Patient Positioning

Before positioning the patient, check to make sure that the slit lamp stage is locked in the position farthest away from the head support unit. Also, fold the tonometer arm completely out of the way if it was left in position. If the stage is not locked, the microscope may roll forward and bash the headrest unit, jarring the delicate optics and light system. If the tonometer arm is in position when the stage is not locked, and the slit lamp then rolls forward, the tonometer could hit the patient in the face or eye. Safety first!

Explain the examination to the patient. The slit lamp may look formidable or frightening, especially to a child. Reassure the patient that this is just a fancy microscope.

Ask the patient to lean forward and place his or her chin in the chin rest and the forehead against the bar. Any movement of the mouth or chin also moves the position of the eye, which means you will be chasing ocular structures with the microscope while trying to get a good look. Tell the patient to keep his or her teeth together and to breath through the nose.

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_What the Patient Needs to Know_

• This instrument is a microscope used to magnify the structures of the eye.

• Please keep your chin in the cup with your teeth together and your forehead against the bar. Try not to lean back. The microscope comes close to your face but will not touch your eye.

• Sometimes the light is bright. Unless specifically told not to, you may blink at any time.

Adjust the height of the table and/or chair so the patient is not hunched over (table too low) or straining and stretching to reach the chin cup (table too high) (Figure 2-1A and 2-1B). If the table is too low, the patient will be uncomfortable. If the table is too high, the patient will be uncomfortable, plus he or she will tend to lean back out of the headrest. If the patient leans back, you will lose your focus. In addition, an uncomfortable patient tends to fidget. It is pretty tough to follow a tiny spot on the cornea at 40X if the patient is moving around! In most cases, the patient's back should be straight, the neck should be aligned with the back, and the patient may be leaning slightly forward over the hips. If the patient is leaning forward too much, ask him or her to slide forward a little, toward the edge of the chair seat.

Most slit lamp models have a mark or notch on the headrest bar. Adjust the height of the chin rest so that the patient's lateral canthus is aligned with the mark (Figure 2-2). When the patient is lined up properly, you will have the greatest latitude in moving the slit lamp.

Patients often do not know what to do with their hands when the table is placed over their lap. Show the patient how to grasp either side of the slit lamp table. This helps stabilize the patient (which is good for both the patient and the examiner) and the slit lamp. Sometimes the mechanisms to lock the table in place get stripped with use, and the table begins to drift even when locked. If the patient is holding the table on his or her side and you are leaning against the table on your side, such drifting can be kept to a minimum. In most cases, you should discourage the

Figure 2-2. The instrument will have full range of movement if the eye is level with the marker. (Photo by Mark Arrigoni.)

Figure 2-1A. The slit lamp is too high for the patient. (Photo by Mark Arrigoni.)

Figure 2-1B. The slit lamp is too low for the patient. (Photo by Mark Arrigoni.)

Figure 2-2. The instrument will have full range of movement if the eye is level with the marker. (Photo by Mark Arrigoni.)

patient from holding on to the sidebars of the headrest assembly. If the hands are placed too low, they might get pinched when you move the microscope forward. Some slit lamps have handles attached to the headrest unit for the patient to hold.

Patients come in different shapes and sizes, and positioning at the slit lamp may need to be modified a bit in certain cases. A large-busted woman may have difficulty leaning into the slit lamp. Once she is positioned, the slit lamp stage may not be able to move all the way forward, making

Photos Slit Lamp

focusing impossible. In this situation, you may have to forfeit ideal patient alignment. Have the patient slide back into the exam chair as far as possible, then lean forward as far as possible into the slit lamp. By positioning her at such an angle, the bustline might be distanced far enough from the table. Another alternative is to attach a clipboard to the bars of the headrest assembly (Figure 2-3). (The patient may still need to be angled into the chin rest as described above.)

Children and other short persons may be better positioned by having the patient stand for the examination. The patient may be asked to stand on the floor just in front of the exam chair (Figure 2-4). A small child might be able to sit on a parent's lap for the slit lamp exam. This is convenient because it elevates the patient to a better height, plus the child feels safer. In addition, the parent can help stabilize the child.

In addition to positioning, a few other items will make examining children easier. This is one situation where you might tell the patient to hold on to the bars of the headrest assembly. Make sure that the child places his or her hands just under the chin rest so that the microscope will not pinch the hands when the stage is pushed forward.

Patient education before examining a child should be adapted as well. Pull the instrument forward. "See this? This is a fancy microscope for looking at your eye. This little cup is where your chin goes." Unless the child has been jumping all over the exam room and trying to play with all the equipment, invite him or her to touch the headrest part of the slit lamp. "This is sort of like a motorcycle, and this part [indicate chin rest, forehead strap] is the helmet. Can you put your chin right there? Good! Lean right up here like this. That's great! Now these are like the motorcycle's handles. [Put child's hands on bars under chin rest.] Hold on right there. Wonderful! Now here come the headlights...[start the exam]...Do you see a mouse in there? No? What about a rabbit? Here comes a turn! [Move the slit lamp to the other eye.] Do you see the mouse with this eye? Maybe a cat chased it away. Do you see a cat? Ride's over. Great job!"

Figure 2-4. A short patient may be better able to reach the slit lamp when standing. (Photo by Val Sanders.)

An alternate child-patient education method is to demonstrate the use of the slit lamp on the parent before attempting to examine the child. You could allow the child to look at the parent's eye through the microscope, reinforcing the ideas: 1) this does not hurt, and 2) this is really neat. As with most testing on a child, decide before starting what information is the most important, and get that first. For example, if a child has a family history of congenital cataracts, examining the lens is the most important thing. So check the lens of each eye first. Then, if patient cooperation permits, check out the other structures. (This same strategy applies to a potentially uncooperative patient of any age.)

A wheelchair-bound patient presents another positioning difficulty. If your office does not have a wheelchair instrument stand, the best solution is to transfer the patient into the exam chair. This is not always possible. To examine a patient in a wheelchair, using a standard instrument stand, you may need to turn the exam chair so it is out of the way. If the armrests on the wheelchair come off, remove them, and the slit lamp should slide right over the patient's lap. In chairs where the armrests are not removable, the patient will have to lean forward a fair distance (Figure 2-5). See if the patient can slide forward a little in the chair. If the patient is weak, have an assistant help him or her lean forward into the chin rest. You might place pillows behind the patient to prop him or her. An extra assistant will probably be needed to hold the patient's head in position. This may be another situation where you should decide what is most important and examine that first, before the patient wears out.

Sometimes, getting the patient into position is not a problem, but other conditions may make modifications necessary. If the patient constantly chews or moves the mouth, you should drop the chin rest all the way down, out of the way. Have the patient lean into the forehead rest, without using the chin rest. You may need an assistant to help stabilize the patient's head, which may tend to drift down.

Examining a patient with head tremors can be challenging. Try having an assistant stabilize the patient's head from behind.

Figure 2-5. Positioning a patient in a wheelchair. (Photo by Val Sanders.)

Patients with nystagmus have often learned that their vision is better if they hold their head in a certain position. This is because the jerking movements are quieter in a certain gaze. Before examining a patient with nystagmus, ask how he or she holds the head to see the best. Try to duplicate that position at the slit lamp. This may mean that the patient's head is turned instead of facing straight ahead or that you must drop the chin rest out of the way. In addition, encourage the patient to keep both eyes open at all times. Occluding one eye often makes the movements worse.

Occlusion may work in your favor, however, in the patient with strabismus. If the patient's eye turn is large enough to pull the eye out of alignment with the microscope, apply a patch to the other eye. Then ask the patient to look straight ahead.

A patient who is in pain can be very difficult to examine. Once it has been determined that the patient does not have a penetrating injury, a drop of anesthetic may be instilled, if the physician approves. Although the eye is then numb, the patient may still be photophobic. Stress the importance of the exam, assure the patient that you will use the dimmest light possible, and explain that you will do your best to be quick and thorough. Decide what information is most important, and examine that structure first. (In severe cases, a technician may want to defer the exam to the physician so that the patient will have to endure only one examination rather than two.)

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