NBEO Part III cheat sheet

Chief complaint: record in patient's own words; duration, laterality, and associated symptoms (pain, redness, photophobia, discharge) guide differential.

Past ocular history: amblyopia, strabismus surgery, refractive surgery, prior contact lens wear, ocular trauma, and previous glasses/contact lens prescription.

Medical history: diabetes (retinopathy risk), hypertension, autoimmune disease (uveitis, dry eye), thyroid disease (Graves ophthalmopathy), and medications (amiodarone, hydroxychloroquine, corticosteroids, anticholinergics).

Family history: glaucoma, macular degeneration, keratoconus, retinal detachment, and high myopia increase screening priority.

Review of systems: transient visual loss (amaurosis fugax), flashes/floaters, diplopia, halos, and headaches with aura require targeted follow-up.

Social history: smoking, occupational visual demands, driving status, and sport/hobby needs influence eyewear and contact lens recommendations.

Medication allergies: document specific reaction (rash, anaphylaxis) rather than simply 'allergic'.

Pediatric history: birth weight, prematurity, oxygen therapy, developmental milestones, and school vision screening results.

Snellen acuity: test at 6 m (20 ft); 20/20 line subtends 5 arc minutes per letter detail; record smallest line with majority correct.

Pinhole acuity: if pinhole improves acuity, refractive error is likely; if no improvement, suspect ocular media or retinal/neural cause.

Best-corrected visual acuity (BCVA): perform manifest refraction; use fogging (plus lenses) to relax accommodation before duochrome and Jackson cross-cylinder.

Jackson cross-cylinder: axis check with JCC at 45° from correcting axis; power check with JCC aligned to correcting axis; flip and compare clarity.

Duochrome test: in emmetropia, red and green targets appear equally clear; if red clearer, add minus; if green clearer, add plus.

Cycloplegic refraction: use cyclopentolate 1% or tropicamide 1% for children and accommodative esotropia; atropine 1% for dark irides or resistant accommodation.

Keratometry: measures anterior corneal curvature (central 3 mm); average K ~43.00 D; astigmatism = difference between steep and flat K.

Trial frame and vertex distance: refractive error changes with vertex distance; compensate when > ±4.00 D or when switching between spectacles and contact lenses.

Cover test: cover one eye and observe uncovered eye for movement; uncover and observe for recovery movement; distinguishes phoria from tropia.

Alternating cover test: detects manifest deviation; no recovery movement indicates tropia; recovery movement indicates phoria.

Near point of convergence (NPC): target moved toward nose; normal break < 5 cm and recovery < 7 cm; receded NPC suggests convergence insufficiency.

Stereopsis: Randot/Titmus circles test; normal 40-60 seconds of arc; absence suggests monocular vision or suppression.

Worth 4-dot test: red-green glasses; 4 dots = fusion; 2 red = left suppression; 3 green = right suppression; 5 dots = diplopia.

Versions and ductions: assess comitance; underaction/overaction patterns localize cranial nerve palsy or restrictive myopathy.

Hirschberg test: corneal light reflex displaced from pupil center; 1 mm displacement ≈ 7° or ~15 Δ deviation.

Krimsky test: prism placed before fixating eye until light reflex centered; quantifies angle of strabismus.

Diffuse illumination: broad beam at 45° for general inspection of lids, lashes, conjunctiva, sclera, and cornea.

Optic section: narrow beam at 45° creates corneal cross-section; assess corneal thickness, infiltrates, and depth of anterior chamber.

Sclerotic scatter: broad beam at limbus; light scattered through cornea reveals subtle opacities and edema.

Retroillumination: light reflected from iris or fundus; highlights corneal endothelial guttata, pigment, and lens opacities.

Specular reflection: angle of incidence equals angle of reflection; used to evaluate corneal endothelium.

Van Herick technique: peripheral anterior chamber depth graded 0-4; grade ≤ 2 indicates shallow AC and risk of angle closure.

Fluorescein staining: sodium fluorescein 0.25% with cobalt blue light; evaluate corneal epithelial defects, abrasions, and contact lens fit.

Seidel test: fluorescein applied to suspected wound; streaming aqueous indicates full-thickness corneal laceration.

Direct ophthalmoscopy: magnification ~15×; upright, virtual, unreversed image; limited field; useful for disc and macula screening.

Indirect ophthalmoscopy: condensing lens (20 D or 28 D) with headset; inverted, reversed, real image; wide field for peripheral retina.

Optic disc assessment: color (pink-orange), margins (distinct), cup-to-disc ratio (normal ≤ 0.5), and neuroretinal rim (ISNT rule).

Cup-to-disc asymmetry > 0.2 between eyes or CDR ≥ 0.6 warrants glaucoma evaluation.

Macula: examine for drusen, pigmentary changes, hemorrhage, exudates, and macular edema; use Amsler grid for metamorphopsia.

Vascular changes: AV nicking, copper/silver wiring, flame hemorrhages, and cotton-wool spots suggest hypertensive or diabetic retinopathy.

Peripheral retina: 360° scleral depression with indirect ophthalmoscopy for tears, lattice degeneration, and detachment in symptomatic patients.

Red reflex: absent or abnormal red reflex in children requires urgent evaluation for retinoblastoma, cataract, or vitreous hemorrhage.

Goldmann applanation tonometry: IOP = (force/area) × 10; normal 10-21 mmHg; corneal thickness affects accuracy.

Central corneal thickness (CCT): thin CCT (< 500 µm) underestimates true IOP; thick CCT (> 600 µm) overestimates.

Non-contact tonometry: air puff; less accurate but useful for screening; avoid in corneal disease or recent surgery.

Gonioscopy: Goldmann lens or Zeiss 4-mirror; grade angle by Shaffer system (Grade 4 open to Grade 0 closed).

Optic nerve head: CDR > 0.6, rim thinning, disc hemorrhage, and RNFL defect indicate glaucomatous damage.

Visual field testing: 24-2 or 30-2 SITA Standard; glaucoma defects respect horizontal midline and nasal step.

Pachymetry: measure CCT before interpreting IOP; adjust risk for thin corneas.

Provocative testing: water drinking or dark room prone testing rarely used; not routine.

Confrontation visual field: screening test; compare patient's field to examiner's; detects gross defects.

Amsler grid: 10 cm grid at 33 cm; detects central 10° metamorphopsia and scotomas.

Humphrey visual field: 24-2 or 30-2 test patterns; SITA Standard shortens test time; reliability indices (fixation losses, false positives, false negatives) must be < 33%.

Glaucomatous field defects: nasal step, arcuate scotoma, paracentral scotoma, and altitudinal defect; respect horizontal midline.

Neurological field defects: bitemporal hemianopia (chiasmal), homonymous hemianopia (postchiasmal), and quadrantanopia.

Mean deviation (MD): overall field loss; pattern standard deviation (PSD): localized loss; glaucoma hemifield test (GHT) compares superior and inferior hemifields.

Visual field index (VFI): percentage of normal age-matched field; useful for monitoring progression.

Test strategy: SITA Fast for screening; SITA Standard for definitive diagnosis; repeat abnormal fields to confirm.

Base curve (BC): measured in mm; flatter BC (larger number) loosens fit; steeper BC (smaller number) tightens fit.

Diameter (DIA): larger diameter increases sagittal depth and tightens fit; smaller diameter loosens.

Soft lens fit: centration, coverage, movement (0.5-1.0 mm with blink), and no limbal compression; push-up test for tight lens.

Rigid gas permeable (RGP) fit: apical clearance or alignment, edge lift 0.1-0.2 mm, and centration; fluorescein pattern guides adjustment.

Keratometry and topography: determine corneal curvature; fit soft lenses with BC 0.8-1.0 mm steeper than flat K; RGP with BC aligned to flat K.

Tear film evaluation: TBUT > 10 sec normal; < 5 sec indicates dry eye and may contraindicate contact lens wear.

Contact lens complications: microbial keratitis, corneal neovascularization, giant papillary conjunctivitis, and solution toxicity.

Replacement schedule: daily disposable reduces complications; extended wear increases risk of keratitis.

Lensometer: measures spherical power, cylindrical power, axis, and prism; calibrate before use.

Spherical equivalent = sphere + ½ cylinder; used for rough estimation and contact lens conversion.

Vertex distance: change in effective power = (F × d)/(1 - dF); compensate when > ±4.00 D.

Prism: 1 prism diopter deviates light 1 cm at 1 m; base direction determines image displacement.

Prentice rule: prism diopters = (decentration in cm) × (lens power in D).

Transposition: convert plus cylinder to minus cylinder by adding cylinder to sphere, changing cylinder sign, and rotating axis 90°.

Base curve: front curve of lens; affects magnification and aberrations; steeper base curve increases magnification.

Anti-reflective coating: reduces surface reflections; improves contrast and cosmesis.

Mydriatics: phenylephrine 2.5% (α1 agonist) dilates without cycloplegia; tropicamide 1% (anticholinergic) short-acting cycloplegic.

Cycloplegics: cyclopentolate 1% (onset 30-60 min, duration 6-24 h); atropine 1% (duration 7-14 days); homatropine 5% (duration 1-3 days).

Topical anesthetics: proparacaine 0.5% and tetracaine 0.5%; never prescribe for home use; risk of corneal toxicity.

Fluorescein: sodium fluorescein 0.25% for staining; avoid in patients with known fluorescein allergy.

Antibiotics: fluoroquinolones (moxifloxacin, gatifloxacin) for bacterial keratitis; aminoglycosides (tobramycin) alternative.

Steroids: prednisolone acetate 1% for inflammation; monitor IOP and risk of infection.

Glaucoma medications: prostaglandin analogs (latanoprost) increase uveoscleral outflow; beta-blockers (timolol) reduce aqueous production; avoid in asthma/COPD.

Punctal occlusion: after instilling drops, press on lacrimal sac for 1-2 minutes to increase ocular absorption and reduce systemic effects.

Informed consent: explain procedure, risks, benefits, and alternatives; document patient understanding.

HIPAA: protect patient health information; share only with authorized individuals; secure records.

Infection control: hand hygiene before and after patient contact; disinfect tonometer tips and trial lenses between patients.

Universal precautions: gloves for contact with blood, tears, or mucous membranes; dispose of sharps in designated containers.

Communication: use plain language, teach-back method, and interpreter services for limited English proficiency.

Cultural competence: respect patient beliefs, values, and preferences; avoid assumptions based on appearance or background.

Documentation: record all findings, procedures, and patient instructions accurately and timely.

Emergency preparedness: know location of fire extinguishers, emergency exits, and first aid kit; follow office protocols.