff decisions

Mandie (Wise-eye Operator/ Optical Assistant) Help patients with frame choosing Measuring segments heights Explanation of payment options to patients Stock taking at the end of the month

Ordering of glasses Repairment of broken frames (nose pads etc.) Phone call answering Administrative work Handling of all wise-eye related subjects (advertising, appointments and sessions) Handling of visigraph testing

Ilz (Receptionist/ Wise-eye Reading Assistant) Booking of Appointments Sending out bills Handling of float Answering phone calls Filling and administrative work Reminding patients of appointments telephonically Calling medical aids for privileges Capturing of all patients information on computer

PATIENT PROFILE OF THE PRACTICE: Patients of all trade, race and economic classes come to Roos & du Toit Optometrist. Then you also have a lot of older patients that know the practice from Mr. Roos days. Mr. Roos still sees a couple of patients that refuses to see another eye care professional. Further more Shani du Toit has a contract with Coke to screen all their workers they send over, and when additional eye care is needed she does a full eye examination on these patients. PATIENT EXAMINATION ROUTINES: *Example of the recording sheet is included at the end of this section* Screening Entrance (unaided) VAs Horizontal Visual Field testing with a metal arch, with exact degree measurements Ophthalmoscopy *if refractive error is found a full eye exam follows* Full Eye Examination Most of preliminary/case history is filled in infront at reception Extra information is noted on the recording sheet by Optometrist according to patients complains If habitual or previous eye testing prescription is available this is used as a starting point Retinoscopy is done to refine, with or without a previous prescription in the phoropter Subjective with VAs taking follows Afterwards balancing is either done by HIC or prism dissociation Associated phorias are only measure as she sees fit (done very seldom) FCC is done on every patients age 30 and up, this is very important to her VAs taken at near with patient looking through phoropter The range is checked on the trail frame, done only when struggle with the ADD determination Ophthalmoscopy on all patients

IOPs measurements, one per eye, only on patients 50 and above TBUT and Slit lamp where she sees fit

FRONT

BACK

CASES: Case History Px, 5 year old male. His mother notices that when he was reading pages that he would shift his head so that his right eye would be in a favoured position to read the page, rather than using both his eyes. No headaches or pain experienced. The child is very hyper, immediately when entering the practice went to fetch the colour in books on the waiting table and ran around. Examination Shani du Toit took his VAs with the pictures on the projector and did a quick Ret on the trail frame. She also tried to do a short subjective with yes/no answers, but the patient was very hyperactive and his concentration span is very short. She did not do a +2.00D test. No sign of a tropia or phoria of any kind with cover test. She referred the patient to an Ophthalmologist to do a cyclo-refraction. Ophthalmologist faxed the following Rx through: OD: +0.50/-0.75x135; OS:+1.25/-1.75x45. Differential Diagnosis

Amblyopia High Refractive Error Latent Hyperopia Diagnosis OU: Amblyopia OD: Mixed Astigmatism (Oblique) OS: Mixed Astigmatism (Oblique) Treatment/Management plan She prescribed glasses (with the cyclo-refraction Rx), and also told the mother that the child must wear the glasses as often as he can and that she must enforce this. Further more the child has regular visits scheduled with the Ophthalmologist and the mother reported that they are going to start with occlusion therapy soon. Px must come back in 6 months time for a re-assessment. Discussion This was very interesting to me to see the way in which the Optometrist communicates with the child and him listening and understanding immediately. She did a normal ret on the trail frame not the Mohindra technique. The child was very hyperactive and his mother had to discipline the child the whole time. At the end the child was very happy with the frame choosing and very willing to wear the glasses (it was cool to him). The concern for me here was that the frame he had chosen did not have riding bow bent-downs, which hindered me, because he was so hyperactive. Something else perplexing me and the optometrist is that the right eyes axis was founded by the ophthalmologist to be 90 away from what Shani du Toit found. This axis was verified to be correct before she ordered the spectacles to be made. References Shani du Toit (Optometrist). Brooks & Borish. (2007). System for Ophthalmic Dispensing, Third Edition.

Case History Px, 51 year old male. He came in with his wife, because his old spectacles had broken. They tried to super glue the glasses back together. While patient is sitting in the chair I notice he is rubbing his eyes a lot and squinting, right after this evaluation he complains of very sore eyes to the Optometrist. He explains to her that its like someone forcing a finger into his eye. Afterwards his wife reports that he has been diagnose with Greaves disease. His eyes looked very red in general as well. Px had did not have hypertension and he stop smoking, because of heart problems. Examination The optometrist started as she normally does with the normal case history question indicated on the recording sheet. She also specifically asked who diagnosed him with this condition (his GP). After this she started working from the previous glasses prescription refining his new prescription with ret,

subjective and HIC. Also she struggled to get his vision to 6/6 and left him with a best corrected VA of 6/7.5. We did Ophthalmoscopy and I found an A/V ratio of (OU) with copper wiring present. C/D ratio was 0.3 (OU), with very indistinct margins. Macula was healthy. Externally the patient eyes was very deeply situated in their orbits with very small palpebrae fissures, which is unusual for someone with Greave disease. She did TBUT on him, but it was normal (6sec OU) and he had been using tearsnatural his doctor gave him. Px prescription: OD: -1.50/-0.50x83 and OS: -1.75/-0.75x96 with a +1.25D ADD. Differential Diagnosis Greaves disease Diagnosis Greaves disease OU: CMA (WTR) OU: Presbyopia Treatment/management plan After the examination Shani du Toit made an appointment for the patient at an Ophthalmologist and new glasses was ordered for him and he should have them within a weeks time. After viewing the fundus I told the patient that when he goes back to the doctors for his heart, he must just ask them to take his blood pressure as well. Discussion This was a very interesting case to me, the patient was male and had no signs of proptosis (which is normally associated with Greaves disease). The only signs which were conclusive with the normal stereotype were that he was a chain-smoker, before he quit and his eyes were sore. A concern was that no ocular motilities of the muscles were checked at all. I wanted to see if it was restricted in anyway. She made an appointment for him at the Ophthalmologist, which was very necessary, because he needs medication for the swollen and sore eye muscles. References Shani du Toit (Optometrist). Kanksi & Bowling. (2011). Clinical Ophthalmology: A Systematic Approach, 7th Edition.

Case History Px, 69 year old male. He came in for a refinement of his script, he was at Roos & du Toit and Shani tested him previously, at that time she noticed something wrong at the cup and disc and referred him to a nearby Ophthalmologist. They found out that he have had Optic Neuritis and he was further referred to Skinner & Kie Ophthalmologists in Durban to see the extend of damage in the brain self. They did a brain scan and injected fluorescein dye into the brain to see the abnormalities properly. With this they released that there has been a few occasions of bleeding in the occipital lobe and said he had a hemianopic visual field defect. They told him there is nothing more they can to for him, but preserving the vision he had left. He reports a family history of blindness and he

thinks what happen to him is the same reason for his familys blindness. He also reported that he was in a car accident, in which he bumped the back of his head badly. The patient stays in Bloemfontein, but does a lot of driving to and from his work which is in Aliwal-North. He also needs to read fine detail like building plans, because he is a builder. They print the plans bigger for him now. Examination This was a follow up examination so the Optometrist only refined the script she got last time. So with a subjective the script did not change with an OD of -5.25/-0.75x108 and an OS of -5.75/1.25x018. The best VA he could achieved was for the right eye 6/20 and the left 6/15, which is reasonable good. Next she refined the ADD on the trail frame, initially the Optometrist got a reading addition of +2.50D, but increased it to a +3.50D to allow the px that bit of extra magnification. Then I did ophthalmoscopy just to see how it looks, the fundi of both eyes where very pale with almost no cup/disc ratio to speak of with a 1/3 A/V ratio.

Differential Diagnosis Optic Neuritis previously with haemorrhages in the occipital lobe of the brain

Diagnosis Optic Neuritis previously with haemorrhages in the occipital lobe of the brain OD: CMA (ATR) OS: CMA (WTR) OU: Presbyopia Treatment/management plan Patient was shown low vision devices such as hand-held illuminated magnifiers which can help him read the plans better, but due to financial circumstances he did not want to pursue this direction. He chose the higher add in his new bifocal glasses, but had to switch from glass lenses to plastic, because they dont make that high of an add in glass anymore. Patient was also warned to be cautious when cleaning the lenses, because of working in dusty surroundings and plastic lenses scratching much easier than glass. Discussion I learned a lot with this case, I know now what to look for specifically and how it looks. This patient had a lot of hardship and expenses with all the eye problems he had face and was so appreciative of Shani that helped him sort it out, he got new glasses which helped him see a line better than with his previous pair. I had no concerns with this patient and the optometrist even game him a Amslers grid to monitor the vision and the scotoma he has. She recorded the exact area of vision lost on her sheet for future reference, which was educational to see. References

Shani du Toit (Optometrist). Kanksi & Bowling. (2011). Clinical Ophthalmology: A Systematic Approach, 7th Edition.