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Clin ical
Proced ures
for Ocular
Exam ination
NOTICE
T e authors and the publisher o this volume have taken care to make certain
that the doses o drugs and schedules o treatment are correct and compatible
with the standards generally accepted at the time o publication. Nevertheless, as
new in ormation becomes available, changes in treatment and in the use o drugs
become necessary. T e reader is advised to care ully consult the instruction and
in ormation material included in the package insert o each drug or therapeu-
tic agent be ore administration. T e advice is especially important when using,
administering, or recommending new or in requently used drugs. T e publisher
disclaims any liability, loss, injury or damage incurred as a consequence, directly or
indirectly, o the use and application o the contents o the volume.
Clin ical
Proced ures
for Ocular
Exam ination
Fo u rth Ed itio n
NANCY B. CARLSON, OD, FAAO

Pro essor Emeritus
New England College o Optometry
Boston, Massachusetts
DANIEL KURTZ, OD, PhD, FAAO

Associate Dean o Academic A airs
Pro essor o Optometry
Western University o Health Sciences
College o Optometry
Pomona, Cali ornia
New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney oronto
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entered, stored, and executed in a computer system, but they may not be reproduced for publication.
ISBN: 978-0-07-184919-7
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S
Contributors xi
T
Preface xiii
Introduction xv
Acknowledgments xix
N
1 Patient Communication 1
Introduction to Patient Communication 2
E
Case History 5
Presenting Examination Results to a Patient 11
T
Verbal Presentation o Your Patient to a Colleague,
Preceptor, or Attending Supervisor 15
How to Write a Consultancy or Re erral Letter 19
N
Reporting Abuse 23
How to Write a Prescription or Medication 25
2 Entrance Tests 29
O
Introduction to the Entrance Tests 30
External Observation 34
Visual Acuity (VA): Minimum Legible 36
C
Visual Acuity (VA): Minimum Legible Using
a LogMAR Chart 43
Visual Acuity (VA): Minimum Legible Using the
Massachusetts Visual Acuity Test With Lea Symbols 51
Pinhole Visual Acuity 58
Amplitude o Accommodation: Push-Up Method and
Pull-Away Method 60
Color Vision 63
Cover Test 67
Stereopsis 75
Screening Stereopsis Using the Random
Dot E and PASS 78
Worth 4 Dot 82
Near Point o Convergence (NPC) 86
Hirschberg Test and Krimsky Test 89
Brückner Test 92
vi Contents
Extraocular Motilities (EOM) 95

Pupils 98
Screening Visual Fields 101
Finger Counting Visual Fields 104
Interpupillary Distance (PD) 107
Summary o Expected Findings 110
3 Refraction 111
Introduction to Re raction 113
Lensometry 116
Keratometry 121
Introduction to the Phoropter 127
Static Retinoscopy 130
Routine Distance Subjective Re raction with
the Phoropter 136
Step-by-Step Procedure or the Routine Distance
Subjective Re raction with the Phoropter 137
I. Monocular Distance Subjective Re raction 138
Initial MPMVA (Maximum Plus to Maximum Visual Acuity) 138
Initial Duochrome (Bichrome, Red-Green Test) 139
The Jackson Cross Cylinder (JCC) Test 142
Second Monocular MPMVA 147
II. Binocular Balance 149
Binocular MPMVA 152
Use o the Trial Frame to Modi y a Prescription 156
III. Side Trips rom the Routine Distance Subjective Re raction 159
Clock Chart (Sunburst Dial) 159
Jackson Cross Cylinder (JCC) Check Test or Uncorrected
Astigmatism 161
Prism-Dissociated Duochrome Test 162
Sighting-Dominance Check 164
Trial Frame Re raction 165
Stenopaic Slit Re raction 171
Contents vii
Cycloplegic Re raction 174

Delayed Subjective Re raction 177
Convergence Controlled Re raction 179
Binocular Re raction with the Vectographic Slide 181
Humphriss Immediate Contrast Method 185
In nity Balance 188
Mohindra’s Near Retinoscopy 190
Determining the Add or the Presbyope 192
Septum Near Balance 197
Near Re nement o Cylinder Axis and Power Using
the Borish Binocular Nearpoint Card 202
Modi ed Humphriss or Near Re nement o Cylinder
Axis and Power 204
4 Functional Tests 207

Introduction to Functional Tests 208
Distance Lateral Phoria by von Grae e Technique 210
Distance Vertical Phoria by von Grae e Technique 213
Horizontal Vergences at Distance 216
Vertical Vergences at Distance 220
Near Lateral Phoria by von Grae e Technique 223
Near Vertical Phoria by von Grae e Technique 227
Horizontal Vergences at Near 230
Vertical Vergences at Near 233
Fusional Vergence Facility at Near 235
Fused Cross Cylinder 236
Negative Relative Accommodation/Positive Relative
Accommodation (NRA/PRA) 239
Accommodative Facility 241
Dynamic Retinoscopy: Monocular Estimation
Method (MEM) 245
Dynamic Retinoscopy: Bell Retinoscopy 248
Amplitude o Accommodation: Minus Lens to Blur 251
viii Contents
Associated Phoria 253

Maddox Rod Phoria 257
Modi ed Thorington Phoria 261
4Δ Base Out Test 266
5 Ocular Health Assessment 271

Introduction to Ocular Health Assessment 273
Biomicroscopy (Slit Lamp) 278
Special Slit Lamp Procedures 289
Examination o the Anterior Chamber 290
Eversion o the Upper Lid 292
Corneal or Conjunctival Staining 294
Specular Ref ection Technique 297
Sclerotic Scatter Technique 299
Instillation o Drops 301
Gonioscopy 304
Tear Breakup Time 313
Schirmer Tests: Schirmer #1 Test and Basic Lacrimation Test 315
Cotton Thread Test 318
Fluorescein Clearance Test (or “Dye Disappearance Test”) 320
Jones #1 (Primary Dye) Test 323
Direct Ophthalmoscopy 325
Binocular Indirect Ophthalmoscopy 328
Scleral Depression 335
Fundus Biomicroscopy 338
Nerve Fiber Layer Evaluation 341
Retinal Evaluation With the Goldmann 3-Mirror Lens 343
Goldmann Applanation Tonometry 348
Pachymetry 355
Noncontact Tonometry 357
Amsler Grid 363
Tangent Screen 366
D-15 Color Test 370
Contents ix
Brightness Comparison Test 372

Photostress Recovery Time Test 374
Red Desaturation Test 377
Exophthalmometry 380
6 Contact Lenses 385

Introduction to the Contact Lens Examination 387
Contact Lens Case History 390
Contact Lens External Examination 392
Inspection and Veri cation o Gas Permeable Contact Lenses 396
Base Curve Radius: Radiuscope or Radiusgauge 397
Base Curve Radius: Lensco-Meter 401
Back Vertex Power and Optical Quality 403
Lens Diameter and Optic Zone Diameter 405
Center Thickness 408
Sur ace Quality 410
Sur ace Wettability 413
Insertion, Removal, and Recentering o Gas Permeable
Contact Lenses 415
Fit Assessment o Gas Permeable Contact Lenses 420
Inspection and Veri cation o So t Contact Lenses 426
Back Vertex Power 427
Sur ace Inspection: Films and Spots 429
Sur ace Inspection: Tears, Nicks, and Scratches 432
Insertion and Removal o So t Contact Lenses 434
Fit Assessment o So t Contact Lenses 439
Insertion and Removal o Scleral Contact Lenses 445
Fit Assessment o Scleral Contact Lenses 449
Over-Re raction: Phoropter 451
Over-Re raction: Spectacle Trial Lenses 453
Evaluation o the Multi ocal Contact Lens Patient 456
Distance Over-Re raction 458
Evaluation o the Monovision Patient 460
x Contents
7 Systemic Health Screening 465

Introduction to Systemic Health Screening 466
Blood Pressure Evaluation (Sphygmomanometry) 467
Carotid Artery Evaluation 473
Orbital Auscultation 478
Lymph Node Evaluation 482
Paranasal Sinus Evaluation 487
Glucometry 493
8 Cranial Nerve Screening 499

Introduction to Cranial Nerve Screening 500
Muscle Field with Red Lens, Ductions, and Saccades 501
Test or a Paretic Horizontal Muscle 504
Park’s 3-Step Method or a Paretic Vertical Muscle 506
Dim–Bright Pupillary Test 508
Near (Accommodative) Response o the Pupil 511
Pupil Cycle Time 513
Pharmacological Tests o the Pupil 515
Trigeminal Nerve Function Test 518
Facial Nerve Function Test 522
Screening Tests or Cranial Nerves I, VIII, XI, and XII 525
References 531
Index 561
S
Robert C. Capone, OD, FAAO
Adjunct Clinical Faculty
R
Sta Optometrist
East Boston Neighborhood Health Center
O
East Boston, Massachusetts
Marion M.W. Hau, OD, FAAO

Adjunct Clinical Faculty
T
Sta Optometrist
U
East Boston Neighborhood Health Center
East Boston, Massachusetts
Ronald K. Watanabe, OD, FAAO

Associate Pro essor o Optometry
B
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This page intentionally left blank
E
It has been 25 years since the publication o the rst edi-
C
tion o Clinical Procedures for Ocular Examination and
11 years since the publication o the third edition. During that
period, health care has undergone numerous changes related
A
to improved technology or testing, changes in insurance
coverage that in uence tests chosen and time spent with the
patient, the addition o electronic health record keeping, and
improved privacy or patients. T e movement to standard-
F
ize optometry on a national level continues. T e intellectual
oundations o optometric practice have been strengthened
by an ever-growing body o scienti c literature. Consequently,
E
we have updated the re erence sections with recent cita-
tions and added or modi ed procedures in accordance with
contemporary concepts and knowledge.
R
One o the key motivations or the 1990 edition o this
book was the lack o standardization or many clinical proce-
dures. Books such as this one attempt to alleviate the problem
to some degree. Nevertheless, it remains true now as it did at
P
the time o the rst, second, and third editions: there is still
more than one acceptable way to per orm many o the proce-
dures. In some o these instances we have added variations in
the step-by-step procedures, clearly indicating that there is a
valid, alternate way to per orm that step or procedure.
T is edition continues the practice o earlier editions
o not including highly technical or equipment-speci c
techniques. o learn to operate these tools, one must re er to
the manual that comes with the instrument. We remain true
to our primary mission: to describe how to per orm a wide
variety o use ul tests without a large body o theory.
N
T e purpose o Clinical Procedure for Ocular Exam
ination is to provide students and practitioners with detailed
O
step-by-step procedures or a comprehensive battery o
techniques used in the examination o the eye. T ese pro-
cedures include tests or assessing the re ractive error, the
accommodative unction, the binocular coordination, and
I
the health o the eyes, monitoring the t and condition o
contact lenses, and screening tests or neurological and sys-
T
temic health conditions. T e book contains detailed, step-
by-step instructions on how to per orm each technique. For
each procedure, the reader is provided with comprehensive
C
in ormation on the purpose o the test, what equipment is
needed, how to set up the equipment and the patient prop-
erly, and how to record the ndings. Expected ndings are
U
listed or most tests. T e text includes diagrams and photo-
graphs to rein orce the descriptions o the techniques.
T e emphasis in this book is technical. It provides little in
the way o the theory or the background o the tests. Removal
D
o the theoretical discussion leaves a pure, concise descrip-
tion o the techniques and allows the reader to concentrate
on the psychomotor mechanics o the procedures. Readers
who are un amiliar with the techniques can use the descrip-
O
tions in this manual to learn the test procedures with little
or no supervision. Readers who are already amiliar with the
techniques can use this manual to review a test procedure
R
to ensure that they or someone under their supervision is
per orming it correctly. Mastery o the techniques and inter-
pretation o the ndings, however, cannot be obtained solely
through the use o this book, but requires supervised clinical
T
practice as well as a thorough understanding o the theoreti-
cal basis or each technique. Included in the Re erences sec-
tion at the end o the book are sources that will provide the
N
reader with the necessary theory and background or each o
the procedures.
T e rst chapter o the book deals with patient commu-
nication, clearly the most important aspect o patient care.
I
Good communication improves patient outcomes and makes
the encounter more enjoyable or both the patient and the
doctor. T e rst time the patient and doctor meet is usually
during the case history, a critical phase o the examination. In
addition to establishing rapport with the patient and setting
xvi Introduction
the tone or the exam, the history marks the beginning o the doctor’s
diagnostic thought process. Knowing the patient’s concerns, the examiner
can now begin to develop his examination strategy. Based on the patient’s
chie complaints and routine background in ormation gathered in the
case history, the examiner can decide which phases o the examination to
concentrate on and which problem-speci c testing should be done.
T e second chapter describes the entrance tests. T ese techniques
are the rst procedures per ormed ollowing the case history. T ey are
relatively simple procedures that use minimal, primarily handheld equip-
ment. T ey screen or problems in each o the three major problem areas:
re raction, visual unction, and health. Most o the entrance tests screen
or problems in more than one o these three areas. T ought ul interpre-
tation o the results o the entrance tests can greatly increase the ef ciency
o the examination. Augmented by the in ormation gathered in the case
history, entrance tests data aid the examiner in pinpointing the patient’s
problem areas and appropriately directing the examination strategy.
Chapters 3 through 5 correspond to the problem areas o re raction,
visual unction, and ocular health. raditionally, a complete ocular exami-
nation consisted o comprehensive testing in each o these three areas. T e
in ormation thus obtained was re erred to as the “minimum de ned data
base.” I a problem was discovered through these procedures, additional
problem-speci c tests were per ormed to enhance urther evaluation. In
this age o managed health care, providers no longer have the luxury o
per orming a battery o procedures on every patient simply to collect data.
It is important to detect problems quickly, with a minimum number o
tests, allowing time to probe each problem with more speci c testing.
In Chapters 3 through 5 we have de ned tests that can be consid-
ered “core” tests. Core tests can be viewed as providing the center or
nucleus o the exam. T ey supply the examiner with enough in ormation
to detect but not to diagnose the vast majority o ocular, binocular, neu-
rological, or visual anomalies, even in the absence o patient symptoms.
T e examiner’s philosophy and the demographic characteristics o the
patient will in uence what tests will be included in the core tests. T e
traditional minimum de ned data base o the past included more tests
than those currently de ned as core tests. T is reduction in the number
o procedures included in a complete examination is reasonable, since
the minimum de ned data base already contained some redundancy. For
this reason, excluding certain tests will not a ect the quality o in or-
mation obtained. However, examiners must be aware o the increased
importance o screening or unexpected problems, and diligently ollow
up with problem-speci c testing in the case o any abnormal test results.
Introduction xvii
Each o these three chapters also describes a wide variety o prob-

lem-speci c tests, by which the examiner explores a speci c area o con-
cern in detail. T ese tests are not done on a routine basis, but are selected
on the basis o the patient’s case history and the results o other test-
ing. Problem-speci c tests are not placed in a separate chapter. T ey are
included in the chapter corresponding to their problem area.
Included within these chapters are owcharts that illustrate how
tests might be grouped or sequenced in order to promote examination
ef ciency. T ese charts do not represent the only appropriate sequenc-
ing o the techniques, but they do illustrate one sequence or ef ciently
combining the procedures.
Separate owcharts are presented or the most commonly applied
core entrance tests, re ractive tests, and ocular health assessment tests.
Since unctional testing and problem-speci c testing are almost always
customized to the patient and depend strongly on the individual patient’s
problem or complaint, there is no standard owchart or these parts o
the ocular examination.
Individual owcharts could not possibly work or all patients. Rather,
they are intended to provide a standard sequence o testing or the major-
ity o patients seen in most examiners’ practices. T is standard test order
can be compared to the itinerary o a trip. T e traveler plans the trip rom
start to nish along a standard pathway, or “main route.” Similarly, the
owcharts depict a standard itinerary o ocular tests that lead rom
the beginning to the end o the routine exam.
However, many patients need problem-speci c tests, which can be
compared to points o interest along the main route. When indicated,
the examiner takes a “side trip.” T at is, he per orms certain tests that are
supplemental to the main route. T e owcharts and text show when side
trips are indicated. Once the necessary side trip is completed, the exam-
iner should usually return to the main route and continue the examina-
tion rom there. For the sake o examination ef ciency, however, some
side trips may be postponed.
Chapter 6 concentrates on the procedures necessary or basic t-
ting and monitoring o contact lenses. T ese procedures are considered
problem-speci c since they are use ul only or contact lens patients. It
is possible to quickly and ef ciently incorporate these procedures into
a comprehensive ocular examination as shown in the ow chart at the
beginning o Chapter 6.
Chapter 7 deals with procedures used to screen a patient’s systemic
health. T e eye care pro essional is o ten the patient’s entry point into
the health care system. T ere ore, they have the responsibility to evaluate
xviii Introduction
the overall health o the patient. T e examiner may select to per orm
certain procedures based on the patient’s age, medical history, or pre-
senting symptoms or as the result o in ormation gathered during the
comprehensive examination. Alternately, the examiner may pre er to
per orm these screening procedures routinely on all patients. Patients
with abnormal results should be re erred to the appropriate health care
provider or more thorough evaluation and diagnosis.
Chapter 8 concentrates on procedures used to assess the cranial
nerves when screening or neurological disorders. T ese techniques are
rarely used or routine screening, but they are particularly help ul when
a problem is suspected on the basis o the patient’s case history or ocu-
lar examination ndings. Many o these screening procedures should be
per ormed as side trips rom corresponding entrance tests.
T roughout the text, the masculine orm o the third person singular
pronoun is used. T is orm is used or the sake o simplicity, and applies
equally to men and women without prejudice.
S
T
We wish to thank our students who have used the numerous
outlines, owcharts, PowerPoint presentations, and hand-
outs that are the oundation o this book. T rough their ques-
N
tions they helped us determine the appropriate level o detail
needed to describe each procedure. We owe a special debt
E
to Dr David Heath and Dr Catherine Hines, who invested
countless hours and dra ted much o the text or the rst
three editions. We also wish to thank Mr Mirza Hasane endic,
M
Dr Robert Gordon, Dr i enie Harris, Mr Ed MacKinnon,
and Dr errence Knisely or their excellent photography;
Dr Susan Baylus or her work on many o the computer graph-
G
ics; Dr Patti Augeri, Dr Bina Patel, and Dr Maureen Hanley,
who were involved in developing the laboratory manual that
was the oundation or Chapter 5, Rudol Mireles, PharmD,
D
or help with preparation o the section on “How to Write
a Prescription or Medication,” and Ms Monique essier,
Ms Lori Rees, and Dr Ida Chung o the Western University
E
o Health Sciences College o Optometry or countless
hours xing last-minute emergencies during the preparation
L
o the manuscript or the ourth edition.
We would also like to acknowledge the sacri ces, sup-
W
port, and contributions o our amilies: om Corwin, Brian
Carlson, Adam, Esther, and Nathan Kurtz, and Kyra and
Lynne Silvers.
O
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K
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A
1
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E
Patient
T
Communication
P
Nancy B. Carlson, OD, FAAO, and
A
Daniel Kurtz, OD, PhD, FAAO
H
C
Introduction to Patient Communication
Case History
Presenting Examination Results to a Patient
Verbal Presentation o Your Patient to a Colleague,
Preceptor, or Attending Supervisor
How to Write a Consultancy or Re erral Letter
Reporting Abuse
How to Write a Prescription or Medication
2 Chapter 1
INTRO DUCTIO N TO PATIENT

CO MMUNICATIO N
Co unic ting with tients is the ost i ort nt s ect o tient
c re. Good tient co unic tion cilit tes the ex in tion ro-
cess, i roves the ccur cy o di gnosis, i roves tient co li-
nce, decre ses tient co l ints nd l r ctice cl i s, nd kes
every tient encounter ore enjoy ble or the clinici n s well s or
the tient. Co unic tion is skill th t c n be le rned nd i roved
over ti e.
Fro the ti e th t the tient c lls or n oint ent until the
tient le ves the o ce, ll st need to know th t the tient is the ost
i ort nt erson in the roo nd they ust be tre ted with dignity nd
res ect.
T ere re ny o ortunities to de onstr te good tient co u-
nic tion in the c re rocess st rting with the c se history. Other co u-
nic tion o ortunities resented in this ch ter include resenting the
ndings to the tient t the end o the ex in tion, resenting the c se
to colle gues or to n ttending doctor, writing consult tion nd/or re er-
r l letters, re orting buse, nd writing rescri tion or edic tion.
C se history is the ost i ort nt rocedure in the entire re ertoire
o ex in tion rocedures, nd it is one o the ost di cult to le rn.
History t king c n be stered only ter the cquisition o bro d b se
o knowledge nd ter ye rs o clinic l ex erience. An ex erienced nd
knowledge ble clinici n o ten c n deter ine the di gnosis ro the
history lone. Conversely, the novice is requently overwhel ed by the
in or tion g thered in the c se history nd is r rely ble to e ectively
g ther nd use the relev nt in or tion in the di gnostic rocess. It is
beyond the sco e o this book to rovide su cient in or tion or
novice clinici n to conduct ro cient, co rehensive c se history.
R ther, the co onents o the c se history re resented to illustr te the
in rts o history or ty ic l ri ry c re ex in tion nd or
ty ic l ollow-u ex in tion.
T e c se history is usu lly conducted t the beginning o the
ex in tion, nd is the ti e or the clinici n nd tient to beco e
cqu inted. T e clinici n ust resent hi sel to the tient s c ring
nd e thetic individu l i he ex ects the tient to be orthco ing
bout his roble s nd to co ly with dvice given. At the s e ti e,
the clinici n begins the di gnostic thought rocess by sking the tient
ro ri te questions to deter ine the otenti l c uses or e ch o the
tient’s sy to s. T e in or tion is then used in deciding which
Patient Communication 3
rocedures the clinici n will use to con r or rule out e ch otenti l

di gnosis. During the c se history the clinici n lso h s n o ortunity
to begin educ ting the tient bout his visu l unction nd bout his
ocul r nd gener l he lth.
T e c se history or ty ic l ri ry c re ex in tion is divided into
sever l rts: the Chie Co l int or History o the Present Illness (HPI),
P st Medic l nd Ocul r History including edic tions nd llergies,
Review o Syste s, F ily History, Soci l History, nd the Su ry. In
the beginning o the history, the clinici n sks o en-ended questions to
ssess the tient’s re son or seeking c re (the history o the resent
illness/chie co l int) nd to scert in the visu l needs o the tient’s
d ily li e. I the tient does not initi lly volunteer co l int, it is wise
to sk key, robing questions bout his vision nd visu l unction nd
visu l e ciency.
T e P st Medic l nd Ocul r History ortion o the history consists
o series o questions to deter ine i the tient is t risk or ny o
v riety o ocul r, syste ic, or neurologic l disorders. T e clinici n sks
bout the tient’s revious ocul r history, his edic l history, nd his
ily’s ocul r nd edic l history. T e clinici n lso gives the tient
list o sy to s o co on eye roble s to nd out i the tient h s
ever ex erienced ny o the . So e clinici ns g ther this in or tion
in written questionn ire th t the tient lls out rior to the ex i-
n tion. Although this is n e cient ethod o d t collection, it ust
be ollowed by convers tion between the clinici n nd the tient to
est blish doctor- tient rel tionshi nd to be cert in th t ll relev nt
in or tion w s g thered.
Fin lly, the c se history concludes with brie rec itul tion, or
su ry, o the tient’s chie co l int or co l ints, but this ti e in
the clinici n’s words. T is su ry ensures both the clinici n nd the
tient th t the clinici n underst nds the tient’s concerns, nd gives
the tient n o ortunity to dd nything th t y h ve been issed.
It lso gives the clinici n n o ortunity to st rt the rocess o tient
educ tion th t will be concluded t the end o the ex in tion.
T e c se history c n be odi ed or roble - ocused ex in -
tion or reviously seen tient by o itting the in or tion th t h s
been g thered in the revious ri ry c re ex in tion nd by sking
only the questions th t re relev nt to the tient’s re son or the visit.
A roble - ocused c se history should include the tient’s re son or
visit, questions bout the sy to s th t will hel the clinici n in the di -
erenti l di gnosis rocess, nd su ry o the tient’s co l ints in
the clinici n’s words.
4 Chapter 1
A ter the ex in tion is co leted, the clinici n ust su rize

the ndings o the ex in tion or the tient long with reco end -
tions or ro ri te c re, re err ls, nd ollow-u c re. It is i ort nt
to rel te the ex in tion ndings b ck to the tient’s re son or visit or
chie co l int.
CASE HISTO RY
Purpose
• o est blish c ring rel tionshi with the tient, showing co s-
sion, e thy, nd res ect or the tient.
• o g ther in or tion bout the tient’s chie co l int, visu l unc-
tion, ocul r nd syste ic he lth, risk ctors, nd li estyle.
• o begin the rocess o di erenti l di gnosis.
• o begin the rocess o tient educ tion.
Setup
Prior to st rting the or l c se history, the doctor should welco e the
tient, show the tient where to ut his co t nd belongings during
the ex in tion, introduce hi sel to the tient, nd exch nge ew
le s ntries with the tient (eg, How bout the P triots/Bruins/Celtics/
Red Sox? Wh t do you think bout the we ther we’ve been h ving?).
Be sure th t the tient is co ort ble where he is se ted nd th t the
overhe d light is not shining in the tient’s eyes. T e doctor should be
se ted t the s e height s the tient, in osition th t kes it e sy
to int in eye cont ct with the tient nd to cilit te convers tion.
When using electronic health records, t blet co uter will cilit te
good co unic tion, s shown in Figure 1-1. Although the c se history
is usu lly done t the beginning o the ex in tion, d t y be dded
to it s in or tion is g thered during testing. P tients so eti es reve l
ore in or tion s they beco e ore co ort ble with the doctor.
Case History Components for an Adult

Primary Care Examination
• History of the Present Illness (HPI)
1. Chie co l int.
a. Initi tion: Ask the tient bout the re son or his visit with
question such s:
Wh t brought you in tod y?”
Wh t roble s re you h ving with your eyes?
How c n I hel you tod y?
Wh t is the in re son or tod y’s eye ex in tion?
6 Chapter 1
FIGURE 1 -1. The doctor takes the case history and records it on a tablet computer, enhanc-
ing his ability to maintain eye contact with the patient.
b. El bor tion o the chie co l int (FOLDARQ).

For e ch co l int the tient resents, sk or ddition l in or-
tion using ny o the ollowing qu li ers th t will hel you in
your di erenti l di gnosis o e ch co l int:
Frequency: How o ten does this occur? H ve you h d nything
si il r in the st or is this the rst ti e?
Onset: When did the roble begin?
Loc tion: Where is the roble loc ted? (eg, OD, OS? At dis-
t nce, t ne r?)
Dur tion: How long do your sy to s l st?
Associ ted ctors: Wh t other sy to s do you ex erience
with this roble ? Does the sy to occur with your gl sses
or only when you do not we r the ? Does this h en only
when you we r your cont ct lenses or lso when you re not
we ring your cont ct lenses?
Relie : Wh t see s to ke your sy to s go w y?

Qu lity: On sc le o 1 to 10, how would you r te the severity
o your sy to s?
2. Visu l e ciency, i not lre dy covered in the chie co l int.
“C n you see cle rly nd co ort bly both r w y nd close
u or ll your visu l ctivities?”
A ter he ring the tient’s descri tion o his co l int(s),
su rize or hi wh t you h ve he rd.
• Past Medical History (including past eye history)

1. P tient’s ocul r history.
a. “When w s your l st eye ex in tion? By who ? Wh t w s the
outco e o th t ex in tion?”
b. Corrective lenses history.
I the tient we rs gl sses, sk:
How long h ve you been we ring gl sses? Are they or
dist nce, ne r, or both? C n you see cle rly nd co ort-
bly with the ?
When were your gl sses l st ch nged?
I the tient does not currently we r gl sses, sk,
“H ve you ever worn gl sses? Wh t were they or? When
did you we r the ? When nd why did you sto we ring
the ?”
Do you we r cont ct lenses? (For urther cont ct lens
history, see Ch ter 6.)
2. P tient’s edic l history.
H ve you ever h d ny edic l ttention to your eyes? Any
surgery, injuries, or serious in ections?
H ve you ever worn n eye tch?
H ve you ever used ny edic tion or your eyes?
H ve you ever been told th t you h ve n eye turn or
l zy eye?
H ve you ever been told th t you h ve c t r cts, gl u-
co , or ny other eye dise se?
8 Chapter 1
How is your gener l he lth?

When w s your l st hysic l ex in tion? By who ?
Are you currently under the c re o hysici n or ny
he lth condition?
H ve you ever been told th t you h ve di betes, high
blood ressure, thyroid dise se, he rt dise se, or ny in ec-
tious dise se?
Are you t king ny edic tions? I yes, wh t edic tion,
how long h ve you been t king the edic tion, wh t is it or,
nd wh t is the dos ge?
Do you h ve ny llergies? I yes, to wh t, wh t re your
sy to s, nd how re your llergies tre ted?
3. Review o Syste s (ROS).
T e Review o Syste s is list o org n syste s th t c n hel the cli-
nici n deter ine the st te o the tient’s gener l he lth. Included
in this list re:
Constitution l
Eyes
E rs, nose, nd thro t
Res ir tory
C rdiov scul r
G strointestin l
Genitourin ry
Neurologic l
Psychologic l
Musculoskelet l
Skin
Allergic/i unologic l/ly h tic/endocrine
4. Sy to s o co on eye roble s.
H ve you ex erienced ny o the ollowing: f shes o light, f o t-
ers, h los round lights, double vision, requent or severe he d-
ches, eye in, redness, te ring, or s ndy, gritty eeling in your
eyes?
• Family History
H s nyone in your ily h d c t r cts, gl uco , or blindness? H s
nyone h d n eye turn or l zy eye? I yes, who, when, or how long,
nd wh t w s the tre t ent?”
H s nyone in your ily h d di betes, high blood ressure, thyroid

dise se, he rt dise se, or ny in ectious dise se? I yes, who, when, or
how long, nd wh t w s the tre t ent?
• Social History
Wh t kind o work do you do?
Wh t re your hobbies? Wh t do you like to do in your s re ti e?
Do you drive?
Do you s oke? Drink lcohol? Use street drugs?
• Summary
T e re son or your visit tod y is nd you h ve concerns bout?
Wh t other concerns bout your eyes, your gener l he lth, or your
ily’s eyes or he lth would you like to tell e bout?
Wh t questions do you h ve or e t this oint in the ex in tion?
Case History Components for a

Problem-Focused Examination
• Establish the reason for the patient’s visit.
Ask, “Wh t is the re son or your visit tod y?” I you sked the tient
to return, use decl r tive st te ent bout wh t you know is the re son
or the tient’s visit such s, “I see th t you re here or dil ted ex .”
Conclude by sking, “Are there ny other roble s you re h ving th t
I c n t ke c re o or you tod y?”
• Probe the patient’s symptoms.

1. Use the questions ro the History o the Present Illness, section 1b
bove, to el bor te on the tient’s re son or this visit.
2. Ask the tient bout his edic l history, the edic tions he is cur-
rently t king, nd ny llergies he h s, rticul rly to edic tions.
• Summary
Su rize wh t the tient h s told you by s ying, “T e re son or
your visit tod y is nd you h ve concerns bout...?”
10 Chapter 1
CASEHISTORYat a glance
COMPONENTS TECHNIQUES
Introduction Introduce yoursel , make the patient com ortable
History o the Establish reason or patient’s visit and elaborate on his com-
Present Illness/Chie plaints to ully understand them and to begin the process
Complaint (HPI/CC) o di erential diagnosis
Past Medical History Ask about ocular history, general health, symptoms o com-
(PMH) and Review mon eye problems, medications, allergies, review systems
o Systems (ROS) to f nd out about the patient’s health
Family History (FH) Ask about problems that run in the amily to determine
patient’s risks
Summary Summarize in your own words why the patient is here and
ask i the patient wants to add anything
Recording
Record ll in or tion, including the neg tives.
P RESENTING EXAMINATIO N
RESULTS TO A PATIENT
Purpose
o rovide concise verb l su ry to the tient o ll ertinent in or-
tion ro the ex in tion.
Indications
Every tient should be given su ry o results ter every
ex in tion.
Equipment
No s eci c equi ent is required.
Setup
A co y o the tient record or other notes y be hel ul re erences to
h ve t h nd. However, you should be su ciently ili r with the ex -
in tion ndings th t you need to consult the record only in requently.
St e p b y St e p Pro ce d u re
1. Begin by st ting the di gnosis to the tient in l ngu ge he c n
underst nd. Alw ys rel te the di gnosis to the tient’s chie co -
l int or re son or visit.
2. Su rize the testing th t w s done to con r the di gnosis nd to
rule out other di gnoses.
3. Describe the etiology, rognosis, nd ex ected course o the
roble .
4. In or the tient o your reco ended tre t ent nd n ge-
ent o the di gnosis. When there is ore th n one o tion or
n ge ent, in or the tient o the v rious o tions with your
reco end tion or the best o tion. Include the risks nd bene ts
o e ch o tion.
5. I the l n involves re err l to nother clinici n, in or the tient
who you would like hi to see nd how urgent it is or the tient
12 Chapter 1
to see nother r ctitioner. I the re err l is urgent, ke the oint-

ent or the tient be ore he le ves your o ce.
6. In or the tient o your reco ended ollow-u interv l or the
next ex in tion. Let the tient know wh t nd when he should
ex ect in ter s o ch nges in his sy to s.
7. Give the tient written teri ls describing his di gnosis nd n-
ge ent when teri ls re v il ble.
8. Conclude by s ying to the tient, “Wh t questions do you h ve
or e?”
Recording
Present tions re given verb lly to the tient. Det ils o the di gnoses,
n ge ent l n, tient educ tion given, re err ls, nd when you w nt
to see the tient g in should be recorded in the tient’s record.
Example #1
Presentation to the Patient
(B ckground, not s id to the tient: Mr XY is 43-ye r-old ccount nt
whose chie co l int is di culty re ding, es eci lly t the end o the d y
or in di light. He re orts th t things re e sier to see i he holds the
urther w y, but his r s h ve beco e too short. Mr XY’s gener l he lth
is good nd urther erson l nd ily histories re unre rk ble.)
S y to the tient, “Mr XY, you h ve resbyo i , roble th t
everyone ex eriences t so e ti e between the ges o 38 nd 45.
Presbyo i is c used by the decre se in f exibility o the lens inside your
eye th t ocuses or close u nd is nor l ex ected ch nge with ge.
T e lens h s been losing f exibility since ge 15 but c tches u to ost o
us in our e rly 40s.
“Presbyo i c n be corrected with re ding gl sses. Since you we r
gl sses ll the ti e, I reco end rogressive ddition lenses. T ese
lenses llow you to see t ll dist nce without h ving to ch nge to di -
erent ir o gl sses.
“I you would like to consider cont ct lenses, I c n discuss sever l
cont ct lens o tions with you.
“As the lens inside your eye continues to lose f exibility u to ge 60,
resbyo i will rogress over ti e whether or not it is corrected with
gl sses. You will notice th t the gl sses I rescribe or you tod y will not
work s well in ew ye rs s they do now.
“I going to give you this hlet bout resbyo i th t will give

su rize the things th t I h ve told you tod y.
“I would like to see you g in in 1 ye r or nother co rehensive
ex . I you h ve ny questions or roble s be ore th t, le se c ll e.
Wh t questions do you h ve or e?”
Recording for Patient #1

Assess ent:
Presbyo i
Pl n:
Rx PALs
P tient educ tion re resbyo i : nor l ge ch nge th t will continue
to worsen over ti e but c n be corrected with gl sses or cont ct lenses.
G ve tient AOA hlet on resbyo i .
old the tient to c ll with questions or concerns.
Reco end co rehensive ex in tion in 1 ye r.
Example #2
Presentation to the Patient
(B ckground, not s id to the tient: Ms BC is 19-ye r college so h-
o ore who h s noticed inter ittent vision loss in eriorly in her right
eye or the st 3 d ys since she w s hit in the he d by te te’s
elbow during b sketb ll r ctice. BC h s lso noticed little bl ck s ecks
f o ting in ront o her right eye nd occ sion l f shes o light. She h s
worn cont ct lenses since ge 12 or oder te yo i nd h s h d ye rly
ex in tions since ge 10. Ms BC t kes no edic tions nd h s no ller-
gies. Her gener l he lth is good nd urther erson l or ily history is
unre rk ble. Check the tient’s he lth insur nce, c ll the ro ri te
retin l s eci list, nd ke n oint ent or Ms BC.)
S y to the tient, “BC, you h ve retin l det ch ent in your right
eye. T is ost likely occurred when you were hit during b sketb ll r c-
tice. Pro t tre t ent o retin l det ch ent is necess ry to revent er-
nent vision loss. I would like you to see retin l s eci list s soon s
ossible.
“I h ve c lled Dr H nd he c n see you this ternoon. I de n
oint ent or you with Dr H t 2:45 pm tod y nd I will send co y o
your record ro tod y to hi . He will ex ine you nd decide on the
14 Chapter 1
ro ri te tre t ent or the det ch ent. Dr H will let e know when

he w nts e to see you g in.
Wh t questions do you h ve?”
Recording for Patient #2

Assess ent:
Rheg togenous retin l det ch ent su eriorly, OD, second ry to
blunt tr u
Pl n:
Re er to retin l s eci list Dr H, ASAP.
Discussed the i ort nce o ro t ollow-u or best visu l outco e
with the tient.
C lled Dr H nd de oint ent or tient or tod y t 2:45 pm.
Sent co y o tod y’s record to Dr H. G ve tient co y o record to
give to Dr H s well.
Will c ll the tient when I h ve received re ort ro Dr H nd
schedule ro ri te ollow-u here t th t ti e.
VERBAL P RESENTATIO N O F
YO UR PATIENT TO A CO LLEAGUE,
P RECEPTO R, O R ATTENDING
SUP ERVISO R
Purpose
o rovide concise verb l su ry o ll ertinent in or tion bout
tient to en ble your rece tor or su ervisor to rrive t n e cient
underst nding o the c se in order to rovide e cient, in or ed c re
o the tient without w sting his ti e. T is rocedure is si il r to the
rocedure or writing consult ncy or re err l letter.
Indications
When it is necess ry to rovide su ry o tient’s ex in tion
ndings to nother ro ession l who will beco e involved in the c re o
th t tient.
Equipment
No s eci c equi ent is required.
Setup
h ve t h nd. However, you should be su ciently ili r with the ex -
in tion ndings th t you need to consult the record only in requently.
1. Begin with n introduction to the tient, giving n e, ge, gender, nd
ethnicity, i ertinent to the c se, nd wh t ty e o ex in tion you
h ve done (eg, co rehensive routine ex in tion, roble -s eci c
ex in tion, ollow-u ex in tion, cont ct lens tting, or ollow-u ).
2. In one sentence, su rize the tient’s resenting co l int or
re son or his seeking c re t the resent ti e. Follow this by giv-
ing ertinent det ils bout the tient’s descri tion o the roble ,
including things he believes cco nied it. Also rovide enough
in or tion to l ce the co l int in ti e.
16 Chapter 1
3. T is should be ollowed by recit tion o ll ex in tion d t rel-

ev nt to the tient’s resenting co l int. Include the roxi te
d te o the tient’s l st ull eye ex in tion. Avoid roviding in or-
tion th t is not relev nt to the tient’s resenting co l int.
4. T e next sentence should rovide other in or tion, including neg-
tive ndings th t re relev nt.
5. Conclude with concise st te ent o your resu ed di gnosis nd
your ro osed initi l tre t ent or n ge ent str tegy. Include
the roble s th t were rt o your di erenti l di gnosis th t you
h ve ruled out nd how you h ve ruled the out. In this rt o the
resent tion, lw ys include rec ll interv l nd s eci c lly wh t
you ro ose to ssess t the tient’s return visit.
Notes:
• Best-corrected VA is relev nt so o ten in eye c re th t you should
include it even i you re not sure it is relev nt. Un ided VA is r rely
relev nt.
• P tient’s edic l history: syste ic illness(es), edic tions, recent
ch nges in ctivities: only i relev nt to the resent tion.
• F ily ocul r nd edic l history only i relev nt.
PRESENTINGACASETOACOLLEAGUEORATTENDINGat a glance
COMPONENTS DETAILS
Introduce patient State name, age, gender, ethnicity, and type o examination
Chie complaint(s) Give patient’s description o his complaint(s) or reason

or visit
Examination data Summarize only the examination data relevant to your

assessment or diagnosis o the patient’s problem(s)
Di erential diagnosis Summarize the other possible diagnoses and the examina-
tion data that ruled out other possible diagnoses
Treatment and Summarize your recommended treatment or management

management o the patient’s problem
Give recommended time or the next visit and what should

be done at the next visit
Recording
Present tions re given verb lly. While they re not recorded, everything
th t is re orted should be rt o the tient’s o ci l ex in tion record.
Notes:
• T e key to good resent tion is to concisely re ort everything th t is
relev nt, but to re ort nothing th t is irrelev nt so s not to ob usc te
the ur ose o the ex in tion or to w ste ti e.
• Knowing wh t is relev nt nd wh t is irrelev nt is the di cult rt, but
th t is the key to resenting c se e ectively nd concisely.
Example #1
1. My tient is 66-ye r-old white le.
2. He is here bec use his brother w s recently di gnosed with gl uco ,
nd our tient w s told th t he needed ull eye ex in tion bec use
gl uco runs in ilies. He h s no other eye or visu l co l ints.
He is not w re o ny other ily e bers with gl uco .
3. His best-corrected vision is 20/20 t dist nce in e ch eye with od-
er te yo ic correction. I ound his IOP to be 23 in the right eye nd
27 in the le t eye. Cu to disc r tios re .5 horizont l nd .5 vertic l
right eye, ollowing the ISN rule, nd .6 horizont l by .75 vertic l le t
eye, not ollowing the ISN rule. His ch ber ngles re o en to the
cili ry body with lightly ig ented tr becul r eshwork in both
eyes. His visu l elds re ull to con ront tion in e ch eye. His l st ull
eye ex in tion w s bout 2 ye rs go. I h ve not dil ted hi yet.
4. He is neg tive or seudoex oli tion or KPs in either eye nd neg tive
or high blood ressure or di betes. His l st hysic l w s 3 onths go.
5. I believe he h s ri ry o en- ngle gl uco with elev ted IOP in
his le t eye nd we should begin tre t ent with bi to rost dro s
0.03% once d ily. He should return 2 weeks ter he begins ther y
to recheck his IOP.
Example #2
1. My tient is 26-ye r-old L tin e le.
2. She is here bec use she h s noticed th t light e rs brighter in
her le t eye th n in her right eye or the st week. She h s no other
co l ints.
18 Chapter 1
3. Her best-corrected vision is 20/20 t dist nce in e ch eye with low

hy ero ic correction. I ound th t her le t u il w s l rger th n the
right u il initi lly nd res onded slowly to light both directly nd
consensu lly, but it did constrict ter bout 5 inutes o testing.
T e right u il res onded briskly to light both direct nd consen-
su l. T ere w s no tosis o either eye. Her visu l elds re ull to
con ront tion in e ch eye. On slit l her eyes were white nd
quiet; I looked or uneven contr ction or iris stre ing, but I did
not see ny. Her l st ull eye ex in tion w s bout 2 ye rs go here
t the he lth center. No roble s were ound t th t ti e.
4. She denies ever seeing double or h ving eye in, exce t her le t eye
w s so ewh t light sensitive when she rst e erged ro seeing
ovie this weekend. She h s never ex erienced nything like this
reviously. She re orts th t her syste ic he lth is good; she is not
t king ny edic tions other th n birth control ills. She w s l st
seen by hysici n 2 onths go to renew her BCP rescri tion.
5. I believe she h s recent onset o tonic u il OS. We should re ssure
her th t she h s no serious thology or dise se nd see her g in in
5 weeks. At th t ti e we c n recheck ll her eye ndings, nd we c n
ex ect to see the ddition o iris signs o Adie’s, such s ver i or
contr ctions nd stro l stre ing.
HO W TO WRITE A CO NSULTANCY
O R REFERRAL LETTER
Purpose
o rovide written su ry o ll ertinent in or tion bout tient
to en ble nother r ctitioner to rovide e cient, in or ed consult tion
nd/or c re o the tient without w sting the ti e o the reci ient o
the letter.
Indications
When it is necess ry to rovide written su ry o tient’s ex i-
n tion ndings to nother ro ession l who will beco e involved in the
c re o the tient.
Equipment
• Word rocessor.
• St tionery with the letterhe d o the re erring r ctice or clinic.
Setup
h ve t h nd.
1. Begin with st nd rd business-letter or t nd s lut tions (eg, d te
o the letter, ddress o the reci ient o the letter).
2. Begin the body o the letter with st nd rd business s lut tion, such
s “De r Dr Xyz”).
3. List the tient’s n e, d te o birth, chie co l int, re son or
re err l, d te o oint ent with the consult nt.
4. T is should be ollowed by n rr tive, such s “(Ms, Mr, or Mrs)
( tient’s ull n e), ( ge)-ye r-old ( le, e le), resented to
( y o ce, the * * He lth Clinic, etc) on (d te) with in co l int
o (concise st te ent o the tient’s chie co l int or which the
consult tion is being requested).”
20 Chapter 1
5. T e next sentence should then st te the ur ose o the consult -

tion or re err l, “We re re erring hi /her to you to st te the ur-
ose o the re err l (eg, or consult tion concerning his... to rule
out..., or tre t ent o ..., or urther di gnostic worku ..., or urther
ev lu tion o ...,” nd so on ). Be s eci c, be concise, identi y s eci c
di gnoses bout which you re concerned, nd st te s eci c tests
you wish to h ve er or ed (eg, “ or electroretinogr hy”).
6. I the tient lre dy h s n oint ent to see the consulting doc-
tor, the next sentence should s y, “M- h s n oint ent to see you
t (indic te the ti e nd d te).”
7. A li y the tient’s chie co l int by su lying the ollowing
d t :
• i e o onset (eg, it beg n 2 d ys go in the evening)
• Dur tion (eg, it h s l sted 2 d ys)
• Descri tion o ti e-course (eg, co es nd goes, getting ste dily
worse, etc)
• Acco nying sy to s or signs observed by tient or by you
(eg, qu lity o the disch rge, in)
8. Provide ddition l relevant in or tion, including relev nt neg -
tives, ro the ex in tion nd c se history, such s:
• Best-corrected VA. T is is relev nt so o ten in eye c re th t you
should include it even i you re not sure it is relev nt. I re er-
ring to nother eye-c re rovider, include your best re r ction
long with the VA. O it the re r ctive rescri tion i re erring to
so eone who is not n eye-c re s eci list.
• Note: Un ided VA is r rely relev nt.
• In or tion obt ined ro extern l observ tion, slit l , etc.
• P tient’s edic l history: syste ic illness(es), edic tions,
recent ch nges in ctivities: only i relev nt to the resent tion
(eg, tient h s se son l llergies).
• F ily ocul r nd edic l history only i relev nt.
9. Finish with n ex ression o your reci tion or the consult nt’s
willingness to rtici te in the c re o your tient nd request
eedb ck bout the results o the urther testing or tre t ent.
10. Sign your n e to the letter.
Recording
Ret in co y o the letter in the tient’s clinic record or le.
Notes:
• Do include other pertinent in or tion.
• Do include relev nt neg tives.
• Do not include in or tion th t is irrelevant to this resent tion
• So e r ctices re er to receive co ies o FAX versions o your let-

ter nd/or ctu l tient record or notes. I you re sending co ies o
your notes, ention this in the re err l letter. It is lso ro ri te to
e- il your consult ncy or re err l letter rovided you c n con dently
co ly with HIPAA.
• T e key to good re err l letter is to concisely re ort everything th t is
relev nt so the consult nt cquires quick nd in-de th underst nd-
ing o the tient’s roble , but to re ort nothing th t is irrelev nt
so s not to ob usc te the ur ose o the re err l or to w ste the con-
sult nt’s ti e trying to nd the i ort nt in or tion in the idst o
irrelev ncies.
• Knowing wh t is relev nt nd wh t is irrelev nt is the di cult rt, but
th t is the key to writing n e ective nd concise re err l letter.
Example #1
Se te ber 6, 2015
LP, OD
XXX YYY Co unity He lth Center
Street ddress
City, st te, zi code
Re Ms SS
dob A ril 15, 1925
Chie Co l int: reduced ne r visu l cuity with her gl sses
Re: ev lu tion or low vision services
A oint ent: October 3, 2015, 9:30 a m
De r Dr P:
I re erring Ms SS, 90-ye r-old e le, to you or low vision ev lu-
tion. During our ex in tion o Ms SS on Se te ber 5, 2015, we ound
severe cul r degener tion in both eyes nd gr de 2 erent u ill ry
de ect with disc llor in the right eye. Her best-corrected dist nce visu l
cuity w s OD light erce tion nd OS 20/400, with no i rove ent
with inhole. We g ve Ms SS ne r vision rescri tion o “b l nce” OD
(LP) nd + 4.50 s h OS (20/200 @ 16”).
22 Chapter 1
She is currently being ev lu ted by her ri ry c re hysici n ol-

lowing high r ndo seru glucose test result but does not h ve di g-
nosis o di betes t this ti e.
Ms SS will be cco nied by her d ughter when she co es to
see you.
T nk you or seeing this tient nd ev lu ting her suit bility or
low vision ids. Ple se tell us your ssess ent nd gener l l ns or her.
T nk you.
Sincerely,
D niel Kurtz, OD, PhD
Example #2
Se te ber 6, 2015
JH, MD
XXX YYY Co unity He lth Center
Street Address
City, st te, zi code
De r Dr JH:
Ms BC, 19-ye r-old C uc si n e le college student, resented to y
o ce or ex in tion t the O to etry Service t XXX YYY Co unity
He lth Center on Se te ber 5, 2015, with chie co l int o inter it-
tent vision loss nd f shes o light in her right eye since she w s hit in
the he d during b sketb ll r ctice 3 d ys go. She h s n oint ent
to see you tod y t 2:45 pm.
Our dil ted ex in tion reve led rheg togenous su erior te -
or l retin l det ch ent three disc di eters ro the o tic nerve he d
nd two disc di eters in size. Ms BC’s best-corrected visu l cuity t
dist nce tod y w s 20/20 in her right eye nd 20/20 in her le t eye we r-
ing her gl sses o OD − 6.00 nd OS − 6.50.
Ms BC will be cco nied to your o ce by her boy riend. Ple se
tell us your ssess ent nd tre t ent l ns or her nd how you would
like to coordin te with e or her ollow-u c re.
T nk you or seeing this tient on n e ergency b sis. I look or-
w rd to he ring ro you.
Sincerely,
N ncy B. C rlson, OD
REP O RTING ABUSE

Purpose
o rotect tients ro h r inf icted by others.
Indications
In the United St te, l ws nd te the re orting o buse or neglect o
vulner ble o ul tions such s children nd the elderly. In gener l, it is
required to re ort even the sus icion o buse. T e o to etrist h s to be
knowledge ble o loc l nd st te l ws to deter ine or who nd under
wh t circu st nces he is nd ted re orter.
Equipment
T e s eci c or s used to re ort buse re usu lly nd ted by the rel-
ev nt jurisdiction. T e r ctitioner should h ve su ly o such or s
re dily v il ble in the o ce. T ese or s v ry ro st te to st te.
Setup
T e r ctitioner is ex ected to h ve knowledge o the signs nd sy -
to s o buse.
(Ma ssa ch u se t t s)
1. H ve v il ble ll necess ry re orting in or tion: the tient’s ull
n e, d te o birth, ddress, hone nu ber, s well s the ty e o
buse you sus ect nd wh t you observed in the tient to ke you
sus icious.
2. C ll the relev nt hotline or the tient nd jurisdiction.
3. Answer ll questions.
4. Obt in nd record the n e o the erson to who you g ve the
verb l re ort.
5. Within 48 hours, le written version o the re ort to the ro ri-
te rty.
24 Chapter 1
Recording
• Your ex in tion record should include ll the relev nt ndings th t
de you sus ect buse.
• A co y o the ctu l re ort does not go into the tient’s clinic l record,
but ust be ke t in se r te, con denti l le.
Example
S e king to the Abuse Hotline in your jurisdiction: “My tient is
9-ye r-old le. He c e or n eye ex in tion this ternoon t
1 o’clock. He w s cco nied by his ther. He resented with round
lesion on his le t u er eyelid. It w s bout the di eter o cig rette.
I did not observe other signs o tr u to his ce or eyes, but the child
w s very reticent. I could not gure w y to t lk to hi se r ted ro
his ther.”
Notes:
In gener l, the go l o re orting is to revent urther h r to the tient
nd to ini ize ddition l risk to the tient.
Whether or not nd how you in or the tient nd ily e bers
th t you h ve led re ort de ends on the circu st nces. Above ll else,
do no h r .
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and character to take the direction, for instance, of important college
departments. Men of power and skill are in demand everywhere, and
not enough can be found for responsible positions. One half the fault
is insufficient education.
There is another phase of power that must not be neglected, the

power to enjoy, to be rich in emotional life. Knowledge, properly
pursued, is a source of rich and refined intellectual emotions. There
is joy in discovery, joy in the freedom and grasp of thought.
Æsthetic power, based upon fine discrimination, finds a perpetual
joy in sky and sea, and mountain and forest, in music and poetry, in
sentiment and song. Our Teutonic ancestors were better seers than
we. The morning sun and the midnight darkness were perpetually to
them a new birth. The leaves whispered to them divine messages;
the storms and the seasons, the fruitful earth, were full of wonder
and sacred mysteries. They were poets. This matter-of-fact age will
yet return to the primitive regard for nature, a regard enlightened and
refined by science. Men will yet find in the most commonplace fact of
nature mystery, poetry, ground for reverence, and faith in a God.
The power of enjoyment alone does not give a fruitful life. It is in
the moment of action that we gain the habit that makes power for
action. As a philosopher recently expressed it: Do not allow your
finer emotions to evaporate without finding expression in some
useful act, if it is nothing but speaking kindly to your grandmother, or
giving up your seat in a horse car.
There has been a weak and harmful philosophy in vogue for years
that would place the natural and the useful in the line of the
agreeable. Even extreme evolution fails signally to show that the
agreeable is always teleological, that is, always directed toward
useful ends. The latest teaching of physiological psychology takes us
back to the stern philosophy of the self-denying Puritan, and shows
that we must conquer our habitual inclinations, and encounter some
disagreeable duty every day to prepare for the emergencies that
demand men of stern stuff. George Eliot proclaims the same thought
with philosophical insight, that we are not to wait for great
opportunities for glory, but by daily, drudging performance of little
duties are to get ready for the arrival of the great opportunities. We
must prepare for our eagle flights by many feeble attempts of our
untried pinions.
If one but work, no matter in what line of higher scholastic pursuit,
he will in a few years waken to a consciousness of power that makes
him one of the leaders. There is every encouragement to the student
to persevere, in the certain assurance that sooner or later he will
reach attainments beyond his present clear conception.
Our inheritance is a glorious one. The character of the Anglo-
Saxons is seen throughout their history. Amid the clash of weapons
they fought with a fierce energy and a strange delight. They rode the
mighty billows and sang heroic songs with the wild joy of the sea
fowl. Later we find them contending earnestly for their beliefs. Then
they grew into the Puritan sternness of character, abounding in the
sense of duty. Their character has made them the leaders and
conquerors of the world. It finds expression in the progress and
influence of America. This energy has gradually become more and
more refined and humanized, and, in its highest and best form, it is
the heritage of every young man; and by the pride of ancestry, by the
character inherited, by the opportunity of his age, he is called upon
to wield strongly the weapon of Thor and hammer out his destiny
with strong heart and earnest purpose.
MORAL TRAINING.
We shall not discuss the philosophical systems which underlie

ethical theories, nor the theories themselves which consider the
nature of the moral sense and the supreme aim of life, but shall treat
practical ethics as a part of didactics, and as a part of that unspoken
influence which should be the constant ally of instruction. It is not the
purpose to present anything new, but rather to give confidence in
methods that are well known and are successfully employed by
skilful and devoted teachers.
The formation of right habits is the first step toward good

character. Aristotle gives this fact special emphasis. Here are some
detached sentences from his ethics: “Moral virtue is the outcome of
habit, and, accordingly, its name is derived by a slight deflection from
habit.... It is by playing the harp that both good and bad harpists are
produced, and the case of builders and all artisans is similar, as it is
by building well that they will be good builders, and by building badly
that they will be bad builders.... Accordingly, the difference between
one training of the habits and another, from early days, is not a light
matter, but is serious or all-important.” Aristotle here expresses a
truth that has become one of the tritest. All mental dispositions are
strengthened by repetition. We learn to observe by observing, to
remember by exercising memory, to create by training the
imagination, to reason by acts of inference. Passions grow by
indulgence and diminish by restraint; the finer emotions gain strength
by use. Courage, endurance, firmness are established by frequently
facing dangers and difficulties. By practice, disagreeable acts may
become a pleasure.
It is by practice that the mind gets possession of the body, that the
separate movements of the child become correlated, and the most
complex acts are performed with ease and accuracy. Physiological
psychology has confirmed and strengthened the doctrine of habit.
The functions of the brain and mental actions are correlated. A nerve
tract once established in the brain, and action along that line recurs
with increasing spontaneity. New lines of communication are formed
with difficulty. Each physical act controlled by lower nerve centres
leaves a tendency in those centres to repeat the act.
The inference is obvious and important. Whatever we wish the
adult man to be, we must help him to become by early practice.
Childhood is the period when tendencies are most easily
established. The mind is teachable and receives impressions readily;
around those cluster kindred impressions, and the formation of
character is already begun. The brain and other nerve centres are
plastic, and readily act in any manner not inconsistent with their
natural functions. As they begin they tend to act thereafter.
Dr. Harris called attention a few years ago to the ethical import of
the ordinary requirements and prohibitions of the schoolroom.
Promptness, obedience, silence, respect, right positions in sitting
and standing, regard for the rights of others, were named as helping
to form habits that would make the child self-controlled and fit him to
live in society.
Whatever you would wish the child to do and become, that let him
practise. We learn to do, not by knowing, but by knowing and then
doing. Ethical teaching, tales of heroic deeds, soul-stirring fiction that
awakens sympathetic emotions may accomplish but little, unless in
the child’s early life regard for the right, little acts of heroism, and
deeds of sympathy are employed; unless the ideas and feeling find
expression in action, and so become a part of the child’s power and
tendency. George Eliot would have us make ready for great deeds
by constant performance of little duties at hand.
Right habit is the only sure foundation for character. Sudden
resolutions to change the tenor of life, sudden conversion from an
evil life to one of ideal goodness are usually failures, because the old
tendencies will hold on grimly until the new impulse, however great,
has gradually evaporated. To prepare for the highest moral life and a
persevering religious life, early habits of the right kind are the only
secure foundation.
The teacher may have confidence in the value of requiring of
pupils practice in self-restraint, practice in encountering difficulties
that demand a little of courage, a little even of heroism—and each
day furnishes opportunities. Pleasure may not always attend their
efforts, but pleasure will come soon enough as a reward, in
consciousness of strength and of noble development. Often we do
wrong because it is pleasant, and avoid the right because it is
painful. By habit we come to find pleasure in right action, and then
the action is a true virtue as held by the Greek philosophers. Aristotle
remarks: “Hence the importance of having had a certain training from
very early days, as Plato says, such a training as produces pleasure
and pain at the right objects; for this is the true education.”
The personality of the teacher is a potent factor in moral

education. Perfection is not expected of the teacher; none ever
attained it except the Great Prototype. All that we can say of the best
man is that he averages high. The teacher who does not possess to
a somewhat marked degree some quality eminently worthy of
imitation will hardly be of the highest value in his profession. I
remember with gratitude two men, each of whom impressed me with
a noble quality that made an important contribution at the time to my
thought, feeling, action, and growth. The ideal of one was action—
energetic, persevering action—and he was a notable example of his
ideal. His precept without his example would have been almost
valueless. The other was a noble advocate of ideal thought, and his
mind was always filled with the highest conceptions; moreover, in
many large ways he exemplified his precept. His acquaintance was
worth more than that of a thousand others who are satisfied with a
commonplace view of life.
Minds that are not speculative, are not ingenious and creative, will
hardly make their own ideals, or even be taught by abstractions.
They can, however, readily comprehend the living embodiment of
virtue, and there is still enough of our ancestral monkey
imitativeness remaining to give high value to example.
And it is important that the influence of the teacher shall not be
merely a personal magnetism that influences only when it is present,
but a quality that shall command respect in memory and help to
establish principles of conduct. The influence should be one that will
be regarded without the sanction of the personal relation. He who is
wholly ruled either by fear or by love gains no power of self-control,
and will be at a loss when thrown upon his own responsibility in the
world of conflict and temptations. Character must be formed by habit
and guided by principle.
The world’s moral heroes are few. Since they can not be our daily
companions, we turn to biography and history, that their personality
and deeds may be painted in our imagination. Concrete teaching is
adapted to children, and select tales of great and noble men, vivid
descriptions of deeds worthy of emulation may early impress their
minds with unfading pictures that will stand as archetypes for their
future character and conduct. Hence the value of mythology, of Bible
stories, and Plutarch.
It is unnecessary to add that such literature should be at the
command of every teacher, and there is enough adapted to every
grade of work. Throughout the period of formal historic study
important use should be made of the ethical character of men and
events. The pupil thus fills his mind with examples from which he
may draw valuable inferences, and with which he may illustrate
principles of action. The ethical sense is developed through relations
of the individual to society, and the broader the scope of vision, the
more just will be the estimate of human action.
Ideal literature, the better class of fiction and poetry, which not only
reaches the intellect, but touches the feeling and brings the motive
powers in harmony with ideal characters, deeds, and aspirations,
may have the highest value in forming the ethical life of the pupil.
Here is presented the very essence of the best ideas and feelings of
humanity—thoughts that burn, emotions of divine quality, desires
that go beyond our best realizations, acts that are heroic—all painted
in vivid colors. By reading we enter into the life of greater souls, we
share their aspirations, we make their treasure our own. A large
share of the moralization of the world is done by this process of
applying poetry to life.
There is, however, one important caution. There is a difference
between sentiment and sentimentality. The latter weakens the mind
and will; it is to be avoided as slow poison that will finally undermine
a strong constitution. There must be a certain vigor in ideal
sentiment that will not vanish in mawkish feeling, but will give tone
for noble action. It is a question whether sentiment that sheds tears,
and never, in consequence, does an additional praiseworthy act, has
worth. You know the literature that leaves you with a feeling of stupid
satiety, and you know that which gives you the feeling of strength in
your limbs, and clearness in your intellect, and earnestness in your
purpose, and determination in your will.
Use ideal literature from the earliest school days of the child;
choose it with a wisdom that comes from a careful analysis of the
subject and a knowledge of the adaptation of a particular selection to
the end proposed. And when you reach the formal study of literature,
find in it something more than dates, events, grammar, and rhetoric;
find in it beauty, truth, goodness, and insight that will expand the
mind and improve character.
There is much truth in the criticism that condemns precept without

example; the two go together, the one is a complement of the other.
We act in response to ideas, and a rule of action clearly understood
and adopted will often be applied in a hundred specific instances that
fall under it. A teacher of tact and skill can gain the interest of
children to know the meaning and understand the application of
many rich generalizations from human experiences that have passed
into proverbs. The natural result of conduct which we condemn may
be pointed out, with often a noticeable increase of regard for duty
and prudence. We may not expect consistency of character,
firmness of purpose, rigid observance of honesty, truthfulness,
honor, and sympathy until the course of life is directed by principles
that have taken firm hold of the mind.
When moral instruction in school passes into what the boys call
preaching, the zealous teacher often dulls the point of any possible
interest in the subject, and thereby defeats his purpose. Sometimes
we, in our feeling of responsibility, trust too little to the better instincts
of childhood, the influence of good surroundings, and the leavening
power of all good work in the regular course of instruction.
For the purpose of moral instruction in the schools we should take
the broad view of the Greek ethics. As summed up by Professor
Green the Good Will aims (1) to know what is true and create what is
beautiful; (2) to endure pain and fear; (3) to resist the allurements of
false pleasure; (4) to take for one’s self and to give to others, not
what one is inclined to, but what is due. This is larger than the
conventional moral code. It makes virtues not only of justice and
temperance, but of courage and wisdom. By implication it condemns
cowardice and lazy ignorance. It urges one to strive for the
realization of all his best possibilities, to enlarge his powers, his
usefulness, and aim at the gradual perfection of his being through
the worthy use of all his energies. It does not dwell morbidly on petty
distinctions of casuistry, but generously expands the soul to receive
wisdom, the wisdom that regards all good.
We are creatures of numerous native impulses, all useful in their
proper exercise. Each impulse is susceptible of growth until it
becomes predominant. The lower animals follow their instincts. Man
is rational, has the power to discriminate, to estimate right and
wrong, to educate and be educated. He is called upon to subordinate
some impulses and to cultivate others. The child is full of power of
action, and it must be exercised in some direction. The work of the
teacher is to invite the native impulses that reach out toward right
and useful things, by offering the proper objects for their exercise.
When these tendencies of the child’s being are encouraged, his
growth will be ethical.
What is the relation of the doctrine of duty to the practical subject
in hand? This is a question that rests upon the broad foundation of
philosophy and religion, and we cannot discuss the grounds of belief.
We may believe that the sense of duty is indispensable to moral
character. True, much has been done in the name of duty that has
been harmful and repellent. Many things have been thought to be
duty that would rule healthful spontaneity and cheerfulness and
needful recreation out of life, and place the child under a solemn
restraint that rests on his spirit like an incubus and drives him to
rebellion and sin. We do not mean duty in this caricature of the
reality. But this is a world in which the highest good is to be obtained
by courage to overcome evil and difficulty. The great Fichte said: “I
have found out now that man’s will is free, and that not happiness,
but worthiness is the end of our being.” And Professor Royce in the
same vein says: “The spiritual life isn’t a gentle or an easy thing....
Spirituality consists in being heroic enough to accept the tragedy of
existence, and to glory in the strength wherewith it is given to the
true lords of life to conquer this tragedy, and to make their world,
after all, divine.” In the name of evolution and physiological
psychology much good has been done in driving to the realm of
darkness, whence it emanated, the spirit of harshness and cruelty in
education and in discipline; at the same time much harm has been
done by superficial interpreters by the attempt to make all education
and training a pleasure. The highest good cannot be gained without
struggle. Character cannot be formed without struggle. You and I
would give nothing for acquisitions that have cost us nothing. While
the child’s will is to be invited in the right direction by every worthy
motive that tends to make the path pleasant, the child at the same
time should know by daily experience that some things must be
because they are right, because they are part of his duty; that they
may be at first disagreeable and require stern effort. Only then will
he be prepared to resist temptation, and to actively pursue a course
that will lead toward the perfection of his being and toward a life of
usefulness. Along the paths of pleasure are the wrecks of
innumerable lives, and this view is one of the greatest practical
importance in the every-day work of the schoolroom.
All proper education is ethical education. How the teacher

encourages the acquisition of truth! With what care he corrects error
in experiment and inference! With what zeal he leads the pupil to
further knowledge! With what feeling he points out beauty in natural
forms and in literary art! With what hope he encourages him to
overcome difficulties! With what solicitude he regards his ways and
his choice of company! What use he makes of every opportunity to
emphasize a lesson of justice in this little society of children, which is
in many ways a type of the larger society into which the child is to
enter! If teachers are learned and skilful, and of strong character, if
they awaken interest in studies and not disgust, if they have insight
into the moral order of the world as revealed in all departments of
learning, the whole curriculum of study, from the kindergarten to the
university, will be a disclosure of ethical conceptions, a practice of
right activity, an encouragement of right aim. If the better tendencies
of the child’s nature are repelled instead of invited, in so far will
instruction lack the ethical element. And herein lies the great
responsibility of the teacher for his own education, methods, and
personal influence.
What are the schools doing for moral training? We believe they
are doing much that is satisfactory and encouraging. The public
schools have at their command the various ethical forces. They form
right habits by every-day requirements of the schoolroom; they
provide the personal influence of teachers whose good character is
the first passport to their position; they employ the lessons of history
and literature, and in distinct ways impart principles of right conduct;
they inspire courage to overcome difficulties; they direct the better
impulses of children toward discovery in the great world of truth, and,
by the very exercise of power required in the process of education,
prepare them for life.
CAN VIRTUE BE TAUGHT?
On a certain occasion Socrates assumed the rôle of listener, while

Protagoras discoursed upon the theme “Can Virtue Be Taught?”
Protagoras shows that there are some essential qualities which,
regardless of specific calling, should be common to all men, such as
justice, temperance, and holiness—in a word, manly virtue. He holds
it absurd and contrary to experience to assume that virtue cannot be
taught. He says that, in fact, “Education and admonition commence
in the first years of childhood, and last to the very end of life.” Mother
and nurse, and father and tutor ceaselessly set forth to the child
what is just or unjust, honorable or dishonorable, holy or unholy; the
teachers look to his manners, and later put in his hands the works of
the great poets, full of moral examples and teachings; the instructor
of the lyre imparts harmony and rhythm; the master of gymnastics
trains the body to be minister to the virtuous mind; and when the
pupil has completed his work with the instructors, the state compels
him to learn the laws, and live after the pattern which they furnish.
“Cease to wonder, Socrates, whether virtue can be taught.”
We can but accept the principles of Protagoras, that the essential
qualities of a rational and moral being are to be considered at each
stage of growth and in all relations of life; that all education is to be
the ally of virtue. We can but accept, too, the fact that guidance,
instruction, and authority help to bring the child to self-realization,
and help to determine modes of conduct. The remaining question
relates to the ways and means adapted to a given stage of
education. When the pupil enters the high school he is already a
trained being. His training, however, has been more or less
mechanical. He is now at an age when his capacity, his studies, and
his social relations admit him to a broader field—a field in which he
makes essays at independent action; when his physical
development brings new problems and dangers; when contact with
the world begins to acquaint him with the vicious maxims of selfish
men; when there is a tendency to break away from the moral codes,
without the wisdom of experience to guide him in his growing
freedom. It is a critical period—one that tests in new ways his mental
and moral balance. If the pupil is not wrecked here, he has many
chances in his favor, although the college or business life or society
may later sorely tempt him. That the teachings and influences of the
period of secondary education have much to do with making
character is recognized by the colleges. Some schools become
known for the vigor of their intellectual and ethical training, and the
successful preparation of their pupils to meet the demands and
temptations of college life. The subject of ethics in the high school
thus becomes a proper one for inquiry.
Shall we employ the formal study of ethics? Hardly. The scientific
or theoretical treatment of the subject belongs to the period of
reflection, of subjective insight, and should follow psychology, if not
philosophy. Such study hardly accomplishes much practically until
experience and reflection have given one an interest in the deepest
problems of life. It belongs to a period when the commonplaces are
fraught with meaning, when a rational conviction has the force which
Socrates gave to insight into wisdom—when to understand virtue is
to conform the life to it. But, nevertheless, the whole period of high-
school work should be a contribution to the end of moral character.
Let us get rid, at the outset, of the idea that a moral life is a
mechanical obedience to rules and conventionalities, a cut-and-dried
affair, a matter that lies in but one province of our nature, a
formalism, and learn that the whole being, its purposes and
activities, the heroic impulses and the commonplace duties lie within
its circle. Everything a man is and does, learns and becomes,
constitutes his moral character.
Ethics is the science of conduct—conduct on both its subjective
and its objective side. It considers the relation of the self to all
consequences of an act as foreseen and chosen by the self, and to
the same consequences as outwardly expressed. Practically it
teaches control of impulse with reference to results as expressing
and revealing the character—results both immediate and remote.
Some acts show a one-sided inclination, uncontrolled by regard for
the claims of other and better impulses; only a part of the individual
is asserted, not the whole self in perfect balance. For example, the
pupil plays truant, acting with sole regard for the impulse to seek
ease and sensuous pleasure. He neglects other more important
impulses, all of which might have been satisfied by attending
faithfully to his school duties: the impulse of ambition, to gain power
and become a useful and successful citizen; the desire for culture,
with all its superior values; the impulse of wonder, leading ever to the
acquisition of knowledge; the impulse of admiration, to seek and
appreciate the beautiful; the filial and social affections, which regard
the feelings and wishes of the home and the sentiments of
companions; the impulse to gratitude, as shown toward parents and
teachers; the sentiment of reverence, as shown toward law and
order and those who stand as their representatives. And all these
neglected demands rise up and condemn him; he is divided from
himself and his fair judgment, is not his complete self. On the other
hand, the pupil spends the day in devotion to work, he maintains the
integrity and balance of his nature, gives each impulse due
consideration and makes a symmetrical and moral advance in his
development. In restraining the impulse to play truant, he does
justice to all the claims of his being; the resulting values as estimated
in subjective experiences are the highest possible—the act is good.
The problem, then, is to bring the pupil to a fuller understanding of
the character of his impulses to action, and the relative value of
each. In many ways the neglected elements of his nature may be
brought into consciousness and emphasized. Everything that creates
conceptions of ideal conduct, all concrete illustrations in the social
life of the school, all conscious exercise of power in right ways,
contribute toward his self-realization. The high-school pupil has not
had a large personal experience; hence the need, in the ways
proposed, of teaching virtue. In the first place, the situation is
advantageous. It is conceded by every school of ethical thinkers that
one finds his moral awakening in contact with society. Society is the
mirror in which one sees a reflection of himself, and comes to realize
himself and his character. The school of the people, which is in an
important sense an epitome of that larger world which he is to enter,
furnishes an admirable field for development. Moreover, it is a
community where the restraint, the guidance, the ideals come of
right from properly constituted authority. The whole problem of
objective relations and corresponding subjective values may find
illustration and experiment in the daily life of the school. The
constructive imagination may be employed to infer from experiences
in school to larger experiences of kindred quality in the field of life.
By judging real or supposed cases of conduct the pupil makes at
least a theoretical choice. By learning and interpreting characters
and events in history his view is broadened.
The whole school curriculum should contribute to moral
development. Whatever of intellect, emotion, and will is exercised in
a rational field expands the soul normally. The pursuit of studies with
the right spirit, and with regard for the activities and relations
incidental thereto, is moral growth. Studies awaken rational interest,
cultivate habits of industry, are devoted to the discovery of truth,
reveal important relations of the individual to society, and present the
purest ideals of the race. There is hardly a more valuable moralizer
than healthy employment itself, employment that engages the whole
man—perception, imagination, thought, emotion, and will—
employment that looks toward ennobling and useful consequences,
employment that has the sanction of every consideration that
regards man’s full development. If the studies of the high-school
course do not make for good, it is because they fail to get hold of the
pupil, to awaken his interest and energies. If the subject matter and
the instruction are adapted to the pupil’s need, if conceptions are
clearly grasped, if healthy interest is aroused and the attention turns
spontaneously to the work, the pupil’s growth will be in every way
beneficent. One who regards the moral development of his pupils will
conscientiously study the method of his teaching, and learn whether
the source of neglect and rebellion lies there.
The personality of the teacher is one of the most important factors
in ethical training. It is ethics teaching by example; it is the living
embodiment of conduct. The ideas that find expression in the life of
the teacher are likely to be imitated. The sympathy of the teacher
with the endeavor of the pupil infuses life into his effort. We do not
refer to a certain kind of personal magnetism; this may be pernicious
in the extreme. It may exist to the extent of partially hypnotizing the
independent life of the pupil, robbing him for a time of part of his
individuality. The ideal instructor should be earnest and noble,
impressing one with the goodness, dignity, and meaning of life. An
easy-going regard for duties, a half-way attachment to labor are sure
to impress themselves on the minds of pupils; as readily will honor,
sincerity, and pure ideals be reflected in their endeavors. You will
ask: What are some of the specific ways in which a teacher may
direct his efforts? We often look far for the means of accomplishment
when they are already at hand. The means of moral influence are
not the exclusive possession of learning or genius; they may be used
by every teacher, and we should have faith in what the schools are
already doing to make good character. The successful use of
methods depends upon the teacher’s judgment and tact. One may
do harm by conscientious but ill-directed effort. With Solomon we
must remember that there is a time for everything. Amongst other
impulses, natural or acquired, the pupil has impulses to regard
honor, honesty, truthfulness, gentlemanliness, good thoughts,
respect, gratitude, sympathy, industry, usefulness. In a fit of rage,
with desire to harm the object of his vindictiveness, he may disregard
nearly every one of the above qualities. The impulse of anger acts
blindly, heedless of external consequences and of the subjective
values that attach to the execution of every desire. All cases of bad
conduct, varying in degree, show a similar disproportionate estimate
of the value of motives. Our problem is to plant in the consciousness
of the pupil an appreciation of neglected qualities. It may be noted in
passing that there are some cases of physical tendency, amounting
to monomania. Conscious wrong never is able fully to conceal itself,
and when the truth becomes evident to the teacher, as it may, he
should seek the confidence of the home, and through the home the
influence upon the pupil of a trusted physician who possesses both
medical skill and moral force.
In approaching the specific ways of moral education, we may first
make our obeisance to habit. The limitations as to time, place, and
activity, which are incidental to all school life, help to form habits
which turn the growing youth still more from the condition of
uncontrolled liberty into one of well-regulated conduct, civilize him,
and make him a fit member of society. Habits of regard for the rights
of others further lay the foundation of altruism. Habit has its value. It
establishes tendencies of conduct, although in a more or less
mechanical way, which make easier the adherence to virtue in the
advanced period of reflective insight. Too, these same duties
mechanically performed may later be known in their full significance,
and become moral acts.
The judicious use of maxims, also, has a value. Maxims are the
first formal expression of the experience of the race as to the things
to do or avoid. Since we act from ideas, maxims may serve
practically for many concrete cases. This is especially true if the full
meaning of a maxim has been presented. Next to maxims, and
greater in importance, are the events and characters of history and
biography. Embodied virtues and vices, real events that show the
movements and reveal the motives of a people, appeal strongly to
the interest. Yet, being remote in time and place, they allow the
freest discussion and may be made permanent types for the
instruction and improvement of mankind. The value lies in the fact
that qualities thus known hasten the self-realization of the same
qualities. The life of a Socrates, an Aristides, of a Cato, a
Savonarola, a Luther, a Cromwell, a Lincoln, a Whittier, of all men
and women who exemplify virtue, heroism, self-denial, all struggles
for the right, are the high-water mark for every aspiring nature. And
in the teaching of history and biography it is not necessary at every
turn to deliver a homily; rather lead the pupil into the spirit and
understanding of the subject—some things shine with their own light.
A yet more fertile source of ideal conceptions is the choice
literature of the world. From this rich treasury we draw the poetry
which we apply to life. In literature truth is given life and color,
idealized and made attractive. Qualities are abstracted, refined,
perfected, and glorified. They serve to show us the meaning of those
qualities in us. Literature presents emotions that in their purity and
refinement seem to transcend the material world; heroes and
martyrs idealized and embodying self-sacrifice and devotion;
sentiments that touch the whole range of chords in the heart and
awaken tenderness or heroism. The pupil reads Homer and gains
conceptions of heroic virtues; the “Lays of Ancient Rome,” and gains
ideas of perfect honor and devotion to country; Tennyson, and he
follows the pure conceptions and feels that life has taken on a nobler
coloring; Carlyle’s doctrine of work and duty, and feels his moral
sinews strengthened. Thoughts that aspire, emotions of
transcendent worth, courage, heroism, benevolence, devotion to
country or humanity—all these are at the command of the instructor,
if he has the skill to lead the pupil into the spirit and understanding of
literature. If he has not the skill, let him not touch it.
The study of science itself offers opportunities. Science searches
for truth, judges not hastily, removes all prejudice, employs the
judicial spirit. It should suggest lessons in fairness, justice, and truth
in the field of human conduct. Hasty inference, prejudiced judgment
are responsible for half the sins of this world, and the scientific spirit
should be made to pass from the abstract field over into practical life.
Something can be done by daily assembly of pupils. While men
have various occupations, there are certain interests that belong to
men as men, as human beings. As there are hymns set to noble
music which are sung for centuries without diminution of interest,
because they are adapted to the want of man’s essential nature, so
there are gems of æsthetic and ethical literature which have stood
the test of time and are approved by common consent. The reading
of vigorous, healthful selections can but have an influence sooner or
later upon the listener. The teacher, in a brief address, may express
some thought or experience or ideal or sentiment, that will reach the
inner life. In no way, however, will the good sense and skill of the
teacher be put to severer test than in the selection of these
teachings. They easily become monotonous instead of giving vital
interest.
Professor John Dewey, in an admirable article on the subject of
interest, defines it thus: “Interest is impulse functioning with
reference to an idea of self-expression.” He further says: “The real
object of desire is not pleasure, but self-expression.... The pleasure
felt is simply the reflex of the satisfaction which the self is
anticipating in its own expression.... Pleasure arrives, not as the goal
of an impulse, but as an accompaniment of the putting forth of
activity.” These expressions mean simply that the human being has
native impulses to activity; that these impulses, under rational
control, aim at proper ends; that pleasure is not the end of action but
merely accompanies the putting forth of activity; that interest is the
mental excitement that arises when the self-active mind has an end
in view and the means of its attainment—a feeling that binds the
attention to the end and the means. His doctrine denies hedonism.
We are not to aim at a good, but to act the good. We are not to work
for the pleasure, but to find pleasure in working. This is a doctrine of
vast importance to the educator. External and unworthy rewards for
effort are false motives. The work itself must furnish interest,
because suited to the activities of the pupil. The great problem of the
teacher is to invite a self-activity that finds its reward in the activity.
False motives should not be held before pupils. There is a view of
life called romanticism, the condemnation of which gives Nordau his
one virtue. The adherents claim for themselves the fill of a constantly
varying round of completely satisfying emotional life. The history of
prominent adherents of this view is a warning to this generation. The
devotees either become rational and satirize their own folly, or
become pessimists, railing at the whole that life has to offer, or
commit suicide, and thus well rid the world of their useless presence.
Carlyle points out that not all the powers of christendom combined
could suffice to make even one shoeblack happy. If he had one half
the universe he would set about the conquest of the other half. And
then follows the grand exhortation to useful labor, the performance of
duty, as the lasting source of satisfaction. If we do not find happiness
therein, we may get along without happiness and, instead thereof,
find blessedness. This is the doctrine of Goethe’s Faust. Faust at
first wishes to enjoy everything and do nothing. He runs the whole
round of pleasure, of experience, and emotional life, and finds
satisfaction in nothing. Finally, in the second book, he finds the
supreme moment in the joy of useful labor for his fellow men. It is to
be noted, however, that as soon as he is fully satisfied he dies, as,
metaphorically, people in that state always do. Pleasure does not
make life worth living, but living the fulness of our nature is living a
life of worth.
Laying aside all theories, even the theoretical correctness of what
follows, it is necessary to hold practically to the transcendental will.
This is a large word, but it means simply going over beyond the mere
solicitation of present pleasure, and holding with wisdom and
courage to the claims of all the impulses of our being—in a word,
living a life of integrity. The transcendental will can suffer and
persevere and refuse pleasure, and endure and work out good and
useful results. It is important to give pupils a little touch of the heroic,
else they will be the sport of every wind that blows and least of all be
able to withstand the tempest or the wintry blast.
There is a well-worn figure of speech, essentially Platonic in its
character, which, once well in the mind of a young man or woman,
will surely influence the life for good. As the healthy tree grows and
expands in symmetry, beauty, and strength, and blossoms and yields
useful fruit, instead of being dwarfed or growing in distorted and ugly
forms, so the normal soul should expand and develop in vigor and
beauty of character, and blossom and yield a life of usefulness. A
stunted soul, one that has gone all awry, is a spectacle over which
men and gods may weep. In some way the nobility of life, the
grandeur of upright character must be impressed upon the mind of
youth.
And moral growth must be growth in freedom. Rules and maxims,
petty prohibitions, and restraints alone will not make morality, but
rather bare mechanism and habit. Moral freedom means that, by an
insight that comes of right development, one views the full bearing of
any problem of conduct, and chooses with a wisdom that is his own.
Morality is not mechanism, but insight. Doctrine does not constitute
morality. Pharisaism is immorality and will drive any one to rebellion
and sin. Mechanical rule has no vitalizing power. A moral life should
be self-active, vigorous, joyous, and free. So far as spontaneous
conduct can be made to take the place of rule and restraint will you
secure a growth that will expand, when, well-rooted by your fostering
care, you finally leave it to struggle with the elements.
Following in substance the thought of a prominent educator,—not
so much pedagogical preaching as skilful stimulating, not so much
perfect ideals as present activities, not so much compulsion as
inviting self-activity are to-day the needs of the schools. Through
guidance of present interest the child may later attain to the greater
interests of life in their full comprehension.

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Clinical Procedures for Ocular

Examination 4th Edition Nancy B.

Clinical Procedures for Ocular Examination, Fourth

Essential Clinical Procedures 4th Edition Richard Dehn

Drug-Induced Ocular Side Effects: Clinical Ocular

Physician Assistant Examination 7th Edition Rachel

Clinical Hematology: Theory & Procedures Sixth Edition

Lange Q&A™: Physician Assistant Examination, Eighth

Diagnostic Imaging: Pediatrics 4th Edition A. Carlson

Psychology Around Us, 4th Canadian Edition Nancy Ogden

NANCY B. CARLSON, OD, FAAO

DANIEL KURTZ, OD, PhD, FAAO

eBook conversion by codeMantra

Extraocular Motilities (EOM) 95

Cycloplegic Re raction 174

4 Functional Tests 207

Associated Phoria 253

5 Ocular Health Assessment 271

Brightness Comparison Test 372

6 Contact Lenses 385

7 Systemic Health Screening 465

8 Cranial Nerve Screening 499

Marion M.W. Hau, OD, FAAO

Ronald K. Watanabe, OD, FAAO

Each o these three chapters also describes a wide variety o prob-

INTRO DUCTIO N TO PATIENT

rocedures the clinici n will use to con r or rule out e ch otenti l

A ter the ex in tion is co leted, the clinici n ust su rize

Case History Components for an Adult

b. El bor tion o the chie co l int (FOLDARQ).

Relie : Wh t see s to ke your sy to s go w y?

• Past Medical History (including past eye history)

How is your gener l he lth?

H s nyone in your ily h d di betes, high blood ressure, thyroid

Case History Components for a

• Probe the patient’s symptoms.

Introduction Introduce yoursel , make the patient com ortable

to see nother r ctitioner. I the re err l is urgent, ke the oint-

“I going to give you this hlet bout resbyo i th t will give

Recording for Patient #1

ro ri te tre t ent or the det ch ent. Dr H will let e know when

Recording for Patient #2

3. T is should be ollowed by recit tion o ll ex in tion d t rel-

Chie complaint(s) Give patient’s description o his complaint(s) or reason

Examination data Summarize only the examination data relevant to your

Treatment and Summarize your recommended treatment or management

Give recommended time or the next visit and what should

3. Her best-corrected vision is 20/20 t dist nce in e ch eye with low

5. T e next sentence should then st te the ur ose o the consult -

• So e r ctices re er to receive co ies o FAX versions o your let-

She is currently being ev lu ted by her ri ry c re hysici n ol-

REP O RTING ABUSE

There is another phase of power that must not be neglected, the

We shall not discuss the philosophical systems which underlie

The formation of right habits is the first step toward good

The personality of the teacher is a potent factor in moral

There is much truth in the criticism that condemns precept without

All proper education is ethical education. How the teacher

On a certain occasion Socrates assumed the rôle of listener, while

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