JPFL75,
Most of the things that you asked about (refraction, slit lamp, DFE) are techniques that you get good at after 1. understanding how it works and 2. practice, practice, practice. I won't try to cover it all at once, but here are some tips on refraction that I have found useful over the years:
* Start with something in the phoropter--old Rx, autorefraction result, retinoscopy result. Just start with something relatively close to what they need.
* Start each eye by finding best spherical result. For a normal patient, blur them up with plus, then add minus until they just barely read 20/20. Then give them a little more minus, but don't give any more than 2-3 clicks of minus monocularly. If they want more, don't give it to them--it's too much accommodation, and it will screw with the cross-cyl test.
* An alternate way to find best sphere on a normal patient: show the 20/25 line, and add plus until the letters are "just a little bit blurry." Then give 2 clicks of minus and go right to the cross cyl.
* On cross cyl, my favorite sequence is power, axis, then power again. Bracket to find the best answer, but don't "over-bracket." Remember that for lower cyl powers, the axis isn't as critical, so don't beat yourself up over 1-2 degrees with 0.50 or 0.75 cyl. And lower cyl is preferable, especially in someone who has never worn a cylindrical Rx. And don't forget the 2-for-1 rule (aka, "The Little Caeser's Rule"). When you give 2 clicks of cyl (plus cyl for you) then take away one click of plus (i.e., give a click of minus) in the sphere wheel. When you take a way 2 clicks, then give a click of plus. This keeps the spherical equivalent equal.
* Don't forget to balance
* Always finish up by opening both eyes, blur them up with about 4-6 clicks of plus, then add minus until they can just barely read 20/20 (50% of the letters correct). At that point, they are 2 clicks away from the final answer. They may ASK for more minus, but they don't need it. You should only give that 3rd click of minus on rare instances, but you will find that it is not necessary on most patients. If you have a problem not giving the patient what they "want" see the next rule.
* You are in charge! Don't let the patient take over. If they seem to be unable to decide, don't be afraid to say "let's move on and come back to that one."
* With older patients and/or subnormal acuity, make bigger changes (2-4 clicks at one time).
* If they say they can't read the letters, push them. Sometimes you will be surprised what they can really read!
Originally posted by JPFL75
I recently started internship and am in the middle of doing an ophtho elective. The 1st year residents at the program I want to continue on with my ophtho residency seem light years ahead of me in terms of their knowledge and diagnostic skills. I've had limited ophtho experience up until now. Nonetheless, I'm doing everything I can to make up for my deficiencies. I am still learning how to use the phoropter, slit lamp, and how to to properly perform a dilated eye exam. I've only been in ophtho for a week and feel like I just gradated from elementary school much less med school. I'd appreciate any words of wisdom from anybody...thanks
