The examination of the eyes

The examination of the eyes, how and where

The most effective therapeutic strategy is one that is based on prevention; For this reason, the best way to avoid eye problems is to carry out an ophthalmological examination on a regular basis. There are multiple disorders that can cause irreversible vision loss, which can be detected with a simple review, before the pathological process begins. Hence, the importance of reviews as a form of prevention.

The ophthalmological reviews aim to:

• Detect diseases in early stages where treatment is still possible.
• Correct or adapt the vision when it is discovered that it is abnormal.
• Reduce Eye fatigue in daily activities.
• Make sure that the visual acuity be the best possible.

Who should perform the eye check?

The examination of the eyes should be carried out optical optometrist or an ophthalmologist. In the first case, it is a diploma in optics and optometry, trained to carry out an examination of the optical conditions of the eyes, as well as to prescribe optical correction through glasses or contact lenses. The ophthalmologist is a graduate in medicine and surgery who has subsequently specialized in Ophthalmology, so is the only one qualified for the diagnosis and final treatment of eye diseases, both with drugs and with interventions through laser or other types of surgery.

Currently, the training of an optician also allows him to carry out a series of diagnostic tests to reveal the presence of certain eye diseases. For example, through the measurement and analysis of the campor visual can be detected glaucoma. Or through a corneal topography the keratoconus. For this reason, we consider that the activity of the optician is the ideal complement for the ophthalmologist, never a substitute for him.

The ophthalmologist and the optician must work together to advise patients on eye problems, revealing possible diseases and treating them when necessary. Their collaboration and work must be in accordance with the degree of competence of each one.

How often should an ophthalmological examination be performed?

The frequency with which eye exams should be performed depends on various factors, including: age, sex, family history of eye diseases, history of trauma or other diseases, both ocular and systemic. Although there is no universal standard, organizations such as the American Academy of Ophthalmology, make the following recommendations.

Children and adolescents

1. The first exam should be done between birth and three months. This first check-up is usually carried out by the pediatrician and in it the intervention of the pediatric ophthalmologist, if they exist visual family problems that may have a hereditary base.
2. Between 6 months and a year, an examination is recommended that should already be carried out by the ophthalmologist. This test will be repeated:
3. To the 3 years.
4. To the 5 years.

It is recommended that children and adolescents undergo check-ups whenever there is a risk situation, diseases such as diabetes, or whenever there is a problem that affects or may affect the eyes.

Adults

It is recommended that all wearers of glasses or contact lenses carry out annual check-ups, while individuals who do not have a family history or suffer from eye problems should follow a schedule of:

• At least one review between the 20 and the 39 years
• Each 2 or 4 years between the 40 and the 64 years
• Annual review after the 65 years

With age, the frequency of check-ups should be increased since the incidence of serious illnesses increases progressively: glaucoma, Cataracts, macular degenerations.

As a general recommendation, it is established that in case of any symptom that affects the eyes, especially those that are accompanied by blurred vision, see the ophthalmologist, even if the last revision is recent.

La sudden loss of vision, totally or partially, supposes an emergency situation that requires an immediate visit to an ophthalmologist.

There are situations in which the recommended review schedule may vary. It will be, then, the ophthalmologist who will mark the frequency of the controls and the situations that may involve an emergency.

Consult your ophthalmologist in any of the following situations:

• Personal or family history of eye diseases
• Old ocular trauma
• Systemic diseases such as diabetes, Hypertension, heart disease or acquired immunodeficiency syndrome.
• Premature birth
• Black breed (increased risk of glaucoma)

What is an ophthalmological examination?

The ophthalmological examination includes making a history based on specific questions and a series of tests to analyze vision and the functioning of the different structures that make up the eyes.

None of the diagnostic tests included in an ophthalmological examination generates pain or important problems of discomfort, only the study of the fundus of the eye is unpleasant when dilation of the eye is required. pupil. Currently this examination can be performed without the need to apply mydriatic drops but, on certain occasions if it is convenient, in these cases It is recommended to go to the ophthalmologist accompanied by another person or to avoid driving after the check-up, for at least 2 to 4 hours, as blurred vision occurs.

At the present time, Ophthalmology has become a highly technical specialty. Therefore, in the review performed by the ophthalmologist, in addition to the clinical history, it should not be surprising that we perform a series of tests with various devices. But we must be cautious in this circumstance, because it is necessary to take into account that the devices, by themselves, do not establish the diagnosis or cure and, not by the mere fact that a center carries out more tests, that center will be better than others.

The ophthalmologist is the one who decides what tests should be performed to help the diagnosis and it will be his global assessment, together with the interpretation of the values ​​obtained, that will bring us closer to the final diagnosis. As bad is the abuse of evidence as the lack of it.

So that the reader has at hand a measure of the demands of an ophthalmological examination, we give the following indications, always considering that the process depends on the diagnosis and the final treatment, especially when it is surgical, in which case, it will be necessary to carry out a series of complementary explorations that escape from what is, essentially, an ophthalmological examination.

The preparation of the clinical history may involve a series of questions. The most frequent are:

• What is the reason for the consultation, do you have any eye problems?
• Have you had any eye problems in the past?
• Do you use glasses or contact lenses and if so, do you feel good about them?
• What diseases have you suffered in recent years?
• Are you taking any medication? Which one?
• Do you have any allergies to medications, food or any other type of allergy?
• Does any member of your family suffer from eye problems such as Cataracts or glaucoma?
• Does any member of your family suffer from general diseases such as diabetes, high blood pressure, or others?

Visual acuity

The measurement of visual acuity is the test that will reveal the quantitative vision of that person, that is, how much they see, something that should not be confused with how they see or qualitative vision, which is explored with other methods. The test is performed by asking us to read some letters or figures (optotypes) that are placed at a certain distance (5 meters) or by adjusting this with the optics of the measuring devices.

The figures have a size that varies according to a predetermined scale, generally logarithmic. Practically, the smallest letters correspond to an angular vision of 1 minute, which is the maximum vision that the human eye has (although some people may slightly exceed it). It is represented with the notation of 1 (unit) or 10/10 (decimal scale used in Europe, although there are other scales and nominations).

Schematic study visual acuity

In the same way, the examination is carried out to measure near vision. A cardboard with figures or letters, of decreasing size, is used, which allows to quantify the vision. Unit vision notation means 100% vision at 33 cm. away from the eyes.

Measurement of refraction

Under normal conditions, the eye that sees the unit (100% vision), is characterized by the light that comes from the outside converges on the retina in a timely manner, which explains why objects look clear and defined. When this does not happen, it is because the rays converge in front of the retina (myopia), or behind (farsightedness), it will look blurry. There are methods that allow knowing the distance between the point of convergence of light rays and the retina. This information makes it possible to determine the refraction of that eye and act by prescribing the appropriate optical correction.

To check if the graduation obtained in the calculations made after the examination is correct, special glasses or trial frames are usually used, in which the corrective lenses are placed and it is checked if the applied correction allows to see correctly. With the data from the examination and its subsequent verification, it is now possible to establish the prescription of glasses or contact lenses with certainty.

The measure is expressed in a numerical value whose unit is the diopter.

Biomicroscopy

We can easily observe the small structures of the eye with a device known as slit lamp, which consists of a binocular microscope, with a beam of light whose thickness can be modified until it becomes a fine slit and, by changing the inclination or angle of projection of this beam, we penetrate the eye through its transparent media.

With this instrument, we can observe the cornea and conjunctiva, we can see details of the Eyelids, of the pupil, of iris, the chamber angle and even inside the eye, of the retina, with the help of a special lens.

Photo Biomicroscopy with slit lamp

Tonometry

In this test that measures the Intraocular pressure. This test is essential for the prevention and control of glaucoma. Goldman had the brilliant idea of ​​establishing a mathematical relationship between the pressure that we must apply on a cone that is applied to the eye, specifically on the cornea, to flatten a surface of known area. In a very simple and fast way, we obtain data of great importance since it allows us to detect increases in pressure and reveal a possible diagnosis of glaucoma. Let us not forget that it is a disease that does not produce other clinical signs that alert the patient, except in advanced stages when the loss of vision, irreversibly.

Normal intraocular pressure values ​​are considered to range between 14 and 20 mmHg, being 16 mmHg the average value of the normal population, which does not mean that higher or lower values ​​cannot be normal, just as values ​​lower than 20 mmHg can be abnormal. It is what we know as alpha and beta error in statistical data distributions. This means that, as almost always happens in medicine, a single isolated data is usually not enough to establish a diagnosis, but the complement of other tests is necessary to reach the final diagnosis through the global evaluation of all the information we have.

Usually the Tonometer of Goldman but currently more sophisticated systems are being imposed in which it is no longer necessary to touch the eye and where the biomechanics of the eye are taken into account, essential to minimize the errors that appeared in a high proportion in the hyperopic or high myopic , are the ORA systems.

Eye fundus

The exam of fundus It is one of the most important tests of the ophthalmological examination. We have seen that the retina is the innermost layer of the eye's walls, and in turn the most important; since in it there is the conversion of the light stimulus that comes from the outside, into an electrical stimulus that will be sent to the brain, so that it is there where the visual sensation is produced. In fact, the retina is part of the brain, so any injury to this area is of great importance. On the other hand, the examination of the fundus of the eye is the only examination that allows a direct view of the microcirculation. For this reason, lesions that affect the blood vessels of the eye can be easily detected by observing the fundus of the eye, in addition, with this test, we can glimpse other possible problems; because what appears on the retina may be happening in other areas of the body where there is also a microcirculation, such as in the brain, heart or kidney.

It is possible that your internist doctor sometimes asks you for an examination of the fundus, to be able to assess what is happening in your body, in the small blood vessels. The possibility of observing the fundus is like peering through a small window into your body, revealing secrets that can help detect a disease in its inception and obtain better control of its evolution. It is especially useful in cases of diabetes, systemic hypertension or degenerative processes.

Dr. Carlos Vergés

Eye fund photo

The examination of the fundus is performed by an instrument known as ophthalmoscope, currently very sophisticated thanks to technological advances in optics and image analysis. There are equipment that allows the recording of high precision images that reveal small details that help diagnose both strictly ocular and systemic problems (of a general nature). In most cases, this test can be performed without the help of drugs, but when we want to cover the entire fundus, it will be necessary to dilate the pupil by instilling drops (mydriatics). This produces blurred vision, which should be advised to patients. In the previous visit, they should be explained what the test will be and recommend that they come accompanied or not driving vehicles.

Campimetry

We name campor visual to the area of ​​space that we can see in front of us without moving our eyes. We can determine this area and its characteristics using the campimetry. This test is not routinely performed and consists of placing the head in a dome where the patient is asked to gaze, with each eye separately, at a central light point. Without looking away from this central point, the patient must try to detect luminous points that appear on the periphery, with different sizes and intensities.

If they exist alterations in the retina or in the optic pathway, including the visual cortex, will become apparent, appearing as black spots which, depending on their location, intensity and size, help specialists to establish a diagnosis of diseases such as glaucoma, retinal hemorrhages, optic neuritis (inflammation of the optic nerve), or compression of the optic pathway by tumor lesions.

Interpretation of the examination and preparation of the medical report

The data obtained in the clinical history and in the examinations carried out must be evaluated by an ophthalmologist. The ophthalmologist is a doctor specialized in the visual apparatus, both in its optical and physiological and pathological aspects; thus, is the only one trained to guide the final diagnosis. Only he will be able to report what is happening in his eyes, as well as establish the most appropriate therapeutic regimen to solve his problem.

The ophthalmologist is obliged to transmit, in a clear and intelligible way, everything that he considers the patient should know about his illness, as well as answering the questions that are asked, in order to clarify doubts and ensure that he understands better what is wrong with you and your treatment possibilities. The ophthalmologist must respect the dignity of the patient as a person, as well as his freedom to make decisions.

In the same way, the patient is obliged not to hide information about their illness or pathological history, their own or that of their relatives.

When these principles are respected and a relationship of trust is established, which is reflected in the signing of the informed consent, the proposed treatment can be established.

What is informed consent?

The doctor-patient relationship has led to contractual aspects. This is due to the fact that not only is a relationship of trust established with the physician, but also a relationship subject to a service contract, with conditions and regulations that leave no doubt about their terms, responsibilities, etc. All this is reflected in writing so that both parties have an objective means where the action process is recorded and, basically, the information issued about the problem presented by the patient and the method proposed by the ophthalmologist to try to solve that process.

The document that tries to collect and capture these aspects is called "informed consent" In it, it is specified that the doctor, in this case the ophthalmologist, has explained in a clear and understandable way the disease that the patient suffers, with the diagnosis that has arrived following the methods or tests currently proposed by the international scientific community. , as well as it must appear in this document, that the doctor has informed him about the therapeutic measures that are available at that moment, the different alternatives, with their advantages, disadvantages and risks and the therapy that has advised him based on his reality.

In this document, the information provided can be included, although Spanish legislation does not require it. Yes it is necessary to specify the most common and the most serious risks that may appear with the proposed therapeutic technique. Once the patient and the doctor reach an agreement to implement the proposed therapy, the document is signed by the doctor and the patient, or a legal representative of the latter, in cases where he or she is not of legal age or has any type of disability that prevents you from understanding and accepting the ophthalmologist's proposal.

Informed consent tries to clarify and ensure that the patient receives the correct information for decision making; however, this wording is often confused with a results contract, something totally different. The objective of this document is to ensure that the ophthalmologist will carry out his activity, both diagnostic and therapeutic, following the protocols proposed by the official scientific bodies dedicated to this purpose, reporting the chances of success and the risks of each process and finally, assuming the patient's decisions.

At no time, the ophthalmologist can ensure a type of result. Thus, it is advisable to flee from centers or specialists that "ensure fantastic results", for life, etc., because this is a fatuous compromise. The scientific community establishes which arguments are completely reprehensible and tries to make whoever emits them take responsibility for them. For this reason, in any case, if someone assures you of that degree of success, you should require them to specify it in the informed consent. This is the best way to unmask fatuous promises.

Where to get an eye exam?

We live in a society where professional competence is increasingly intense, a phenomenon that has great advantages but, at the same time, serious disadvantages. An important negative aspect is the need to make the differences explicit, to "capture" more patients or, applying economistic terms, achieve higher market value. This need leads to better prices and to promise superior results compared to other centers.

With regard to medicine and in our case to ophthalmology, we can see how the press and all the media are loaded with advertisements and advertorials in which information appears about centers that increasingly offer "more for less" . These arguments could be very positive if what is offered were always true, adjusting to compliance with appropriate quality and professional ethics criteria.

This does not mean, in any way, that everyone who advertises and discloses his offer of services enters into the dynamics of deception; but due to strong competition, in many cases, what is promised is not always fulfilled and, above all, the quality of the service offered is not always ideal.

But, this problem is not exclusive to ophthalmology, but affects all of medicine. Medical activity has reached a degree of sophistication and the need for high technology that has made all diagnostic and therapeutic processes more expensive.

This situation is aggravated by the legislative requirements, which generate that, although the doctor considers that he has already reached a diagnosis, in many occasions, he requests to carry out a greater number of tests due to the need to "cover" himself before a possible demand; before the possibility that a judge may recriminate you not having requested a certain type of analysis or diagnostic tests.

These circumstances lead to an increase in the cost of medicine. The problem lies in who should defray that cost. Politicians have promised a "welfare society", in which the health of the population is included as a public benefit. However, public health can not assume this high cost and, in many cases, lacks adequate technologies due to lack of investment and can not provide high-level medical assistance. In front of it, private centers are located, which try to compete by providing "cutting edge" technology, assuming a strong economic investment that, in many cases, generates a "price war", due to the need to gain a greater percentage of the population. But, unfortunately, this premise is usually accompanied by another, which is to reduce the cost and quality of services to maintain those prices.

Thus, what was initially intended, that private management could lower costs through better management of resources, eliminating part of the bureaucracy of public assistance, in the end it has been seen that "a better price" is usually accompanied by a reduction in the quality of the service, especially with regard to human personnel and their level of competence.

But, it is not the objective of this manual to carry out an analysis of the current health situation in our country, so we will limit ourselves to establishing some practical guide, so that the user of this health network can have an approximate idea of ​​when to choose the center that offers the best guarantees.

How to correctly choose the center and the right surgeon

We have just seen the difficulty in establishing guidelines for the correct choice, because there are many factors that influence the final result of an ophthalmological treatment, from the doctor-patient relationship, ease of access to the center and to the doctor, degree from the professional and human quality of the attached staff, to the management of the center and the level of technology that it has.

We consider that a first practical measure is to select centers that have a guaranteed track record and solvency for the time. A second aspect is to find out if they enjoy some kind of accreditation in quality regulations. Currently, the majority of companies that pride themselves on a certain degree of credibility, are accredited with international quality standards such as ISO. This type of accreditation guarantees that what has been said is done. If this is accompanied by the acquisition of protocols recommended by WHO, such as the Good Clinical Practices, we are already at a level of excellence that offers guarantees in the medical service that is being offered. The centers with this type of accreditation allow to establish a fast and very effective difference with respect to those centers that do not have any official accreditation.

To serve as an example, we transcribe the guidelines recommended by the Mayo Clinic (Rochester, USA), an institution of recognized solvency, to select a center for refractive surgery:

Select the center not guided by the campadvertisements, but because the chosen center or professional is known, either directly by the interested party or by someone who has given him references about his personal experience and the solvency acquired over the years.

After the exploration that you have carried out, you should ask the surgeon a series of questions:

• How long have you been performing this type of surgery? He should answer that his experience is calculated in years and not in months).
• How often do you perform these interventions? The doctor should answer that with a weekly frequency and with a number that exceeds several hundred each year).
• What are the results obtained, percentage of cases with 100% vision after surgery, without glasses, and percentage of patients with vision greater than 50%? A good surgeon must
  place their percentages in 70% of cases with vision greater than 0.7, and 90% with vision greater than 0.5).
• How many cases should be portrayed? An acceptable percentage is between 5 and 15%.
• You should also ask about the risks and possible complications of the proposed therapy. And this answer is crucial, because: a surgeon who guarantees him an optimal result and who assures him that he will never need glasses or contact lenses and who affirms that his complication rate is insignificant, is a surgeon who does not give him real arguments . And this one does not suit you, look for another.

This type of surgery involves risks and complications, different in each case. And they can't refuse. The correct thing is to present the real situation and discuss the risk-benefit balance and how to deal with possible complications..

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Address: Edifici Jardi 0 Plant, Gran Via de Carles III, 71, 08028 Barcelona
Email: [email protected]

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