used with local anaesthetic and a cushioning fluid between the lens and the eye. Explain that they may feel some pressure from the lens and will likely feel the lens on the eyelid, but will feel no discomfort with the instillation of anaesthetic. Obtain informed consent and dilate the patient’s pupils (section 6.17).

2.Having determined the anterior-to-posterior positioning of the lesion to be evaluated, choose the mirror most likely to detect the lesion; that is, for a lesion at the ora serrata, use the thumbnail mirror; for a lesion in the peripheral retina, use the rectangular mirror; and for the midperiphery or equatorial fundus, use the trapezoidal mirror.

3.Prepare the patient at the slit-lamp and prepare the lens for insertion. Apply the lens to the eye (see section 6.13.3). Usually, the patient can maintain a primary gaze position for the examination of most areas of the fundus.

4.Rotate the lens such that the chosen mirror is positioned 180° from the lesion. To examine the posterior pole, use the central contact lens.

5.With the biomicroscope in a ‘full-back’ position, direct the slit-lamp light into the mirror of choice. Move the slit-lamp forward until the fundus is in focus, then rotate and tilt the lens to locate the lesion. If the lesion is more posterior to that portion of

the fundus which is being viewed, tilt the lens away from the mirror; if more anterior (i.e. more peripheral), tilt the lens towards the mirror.

6.Once the lesion has been fully examined, remove the lens as indicated in section 6.13.3.

6.24.4 Recording

See sections 6.19.5 and 6.22.4. The fundus image viewed through the mirrors in the lens is a virtual and erect but reversed image. Record all observations.

6.24.5 Interpretation

See sections 6.4, 6.5 and 6.22.5. Subtle findings can be revealed with the different view afforded by the different light path and viewing with this lens.

6.24.6 Most common errors

1.Misinterpreting the location of the lesion to be examined. This is facilitated with scanning in the mirrors with rotation and tilting of

the lens.

2.Using too little solution in the lens, causing bubbles behind the lens, limiting the view of the fundus.

3.Recording the location or dimension of the defect inappropriately. It is more difficult to compare defects with the size of the disc than with methods that can view all structures simultaneously or with the same lens/ mirror.

6.25 DIGITAL IMAGING

A brief mention should be made of new imaging technologies. Imaging of the anterior eye, optic disc and fundus is becoming increasingly common in primary and secondary eye care. For fundus assessment, modern digital fundus cameras can produce a 2-D photograph of the posterior pole of the fundus through an undilated pupil (view the photographs in sections 6.4 and 6.5, which were virtually all taken through non-dilated pupils) and allow a significantly superior assessment compared to direct ophthalmoscopy and similar to that provided by a dilated fundus examination (Chow et al. 2006). It should be noted that 2-D fundus images provide slightly smaller assessments of cup-to-disc ratio than fundus biomicroscopy, although the reliability of assessments is similar (Hrynchak et al. 2003). The advantages that are brought about by using digital imaging are the speed with which the images can be examined (which mean that images can be examined immediately and a repeat photograph taken if necessary) and the ability to archive the images in an efficient, longlasting and flexible fashion using a computer. The images can be shown to patients and can even be

printed out and given to the patient. Computer manipulation also allows for the easy enhancement of images and automated measurements of diagnostic features within images. Finally, transmission of digital images through computer networks introduces the possibility of ‘teleophthalmology’, where the expert diagnostician is remote from the patient. With increasing technology and more widespread use, the quality of the images and storage facilities is improving while the cost is decreasing. Optic disc imaging techniques, such as scanning laser tomography with the Heidelberg Retina Tomograph (HRT) II, provides repeatable, objective and quantitative three-dimensional imaging of the optic nerve, that is particularly useful for individualised analysis of change or progression of the neural retinal rim and/or optic cup (Flanagan 2001).

6.26 THE PROBLEM–PLAN LIST

The problem–plan list is a system for recording a patient’s diagnoses and the management plan for each diagnosis. If a diagnosis cannot be made, then the patient’s problems (i.e. symptoms and/or signs) should be listed and a list of the further investigations required to attempt to obtain a diagnosis should be listed in the plan section.

6.26.1 Recording diagnoses and management plans

It is important to record a summary of your diagnoses and suggestions to the patient. This is useful for several reasons:

1.It is important legally to document all your diagnoses, treatment suggestions, suggestions of referral, etc. Similarly, it provides valuable support when dealing with patients who return with complaints that you failed to provide advice regarding the management of a certain condition.

2.It ensures that you must review the case history and discuss each of the patient’s symptoms.

3.It ensures that you must review the record card and deal with any significant findings.

4.In subsequent examinations of the same patient, a review of the problem–plan list provides a thorough and complete summary of the examination without having to read the whole record card.

6.26.2 Advantages and disadvantages

The problem–plan list appears to be the only formal procedure that has been described to document a patient’s diagnoses, treatment suggestions, further investigations necessary, comments made to the patient, etc. The problem–plan list is part of the problem-oriented examination.

6.26.3 Procedure

1.List each separate diagnosis in a column. Do not list the individual symptoms and signs that allowed the diagnosis. Order diagnoses with the most important first.

2.If a patient has symptoms for which no diagnosis has been made, include the symptoms in the problem list. Similarly, include any abnormal signs or test results for which a diagnosis was not yet possible in the problem list. By this method, any problems you do not immediately understand are highlighted and this prompts the consideration of further investigation.

3.For each problem, outline a plan or a series of actions to be taken in an adjoining column. Consider including the following forms of plan:

a)Treatment plans.

b)Further diagnostic procedures required.

c)Counselling provided.

4.Counselling is a fundamental element in patient management. Effective counselling requires that all diagnostic and therapeutic plans be clearly stated to the patient in terminology that they can easily understand.

6.26.4 Recording

Examples of problem–plan lists are provided in Table 6.5.

6.26.5 Most common errors

1.Listing signs and symptoms rather than diagnoses, when diagnoses are possible.

2.Ignoring and not listing an unexplained symptom.

3.Not providing a complete plan list for a given problem. For example, the treatment may be identified but not the counselling or vice versa.

6.27 PERSONAL LETTER OF

REFERRAL OR REPORT

This is a referral letter or report written on headed notepaper that includes your practice address and contact information.

6.27.1 Referral letters and reports

Letters of referral to medical personnel or specialist clinicians are required to provide information regarding the reason and urgency of referral. Reports may be required to a referring colleague, teacher, general physician, etc. The categories of patients that require a report may be covered by legal or contractual obligations.

6.27.2 Advantages and disadvantages

in. Form letters can save time and if well designed may reduce the possibility of the omission of pertinent information. However, they are somewhat impersonal and restrictive and can lead to the inclusion of irrelevant information. Form letters can even lead to vital information being left off the referral, such as the optometrist’s name and even the practice address (Lash 2003). Well-written referral letters are important to help develop a good relationship with secondary eye care personnel and increase the likelihood of feedback being obtained regarding referrals. A lack of feedback appears to be a significant problem in some areas (Steele et al. 2006), and without it the optometrist cannot learn from the process and improve the quality and appropriateness of referrals.

6.27.3 Procedure

1.Indicate to the patient that you will be sending a referral letter/report to another person or office. You should inform them of the reason for the referral or report.

2.Write the letter on headed notepaper that includes your practice address and contact information. The letter should ideally not be hand written, as this will make it less legible.

3.Include the date and the recipient’s name and address at the top of the letter.

The alternative to a personal letter is a form letter, with a standardised format and various boxes to fill

4.Begin the letter with the patient’s name, address, date of birth (you may need to distinguish between several people with the

same name and even between two people with the same name and address), appointment date and file number

(if applicable).

5.Remember that the person you are writing to is likely to be very busy, so that they want to read only essential information. Do not include information that is irrelevant to the referral as this could result in your letter not being read or being skim-read and misinterpreted.

6.A likely outline of a referral letter would be:

a)Indicate the relevant symptoms and signs.

b)Provide a diagnosis or tentative diagnosis if possible.

c)Indicate if there is any urgency in the referral.

d)If appropriate, you might indicate what further investigations or treatment you believe to be necessary.

e)Request a reply regarding the outcome of the referral. This may require the patient’s written consent.

f)Indicate if you have copied the letter elsewhere (typically to the patient’s general physician).

7.If referring a patient because of cataract (the most common referral letter, see Box 6.4) also include:

a)The effect of reduced vision on the patient’s lifestyle.

b)Their willingness to undertake surgery.

c)If a patient with cataract is at high risk of falling, this information could also be included as cataract surgery appears to reduce the risk of falls (Buckley & Elliott 2006).

8.A likely outline of a report would be:

a)Thank the referring person (if applicable).

b)Indicate the relevant symptoms and signs.

c)Provide a diagnosis or tentative diagnosis if possible.

d)If a diagnosis is not possible, indicate which tests were performed and any pertinent results.

e)Indicate any management plan and the time of your intended follow-up appointment.

9.Make sure your spelling is accurate and grammar correct. Spelling and grammar checkers are available on all modern word processing packages.

10.Present the information at a level suitable to the recipient’s knowledge. However, do not automatically assume that lay terms are appropriate in a letter to a non-medical person. It may be best to use the correct term with the lay term in

brackets to avoid offence. For example, in a letter to a teacher, you may include a statement that ‘David has myopia (shortsightedness). . .’

11.Sign the letter with your preferred title and qualifications.

12.Keep a copy of the letter for the patient’s file. If the letter or report was not to the patient’s GP, you may be required to send them a copy. If it is not a requirement, it is usually good practice to do so.

6.27.4Recording

The style and content of referral letters and reports is likely to vary widely in different countries and areas within a country and because of a variety of other factors. Given this proviso, examples of a referral letter and report are given below (Boxes 6.4 and 6.5).

6.27.5 Most common errors

1.In a referral of a patient with cataract, failing to include information regarding the effect on a patient’s lifestyle and their willingness to undertake surgery (Lash 2003).

2.Not including the patient’s written consent for release of medical information back to you (Lash 2003).