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«Primary Eye Care and Training Manual Summary reaching out to people and programs near and far to promote healthy eyes and clear vision for all ...»

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Interprofessional Fostering of Ophthalmic Care for Underserved Sectors

a non-profit organization promoting “eye care for all"

Primary Eye Care and Training Manual Summary

reaching out to

people and

programs near

and far to

promote healthy

eyes and

clear vision

for all

Primary Eye Care

Primary eye care is considered the “first encounter” with eye care. Often, the only eye care offered to many

people in poor and rural communities is a vision screen. About one billion people need an eye exam but do not have access to an eye care provider.

The Need for Eyeglasses One of the most widespread eye problems is simply the need for eyeglasses. At least 900 million people in the world today need a correction for visual refractive errors (i.e., need eyeglasses). However, many are unable to obtain a prescription because of geographic or financial barriers. Despite abundant good will on the part of eye care professionals and medical institutions to reach out beyond their usual service areas to individuals and populations in need, only a tiny fraction of the need is being met.

Uses for This Manual

Primary Eye Care Assessment:

1. Measuring visual acuity, screening for binocular dysfunction and color vision problems;

2. Determining which patients have refractive errors and need eyeglasses;

3. Recognizing symptoms of eye diseases;

4. Promoting eye health How the Eye Works Your eyes and brain work together to make it possible for you to see. Light is reflected from objects onto the front surface of your eye, the cornea. The cornea bends the light, which then passes through fluid called the aqueous humor, through the pupil, and to the lens. The lens, which can change its shape, helps to focus light onto the retina at the back of the eye. On the retina, light forms an upside-down image on the cones and rods, the light sensitive receptors in the eye. The cones and rods send images to the brain via the optic nerve.

Shortly after leaving the eye, the optic nerves from each eye cross and separate, sending their fibers to receiving and analytical stations in the brain. In effect, the brain receives messages from both eyes. Besides interpreting the visual input, if movement of both eyes is coordinated, the brain fuses images from each eye together to form one three-dimensional image.

Common Sight Problems

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*When compound lenses are not available, then spherical lenses may be substituted which contain an additional correction beyond the amount required to correct the patient’s nearsightedness.

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Benefits Address health problems  Early detection of eye conditions which are treatable if addressed in time. Ex. Amblyopia, also called lazy eye, can be treated up to the age of six.

 Early detection of other health conditions of which the patient may not be aware. Ex. Diabetes and Glaucoma. Although there are no cures for these conditions at present, the patient can take steps to prevent blindness by adopting a regimen of medication and other strategies in partnership with medical personnel.

 For chronic conditions involving either the eye or general health, the exam provides patient with feedback, support, and treatment, if applicable, for managing the condition.

Provide clear vision using corrective lenses

 Refractive errors –Exams are used to measure the patient’s refractive errors and, if needed, to prescribe the lenses required to correct blurred vision. Refractive errors are not due to disease but rather the shape and size of the eyeball.

 Presbyopia –Exams are used to detect if the patient’s ability to see objects up close is decreasing.

Presbyopia is common starting around age 40. When corrective lenses for Presbyopia are combined with corrective lenses for farsightedness, the glasses are called bifocals.

Learn how to ensure eye health and safety  Learn strategies that protect the eyes such as good nutrition, good hygiene, protection from UV rays, and injury prevention.

Vision Assessment Protocol for Primary Eye Care Examination*

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Visual Acuity Charts  Use standardized charts to measure visual acuity. Two charts commonly used to measure distance vision are the Snellen chart and the Tumbling E chart shown below.

 Visual acuity is measured in terms of the “Snellen Fraction” named for the physiologist who invented it.

The fraction “20/20” denotes normal or average vision.

 The number above the dividing line represents the testing distance of 20 feet (equivalent to 6 meters)  The number below the dividing line indicates the number of feet at which a line of letters can be seen by persons with normal vision.

Example: Individual has 20/40 visual acuity. Individual was tested at 20 feet from chart however the smallest line of letters he/she could read was the line marked 40. Persons with normal vision could read that same line at 40 feet.

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Steps: 1. Test right eye first. Cover left eye with occluder. Be sure that patient is using only the right eye.

2. Test vision by starting with the largest letters first. Proceed down the chart to the smallest letters the patient can see. It is advisable to skip lines so as to identify the smallest line that the patient can read.

3. Record the smallest line in which the patient can see at least half of the letters. See Record section below.

4. Repeat the test with the left eye.

5. Repeat the test with patient wearing his/her corrective lenses.

6. If patient cannot see largest letters, then follow the procedure in Notes section.

Interpretation of Test Results:  Normal Vision: 20/30 or better*  Subnormal Vision: worse than 20/30  Blindness: 20/400 or less *Patient may benefit from glasses, if available. 20/30 or better is an “acceptable” level of visual acuity but with the proper resources vision may still be improved.


If the patient cannot read the largest letters, then use the following test sequence. Failure at one level of the test requires testing at the next level.

1. Ask the patient to walk toward the chart and report when the largest letter is legible. The distance from the chart would be the number of the acuity fraction, i.e. 3/400.

2. The patient is seated and asked to count the examiner’s hand. Record as “finger counting at 3 feet.”

3. Ask the patient to tell whether the examiner’s hand is moving or still. Record as “hand movement at 3 feet.”

4. The patient is asked to indicate whether a light source is on or off. If the patient is accurate, it is recorded as “light perception”; if not, “no light perception.”


The patient’s visual acuity is measured for the right eye, left eye and both eyes. Visual acuity is recorded in one of the

following ways:

1. Smallest line patient can read at least half of the letters along with number of letters missed on that line.

Ex. 20/40 –2 --or-Smallest line patient can read completely, along with the number read correctly on that next line.

Ex. 20/20 + 2 i.e. patient can read all the letters on the 20/20 line and can also read 2 letters on the 20/15 line. So credit is given for the 2 letters read on the line below the 20/20 line.

Procedure: Measuring Near Vision

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Steps: Using Near Point Card

1. Test right eye first. Cover left eye with occluder. Be sure that patient is using only the right eye.

2. Test vision by starting with the largest letters first. Proceed down the chart to the smallest letters the patient can see. It is advisable to skip lines so as to identify the smallest line that the patient can read.

3. Record the smallest line in which the patient can see at least half of the letters.

4. Repeat the test with the left eye.

5. If patient wears corrective lenses, have patient wear glasses and repeat steps 1 – 4.

6. Record results on Patient Record form.

Using Other Targets

1. Same as above

2. Test vision by asking patient to hold target at range in which material is clear.

3. If patient reports that he/she cannot clearly see target at any range when holding the target, then record on the form that patient needs magnification lenses to see at near.

4. If patient reports that he/she can see target clearly, ask patient to demonstrate the distance(s). Record on the form the smallest line seen clearly on the Near Point card

–  –  –


Nearsighted patients will generally see better at near without glasses. Farsighted patients have difficulty seeing up close or cannot see at all up close without their glasses. Therefore, patients should be tested both with and without their glasses. Presbyopes who are also myopic may be able to see clearly at near while not wearing their prescription for distance.

Near Vision Assessment

The smallest type (4.5 pt. type) on a near point card should be seen clearly through the individual’s prescription glasses or without glasses for those with 20/20 vision, when the card is viewed at 14 inches in moderate lighting conditions. In order to see the small type clearly, older adults may need to increase the distance between the eyes and the card, or use magnification (plus power lenses). Plus lenses may be an “add” applied to the distance prescription with bifocal eyeglasses, or reading glasses may be indicated for those not needing a distance prescription.

For children, dispense the lowest power of lenses that offer the best clarity when the card is viewed at 14 inches.

This near assessment is especially important for children who are suspected to have difficulty reading or seeing up close (hyperopes). A children’s near vision card with symbols is used for those who cannot read letters or words, (Fig. A). The smallest line is equivalent to 20/30 near vision at 14 inches, which should be sufficient for good reading performance in school.

Note that children with astigmatism may also have difficulty reading small print, unless the astigmatism is corrected with cylindrical lenses.

Figure A (Example of children’s near point card. This example lacks clarity due to the photocopying process. Not intended to use with patients.) Figure B Example of Near point card (side A) Figure C Example of Near point card (side B) Not actual size Procedure: Pinhole Occluder Test

–  –  –

1. Test right eye first. Cover left eye with cardboard or cup. Ask patient to read a line on visual acuity chart such as Snellen or Tumbling ‘E’. Ask patient if his/her sight is the same through the occluder.

 If improved, then patient could probably benefit from corrective lenses.

 If not improved, then patient would not benefit from corrective lenses.

2. Test left eye.

3. Repeat steps 1 and 2 wearing corrective lenses.

4. Record results on Patient Record form.

–  –  –

1. Test right eye first. The patient is asked to look at the target, the large “E” on top line of the acuity chart at 20’ and maintain fixation with both eyes.

2. The left eye is then covered while telling the patient not to lose fixation with the uncovered (right) eye. The right eye is observed for movement.

3. Note if any movement is detected, and if possible, indicate whether the movement is consistently towards the nose, or towards the ear.

4. Test the left eye. Repeat steps 1 –3 with the right eye covered and look at possible movement in the left eye.

5. Then repeat for each eye using the near target (examiner’s nose at a distance of 3’ to 5’).

6. Any movement of either uncovered eye should be recorded on form and a referral should be made to an eye doctor for full assessment of binocular function.

7. The examiner records “pass” or “fail” on Patient’s Record form, and those who fail are referred for a complete eye exam.

–  –  –

1. The patient is asked to look at the examiner’s finger and follow the finger with both eyes without moving the head as a wide rectangle is traced through the air. For children, use a puppet.

2. The examiner watches the patient’s eyes, to ascertain that both eyes follow the finger and work together throughout the sideways and up and down movements.

3. Refer to appropriate eye professional if eyes don’t follow together.

4. The examiner records either “unrestricted” or “restricted” on Patient’s Record form.

Procedure: Screening for Limitations of Visual Field

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1. Test right eye first. Tell patient to close or cover left eye. Patient stares straight ahead to the large letter at the top of the acuity chart.

2. Examiner places one of his/her hands behind the patient’s head. With either one or two fingers showing, the examiner brings his/her hand around the side of the patient’s head to the front.

3. Patient reports when the number of fingers is visible and the number seen.

4. Examiner repeats the same movement on the other side of patient’s head. The movement is repeated two more times  over patient’s head  under patient’s head In this way, each quadrant of the patient’s potential field of vision is tested, one quadrant at a time.

5. Repeat with left eye.

6. Record any difficulties with visual field on Patient Record form. If found, refer to an eye doctor for a full assessment.

Procedure: Screening Color Vision

–  –  –


1. Patient is instructed to inspect various standardized color vision plates and respond to examiner’s questions.

2. Examiner asks the patient to say the number or letter seen.

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