Section 3 - Adult health checks

Health check recommendations

• All adults > 15 years of age if clinically indicated
• All Aboriginal and Torres Strait Islander > 15 years of age annually

1. Procedure

• Ask the questions as per Table 1.
• Determine if the person requires further assessments and undertake if required
• Provide brief intervention
• Determine if the person requires a referral and place onto a follow-up and recall register

1. Eye appearance ^3–5
   • With an ophthalmoscope visualise external and anterior eye:
     • symmetry of pupils
     • abnormal movements (nystagmus)
     • lift each eyelid with thumb and check for:
       • cysts
       • styes
       • droopy eyelids (ptosis)
       • inturned eyelash that touches the eyeball
       • evidence of inturned eyelash being plucked
     • conjunctiva and cornea for:
       • redness
       • swelling
       • discharge
       • pain
       • fleshy overgrown membranes
       • teary or watery
     • sclera for jaundice (Hepatitis B), bloodshot or haemorrhage (trauma)
   • Ophthalmoscopy of the lens and retina:
     • ask person to focus on a distant point e.g. your ear, the wall
     • direct the ophthalmoscope light at the pupil from 30 cm away
     • look through the scope slowly moving back and forth, up and down until you see a red reflex (the blood at the rear of the retina) reflection (red flash)
2. Assessing VA ^3–5
   • Test while patient wearing prescribed glasses or contact lenses
   • Place a Snellen eye chart (or Tumbling E eye chart for those with limited literacy) 6 metres away in a well lit area at eye level
   • Note the numbers next to each line on the chart:
     • the first number represents metres the person is standing from the chart i.e. 6
     • the second number on each successive line increases, mimicking increased distance in metres, with smaller lettering e.g. 9m, 12m, 18m, 24m, 36m or 60m
   • Tell the person to state the letter you point to or if using the Tumbling E chart, show how 3 fingers makes an ‘E’ and to hold these fingers left, right, up or down to indicate what they see
   • Cover one eye with occluder and begin test
   • Start at the top line and point clearly to each letter
   • Allow the person adequate time to respond

• Progress along each line until the person can no longer identify letters
• If they get > 3 letters incorrect on a line, stop, go up a line and repeat
• Allow 2 attempts
• Record the last line the person can read without making any mistakes
• Cover the other eye and repeat process

3. Near vision test ^3–5
   • Use any normal sized print at a comfortable reading distance
   • Ascertain a person’s ability to read (see) at this distance
4. Eye movement ^3–5
   • Hold an object (e.g. pen) 30 cm away and slowly move it up, down, left and right in an ‘H’ pattern
   • Encourage person to look at the object without moving their head
   • Observe whether the eyes track the object equally and bilaterally

2. Results

1. Eye appearance results
   • The eyes should appear:
     • conjunctiva white clear, clean, free of redness, swelling and pus
     • pupils symmetrical
     • eye movements equal and intentional
   • No red reflex can indicate an obstruction between the pupil and retina e.g. a tumour, congenital cataract or haemorrhage
   • Trichiasis is present if:
     • at least one eyelash touches the eyeball or
     • evidence of recent plucking of in-turned eyelashes
2. VA results
   • Normal VA for adults is 6/6
3. Near vision test results
   • All adults should read at a comfortable distance (+/- glasses) without squinting or holding the book at arms length
4. Eye movement results
   • The eyes should track the object smoothly and equally in all directions without the head moving

3. Brief intervention ^3–5

• Visual impairment is common in older people and is associated with falls and reduced quality of life
• Older people often do not report visual problems to medical services
• Incidence of visual impairment, blindness and trichiasis is highest for Aboriginal and Torres Strait Islander adults
• Encourage annual visual assessments especially if driving
• The MO/NP or optometrist can remove one or more eyelashes as a temporary measure to prevent trichiasis progressing if patient:
  • is waiting for surgery
  • refuses surgery
  • understands that broken or regrowing eyelashes risks corneal damage
• See Resources 2–6.

4. Referral

• Refer to the MO/NP, optometrist or ophthalmologist for any:
  • redness, puss or swelling
  • abnormal eye appearance
  • reported blurriness
  • squinting to read
  • holding text away at arm’s length to read
  • uneven eye movement
  • the person’s VA in either eye is outside normal range (6/9, 6/12, 6/18, etc.)
  • eligible person requiring new glasses under state specific Spectacle Supply Scheme. See Resource 7.
  • person obtains > 4 errors on the 24 plate Ishihara colour blindness test
• Refer all cases of trichiasis to an ophthalmologist urgently to preserve the person’s sight

5. Follow-up

• Place the person on a recall register if required
• Ensure all referrals are actioned
• Provide the person with details for the next scheduled follow-up appointment

6. References

• All Chronic Conditions Manual references are available via the downloadable References PDF

7. Resources

1. 24 plate Ishihara colour blindness test
2. Queensland Health Eye Health
3. Health Direct Eye Health
4. AIHW: Eye health in Aboriginal and Torres Strait Islander people
5. Vision Australia
6. Indigenous Eye Health Unit
7. Spectacle Supply Scheme - eligibility and how to apply