Ratings of importance to the care process (A-C) and ratings of strength of evidence (I-III) are defined at the end of the "Major Recommendations" field.
History
In general, a thorough history may include the following items, although the exact composition varies with the patient's particular problems and needs.
- Demographic data [A:III] (e.g., name, date of birth, gender and where appropriate, ethnicity or race)
- The identity of the patient's other pertinent health care providers [A:III]
- Chief complaint and history of present illness [A:III]
- Present status of visual function [A:III] (e.g., patient's self-assessment of visual status, visual needs, any recent or current ocular symptoms, and use of eyeglasses or contact lenses)
- Ocular history [A:III] (e.g., prior eye disease, injuries, surgery, including refractive surgery, or other treatments and medications)
- Systemic history: pertinent medical conditions and previous surgery [A:III]
- Medications: ophthalmic and systemic medications currently used, including nutritional supplements [A:III]
- Allergies or adverse reactions to medications [A:III]
- Family history: pertinent familial ocular and systemic disease [A:III]
- Social history [B:III] (e.g., occupation, smoking history, alcohol use, family and living situation as appropriate)
- Directed review of systems [B:III]
Examination
The comprehensive eye examination consists of an evaluation of the physiologic function and the anatomic status of the eye, visual system, and its related structures. This usually includes the following elements:
- Visual acuity with current correction (the power of the present correction recorded) at distance and when appropriate at near [A:III]
- Measurement of best corrected visual acuity (with refraction when indicated) [A:III]
- External examination [A:III] (e.g., lids, lashes, and lacrimal apparatus; orbit; and pertinent facial features)
- Ocular alignment and motility [A:III]
- Pupillary function [A:III]
- Visual fields by confrontation [A:III]
- Slit-lamp biomicroscopic examination: eyelid margins and lashes, tear film, conjunctiva, sclera, cornea, anterior chamber, and assessment of peripheral anterior chamber depth, iris, lens, and anterior vitreous [A:III]
- Intraocular pressure measurement preferably with a contact application method (typically a Goldmann tonometer) [A:III]
- Examination of the fundus: vitreous, retina (including posterior pole and periphery), vasculature and optic nerve [A:III]
- Assessment of relevant aspects of patient's mental and physical status [B:III]
Examination of anterior segment structures routinely involves gross and biomicroscopic evaluation prior to and after dilation. Evaluation of structures situated posterior to the iris requires a dilated pupil. [A:III] Optimal examination of the peripheral retina requires the use of the indirect ophthalmoscope or slit-lamp fundus biomicroscopy. [A:III] Optimal examination of the macula and optic nerve requires the use of the slit-lamp biomicroscope and accessory diagnostic lenses. [A:III]
Diagnosis and Management
The ophthalmologist evaluates and integrates the findings of the comprehensive ophthalmologic examination with all aspects of the patient's health status and social situation in determining an appropriate course of action. Patients are considered in one of three general categories based on the results of the evaluation: patients with no risk factors, patients with risk factors, and patients with conditions that require intervention.
Category I: Patients with No Risk Factors
- When the initial comprehensive evaluation is normal or involves only optical abnormalities that require spectacle correction, the ophthalmologist reviews the findings with the patient and advises him/her of the appropriate interval for re-examination. [A:III]
- In the absence of symptoms or other indications following the initial comprehensive medical eye evaluation, periodic evaluations are recommended at the frequency indicated in Table 2 in the original guideline document, which takes into account the relationship between age and the risk of asymptomatic or undiagnosed disease. [A:III]
- Interim evaluations, such as screenings, refractions, or less extensive evaluations, are indicated to address episodic minor problems and complaints or for patient reassurance. [A:III]
Category II: Patients with Risk Factors
- The ophthalmologist determines an appropriate follow-up interval for each patient based on signs or risk factors, the incidence of disease, and rapidity of progression. [A:III] For example, individuals of African descent require more frequent examinations because they are at higher risk for an earlier onset, higher incidence, and more rapid progression of glaucoma. It is recommended that patients with the conditions and risk factors noted in Table 3 in the original guideline document undergo a comprehensive medical eye evaluation at the listed intervals. [A:III]
Category III: Conditions that Require Interventions
- The response of the ophthalmologist to patients that require intervention depends on the nature of the abnormal findings. For a patient with ophthalmic abnormalities, the ophthalmologist prescribes glasses, contact lenses, or other optical devices; treats with medications; arranges for additional evaluation, testing, and follow-up as appropriate; and performs nonsurgical procedures or surgical procedures including laser surgery when indicated. For a patient with non-ophthalmic abnormalities, the ophthalmologist will arrange for further evaluation or referral, as appropriate.
- The ophthalmologist must discuss with the patient the importance of the findings and the need for further evaluation, testing, or treatment. [A:III] The findings should be shared with the patient's primary care physician or other specialists, as appropriate. [A:III]
Definitions:
Ratings of Importance to Care Process:
Level A, most important
Level B, moderately important
Level C, relevant, but not critical
Ratings of Strength of Evidence:
- Level I provides strong evidence in support of the statement. The design of the study allowed the issue to be addressed, and the study was performed in the population of interest, executed in such a manner as to produce accurate and reliable data, and analyzed using appropriate statistical methods. The study produced either statistically significant results or showed no difference in results despite a design specified to have high statistical power and/or narrow confidence limits on the parameters of interest.
- Level II provides substantial evidence in support of the statement. Although the study has many of the attributes of one that provides Level I support, it lacks one or more of the components of Level I.
- Level III provides a consensus of expert opinion in the absence of evidence that meets Levels I and II.
