The Routine Eye Examination

B2 The routine eye examination

Guideline

B2.01 The optometrist has a duty to carry out whatever tests are necessary to determine the patient’s needs for vision care as to both sight and health. The exact format and content will be determined by both the practitioner’s professional judgement and the minimum legal requirements. B2.02 The optometrist has a duty to examine patients at the most appropriate intervals in accordance with clinical needs.

Advice

General

B2.03 It is for the practitioner to satisfy him/herself that procedures are included or excluded according to the patient’s clinical need. B2.04 A full examination should include: (a) Full and accurate collation of patient details. To include name, address, other relevant contact details, date of birth, and relevant details of visual needs, whether occupational, recreational or general (e.g. driving); (b) Note of reasons for visit, description of onset, character and duration of symptoms, if any, and findings of all tests undertaken; (c) History: to include any relevant personal or family history of an ocular or general health nature and any medication the patient is taking. Where possible, the patient should be asked to bring details of medication and dosage. Details of previous optical prescription and date of last eye examination or sight test (best estimate if date not known); (d) The determination of the aided and/or unaided vision of each eye (aided vision should be accompanied by the specific prescription used); (e) Assessment of habitual ocular muscle balance; (f) An internal and external examination of the eye (note the requirements of a statutory sight test – see s.B2.19 below). As a minimum this will include direct ophthalmoscopy on the undilated eye. Pupil dilation and/or the use of indirect methods will be appropriate in certain circumstances where an inadequate view of the fundus would otherwise be obtained. Slit-lamp biomicroscopy will be appropriate where a detailed view of the anterior...