How to put the patient first in your routine eye examinations

A routine eye examination is a medical consultation at the primary care level. As with any consultation, the main output is the advice given. It can be about:

• The presence of refractive errors, and what that means.
• Correction options that will give good and comfortable vision.
• How and when to use products to make sure patients get the most out of them in a safe way.
• Presence of, or risk for, eye diseases, including helping patients to understand that means, and potentially refer for treatment.
• A personal follow-up plan to ensure patients will keep good vision through life.

Several of the points above involve increasing the patient’s knowledge about their vision. Without this educational part involving the patient in the process, your advice will turn into a monologue about what you think the patient needs. We should always let the patient’s voice be heard.

In the consultation process, you should keep the knowledge level of your specific patient in mind. Personalise your communication and use words that the patient understands. Simplify explanations when needed, be more advanced if the patient expects that. The patient will then know what you say and decide how to best act upon your advice. A patient’s knowledge level and comprehension of the medical service is a core focus in person-centred care. Working according to these principles will create positive health outcomes.

How to measure health outcomes?

A health outcome is when you have initiated a patient’s health status change. That impact can be both objective and subjective. Both are equally important.

Objective health outcomes
Examples of objective outcomes are if you detected myopia or early glaucoma. The next level is if the myopic patient bought glasses and is satisfied with them. In the case of glaucoma, it can be the start of treatment with eye drops. You can also count the number of referrals and – not least – how often your referrals were correct based on feedback from the receiver.

Remember to also look at your incorrect referrals. The result shows how many persons you’re sending on a medical eye care journey that is unnecessary and causes anxiety for the patient and their relatives, not to mention costs time and money. Other measurable health outcomes are how many eye conditions you detect and follow up on yourself. An example is dry eyes and AMD in early stages that will not get treatment anyway. The impact you have on eye health in your local area and for your patient base should be made visible by measuring the clinical data and health outcomes you produce.

Important objective measurements are detection rates and patient satisfaction levels for prescribed products.

Subjective health outcomes
A subjective health outcome could be creating a positive healthcare experience and giving the patient a better insight into their eye health status.

It can be as easy as explaining why near vision starts deteriorating at the age of 38, what to expect in years to come, and how to fix it. In addition, you can ask your patients if they learned something new about their vision during the exam. The feedback can help you develop your educational processes, including better visual tools as part of the eye exam. Finally, a subjective health outcome can also increase patient awareness and knowledge about their eye health. You can, for example, explain findings on a fundus image, even if you don’t detect any pathology.

An excellent subjective health outcome – easy to measure – is simply if the patient wants to come back for the following eye exam.

Time
The time spent on delivering the service is part of measuring the value we create for a patient:

• Patients want services to be on time and not spend more time than needed to fix their problems.
• Time spent on one every clinical service ultimately defines how many patients you can help

Setting benchmarks on the different clinical outcomes based on research is a natural next step. Benchmark creates a foundation for managing and increasing your clinical quality. Your strengths and areas to improve will become visible.

An example of an outcome-led and data-driven way of working is to measure how many correct referrals you make and match that number with the prevalence of the respective eye diseases in the population. Remember to balance the numbers for the age groups of your patients. Do you find as many glaucoma or cataract cases as you should in a year? How many low-tension glaucoma cases do you detect versus high-tension cases? You need the right IT tools and a clinic culture that nurtures qualitative and quantitively measuring to get there. It’s also necessary to establish patterns for getting feedback and learning from it, rather than feeling sorry for any eventual underperformance.

Conclusion

As a healthcare professional, you should demand to be measured and get feedback! It’s the only way to improve yourself as a professional. In many other healthcare professions, this is the norm. However, in optometry, it’s still not that common to measure the objective and subjective impact we have on patients and society, which means that we don’t take the opportunity to show how the industry contributes positively to improving health in society. We need to become more visible as a profession. One way of getting there is to make sure we produce our own data to document the effect of our work. In this way, we can prove our relevance and be aware of areas for improvement. After all: Who doesn’t want to become better at their work?

There are two extremes in delivery models for clinical services.

You can approach the routine eye examination with an already established set of tests and questions. The opposite is that you are 100% flexible and only use the tests and questions needed to solve the presenting problem. If the goal for a medical service is to offer the most extensive and comprehensive package of tests, you might lose track of the patient’s needs and instead deliver a long list of “mandatory” actions. Typically, the time spent listening to the patient gets a lower priority in your pursuit of fulfilling the customer promise of delivering all the “to-do’s”.

In a problem-orientated model, the approach is testing what you need when you need to. That requires listening to the patient and tailoring the examination to the presented problem. Sounds like the person-centred way of working, right? The World Council of Optometry (WCO) advises a problem-orientated approach for optometrists. In fact, that’s the recommendation for most healthcare professions, as it combines patient expectations and smart use of resources, including time.

Optometry organisations in different countries often have clinical guidelines for what members should include in their eye examinations. In some countries, these rules are stringent, and the list of “need-to-haves” is long. Unfortunately, following such lists too notoriously can be a showstopper for an effective problem-orientated working method.

Specific tests need to be included in every examination regardless of the presenting problem. More on that in the following chapter, but let’s take visual acuity as an example for now. Visual acuity needs to be measured, even if the presenting problem initially appears to be mild conjunctivitis. You never know. What if mild conjunctivitis turns out to be uveitis instead? Same with pupil reactions. That’s the single most important test you can perform to understand how the eye and brain’s visual nerve pathways function. Any defects here can indicate life-threatening conditions. It takes five seconds, so I see no reason not to do it in every routine eye examination.

While we are talking about inflammation, intraocular pressure (IOP) can also indicate this or not. Therefore, we should include the IOP measure in most of our exams, even the ones about the anterior eye. Read chapter four to learn what the minimum test battery should look like. Let’s take another example of a problem-based way of working. A patient comes in with a headache. If you don’t find a reasonable explanation for the headache based on refractive or binocular status, you may want to do a visual field. Even if it falls outside the mandatory list of tests, you should always do it, right?

Hans Torvald Haugo, the president of the Norwegian Optometry Association, published a good article that supports problem-based ways of working. It was published in “Optikeren” in September 2021 under the headline “More is not always the best”. Hans Torvald Haugo based his article on the international campaign “Choose wisely”, which several Western world healthcare systems have backed. The campaign is about making sure we don’t overspend medical testing. It’s a waste of everyone’s time and adds unnecessary costs. The article highlights four questions that both patients and professionals should include in a medical consultation, showing the impact of a patient-centred approach. Always include the patient in your decision making. The questions are:

• Why do I need to perform this test or treatment?
• What are the medical risks and side effects?
• What happens if I don’t do it?
• Is there a better alternative?

SOAP stands for Subjective Objective Assessment Plan. It’s a model that describes how we structure the interaction with a patient. Its history goes back to the seventies in the United States, where it was introduced to write medical files in hospitals more efficiently. At that time, all medical files were handwritten and could consist of hundreds of papers in complex cases. So every new file had the SOAP structure on the front page for a quick overview, making sure the different presenting problems, assessments, and plans were easily visible. As a result, the system improved medical safety.

The introduction of the SOAP method became the starting point for a stronger focus towards patient needs: What is the presenting problem that needs to be solved? If you structure your patient examination after the SOAP model, you:

• Listen to the patient
• Measure their needs
• Evaluate the findings in open discussion with the patient
• And finally, agree on a plan also in dialogue.

A weak point of the SOAP model is that it, in its purest form, only pays attention to the presenting symptom. We wouldn’t detect many cases of glaucoma if the presenting problem were our only steer, right? Our clinical approach needs to be more refined. Yet, the order of the phases in the exam described by SOAP still works excellent. It adds a structure to how you deliver your consultation. Following the SOAP model makes it easier for your patients to understand the advice given towards the end of the consultation and increases the probability of following them. The structure makes it easier to be a patient, as the flow in the consultation makes sense.

The above might be obvious for you, but make sure you keep to one SOAP structure throughout the test. In cases where you have multiple diagnoses, it’s tempting to deal with them one at a time. I.e., to examine the first problem, assess and communicate your conclusion, continue to do the same for the following symptom, then the third, etc. The intention with SOAP is that you capture all symptoms, do all the tests you need, assess the complete picture of symptoms and data before you, in the end, discuss the solution to your findings. It feels comforting and welcoming for the patient if you start the process by listening to them explain their problem. Afterwards, you communicate the needed tests and give a comprehensive summary of the complete examination. In that way, you include the patient throughout the examination process.

Conclusion

Make sure you work problem-orientated. Your routine examination should start with understanding why the patient has sought your help. Always follow the SOAP process, so the patient feels that every measurement and test reflect their need. Give them one conclusive summary in the end and do a joint SOAP structure for all sub-problems. It’ll confuse the patient if you split the process into different sections with individual conclusions.

Before you read this chapter, it’s helpful to update yourself on the legislation for optometry in your market. Legislation may come from authorities or the optometry associations. Be aware that the guidelines from the associations will have a variable impact from country to country, depending on how authorities rely on them in, for instance, legal complaint cases. However, the statements of national optometry guidelines can also limit or steer what tests you should perform as an optometrist. For that reason, it’s wise to read clinical guidelines from your ophthalmology association as well.

Generally, legislation for optometry has more similarities than differences for the Northern European markets (the Nordic countries and the Netherlands). Some of the guidelines are old and, practically speaking, outdated. If a clinical guideline doesn’t meet the modern principles of person-centred care, it should most likely be reviewed.

Which tests to include – always

With that in mind, here are a few selected standard tests that are always useful to include in your routine eye examination.

Anamnesis
The most important activity in the entire test. You can’t skip it even for the slightest presenting problem. We must create an atmosphere with the patient that invites them to talk about the presenting problem and ask questions. Avoid questions that can be answered by yes or no. I’ve looked into several complaint cases in eye care over the years, and it’s surprising how many times a medical file doesn’t explain why the patient wanted the eye exam. I recommend adding a questionnaire before the patient sees you, to assist the anamnesis process. It’ll help you get structured information, and it’ll help the patient understand what information you need from them.

Visual acuity
Uncorrected visual acuity is under-evaluated, and we often forget to measure it. However, you should measure it every time a patient comes in because it indicates how they see without correction. It’s the baseline measure for how the patient experiences their dependency on glasses and contact lenses. Uncorrected visual acuity defines the size of the visual disability. Without understanding that, you can’t fully understand the patient’s need.

It’s amazing how much variability you can find in uncorrected visual acuity among persons with the same refractive error. I personally often refer to my good friend with -4,5D correction. She prefers to be uncorrected most of the day. She is an artist, a painter inspired by her own thoughts and visualisation, and she doesn’t care if her distance vision is a bit blurry when she works. Believe it or not, she has 0,4 in uncorrected VA without squeezing her eyelids.

Measuring visual acuity is a skill that needs practice in listening to both what and how the patients express themselves. Some patients need more time, and others are fast. The speed of the test can also indicate what the underlying problem is. Think of keratoconus, cataracts, and early macular conditions. It can be tricky for the patient to give feedback on visual acuity in these situations because of reduced contrast or metamorphopsias, right?

While ophthalmologists are trained to use a pinhole when examining subjects with reduced visual acuity or when having difficulties refracting a patient and achieving the expected acuity, I find that optometrists usually don’t perform this test. Yet, it’s both easy and fast. Therefore, I’d claim that a referral about reduced visual acuity, where pinhole visual acuity is missing, is incomplete.

Refraction
A “no-brainer”. Note that modern refraction technologies are so good that you can skip the cross-cylinder method in many cases. To explain how to do that without reducing refraction quality is out of scope for this text. A good start is to read the user guide for your autorefraction device if one of the most modern ones.

To be good at refraction, you need to have an indication of the patient’s maximum pupil diameter when it’s dark. Without knowing the diameter, you can’t estimate the effect of the refractive shift that an eventual huge pupil can induce. Modern autorefractors will measure this automatically if you do the test in reduced light conditions.

Remember that young patients, and not only children, can benefit from refraction in cycloplegia.

When giving feedback about referral quality from optometrists, ophthalmologists often mention that they prefer to get them from us instead of the GP’s because we are more precise and have refraction and VA.

Binocular testing
This text doesn’t cover which tests to perform when there are symptoms or indications of binocular problems. As I see it, every vision exam should include the test below, even if there are no symptoms of binocular vision:

• Cover test at a distance and near
• Convergence near point
• Motility by pen torch

These three are fast to perform and give a lot of relevant information for the choice of products on how to correct refractive errors.

Eye health
Eye health is tricky to define as optometrists need an extensive battery of tests to evaluate our patient’s eye health. The list below is what I consider the minimum set of tests. Add other tests if you suspect diseases. Again, it’s about the right tools for the right problem, but you should perform a core of tests every time:

• Structured capturing of risk factors for eye conditions
• Pupillary testing using a pen torch
• Visual field screening for new patients – can be confrontation testing like Donders
• Visual inspection of the eye front to back by images and screening by slit lamp

Remember that when you see a finding on eye images, you’ll need to examine it in 3D. Using a +90 or similar together with a slit lamp is the gold standard. Yes, OCT gives 3D images, which is good and, in some cases, better than manual use of +90. Still, colours and shadings are not the same as with +90. OCT is black and white (or with artificial colours). Fundus cameras that use laser scanning show you artificial colours as well. You need to know all errors in the technology you are using to know precisely what you are doing.

Which tests can be delegated?

What tasks you can delegate varies in every country. You might find a discrepancy between what national and general laws say about delegating tasks in healthcare versus what national optometry regulations say. Again, make sure what is valid for your market. If there is reason to disagree, the optometry organisations should pick it up. Remember that WHO is clear that more delegated work is needed in healthcare.

The practical impact on delegations within optometry can – and will – be diverse because of different national market regulations. However, below are some areas for your reflection.

Can we delegate:

• Mapping of symptoms and risk factors for eye diseases?
• Performing subjective best refractions and visual acuity?
• Imaging the eye?
• Informing about correction options?
• Taking care of contact lens handling and fitting, if an optometrist supervises it?

To move forward in delegating tasks, we need a good reason to do it. As I see, the primary reasons are a lack of optometrists and more effective use of resources. Delegating more will mean that optometrists can let go of some repetitive tasks, making it more attractive to be an optometrist.

Conclusion

Remember that you must rely on evidence-based methods when using a problem-orientated approach. It means you should choose the right tests for the right problem. Always consult the national and association optometry guidelines but don’t let them decide which tests to perform. Instead, you should select the tests based on a case-to-case basis. However, a standard set of tests helps detect certain diseases or developments such as glaucoma at an early stage – even if the patient currently has no apparent symptoms. A time-efficient eye examination balances these basic tests and tests targeted at the presenting symptoms.