For Students

Part II: Graduates Guide To Kick-Start Their career In A Clinic-Based Setting

Congratulations! You made it and the hard part is over. Most Clinics are chilled and know that you are a fresh graduate and will allow you heaps of opportunities to ask questions, make mistakes and learn. Keep a small note pad to record each doctor’s preferences. Their style in recording notes, new cases and minor-op equipment lists, sterilisation process and many more. As promised, I have shuffled through my memory and collated as many tips as I can.

Tip # 1. Everything About VA Testing:

Start by asking patients if they own a pair of glasses  for distance (not wear). Don’t assume they don’t simply because they are not wearing one. Many prefer not to wear theirs and will answer no to “Do you wear glasses” question. Otherwise you will be momentarily puzzled when someone with no known history of eye conditions (except refractive) has reduced vision that improves with pinhole. 

You might have noticed I advised students to follow the staircase method in the student’s tips post. Well in real life, it won’t be as practical. The majority of patients are elderly, and often they don’t follow instructions very well. You will notice that many would prefer to read from the top (non-electronic chart) and would repeat the same line 10 times until they are confident they have read it correctly. Be patient. Do not comment or correct, instead always offer encouragement “Keep going…Good job.” 

Many will peak or deliberately move the occluder to double check. Some will hold the occluder incorrectly. Always make sure the patient is properly covered. 

In some cases, you may want to offer some assistance by pointing. I prefer to reduce the crowding by using a blank good sized card/folder/etc to cover the line underneath.

Tip # 2. Ocular motility testing:

Try not to miss out on A or V patterns. 

Tip # 3. PBCT:

Unsure if the deviation is congenital or not? Examine the head tilt. If patient straightens the head when one eye is occluded, then head tilt (and deviation) is not congenital.

In Gaze palsies, Deviation may be larger if the paretic eye is fixing.

Stacking prisms will create a positioning error, that is a higher effect than the sum of the 2 prisms. Patient will then be under corrected.  Best to measure individually then use a conversion table.

Roughly, there will be a 1 mm shift in the deviation for ever 8 prism diopters.

Tip # 4. New glaucoma patients:

It is always a good idea to perform pachymetry to measure central corneal thickness (CCT) to determine patient’s true IOP levels. 

N.b: Every Doctor will have his/her own preferences. Follow their protocol

Tip # 5. IOL measurements:

It might be a good idea to test each eye 3 times, compare values and pick the average. Keep repeating if measurements are off. These measurements need to be accurate for proper lens selection

Tip # 6. Machine Measurements:

If you find that patients’ measurements are off, or can’t seem to focus an image; make sure patient’s head and chin are still properly positioned. Next pull the joystick all the way out and start again!

Tip # 7. Dealing with children:

Put on your upbeat personality. Great patients in the waiting room before calling them in. Introduce yourself and offer a compliment such as “I wish I had shoes that light up just like yours…they are so cool”. Next explain that you will go inside to play a few games that allow you to see how strong their eyes are.

Whilst in the waiting room trying to break the ice or during history taking with the caregivers, take a minute to assess the child’s personality and developmental stage. Choose the appropriate tests and get started.

Always use a playful manner and compliment the child by saying things like “good job…you are so smart!”. Encourage participation by offering them a sticker of their own choice at the end.

If a child refuses the pirate patch or the patched glasses frame and does not wear glasses then offer to stick a sticker on the patch. If the child does wear glasses slip a folded tissue underneath the lens to create a patch. If the child still fusses, use a huge sticker (stick it as nasally as possible) on the lens to cover that eye. Worse case scenario ask the parent to hand cover.

Once vision is documented and the child can notice a bit of reduced vision himself, move on to the pinhole trick “let’s do a bit of magic!”

Sometimes asking the uncooperative child for 5 minutes of his/her time can help. Set a timer on (10 minutes) and tell him/her that once the alarm goes off he or she is free to do whatever they want.

I’m a huge fan of science, and so for older kids (7+), I use science to get their attention hooked. Things like using an eye model to show them that the unseen part of the eye (eye-ball) and that the pupil is hollow so that light goes through. The eye works like a camera and this is what the back of your eye looks like (retina photo).

Use your best judgement. Prioritise tests and be quick! Sometimes you will fail to perform a single test. Yet, a single eye movement can give you the biggest clue so keep an eagle-eye on detail. If all goes well, be sure to double check your measurements for accuracy.

Finally when it comes to using dilating drops, I always toss between informing the child about the stinginess or not. It depends on the child and how brave/ cooperative he or she sounds. In this case, I would fully explain that I will be using 2 kinds of drops (alcaine and the mydriacyl). “The first one would sting for 5 seconds only. I promise. Can you count to 5?” The kid will often count quickly. Ask them to start over and count slowly and by the time the conversation is over, the burning would have disappeared. Say things like “magic!”, “see I told you” or “you are so brave!” or “was it that bad?”

Next mention that the second drop won’t be felt at all. 

In the end, thank the child for their braveness and cooperation and allow them to choose a sticker

If you are an orthoptist or an optometrist please share your experiences and tips in the comments section below.


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