Ophthalmological Apparatus For Use In An Examining Room

Abstract

A system for use by an ophthalmologist for the examination of a patient basically comprises a plurality of environmental devices such as lights, fixation devices, and the like, in combination with the various ophthalmological instruments employed by the ophthalmologist, all of said environmental devices and instruments being interconnected to a central control system whereby the ophthalmologist is afforded optimum environmental conditions for the several tests which he conducts during an examination.

Description

The present invention relates to a system for use by an ophthalmologist, and more particularly a unique system employing all of the environmental apparatus and testing instruments required by the ophthalmologist in order to efficiently and accurately examine a patient. All of the environmental devices and apparatus are embodied in a single room and are interconnected to a central control system whereby, when a doctor removes an instrument from its holder, the environment within the room is automatically changed in order to provide the optimum environmental conditions for the examination of the eye for the specific test to be conducted by the ophthalmologist.

A detailed discussion relative to the system of the subject invention is presented hereinafter, with particular reference to FIG. 1, which is a perspective view of an ophthalmologist's office containing the system of the subject invention; and

FIG. 2 which schematically illustrates the interconnections between the various devices of the system of the subject invention.

Referring to FIG. 1, the system of the present invention is preferably embodied in a room having a length L of approximately 20 feet and a width W which may be on the order of 8 feet, which is substantially less than present ophthalmologist examining rooms. Located at one end of the room is the patient's chair 1, and adajcent thereto is the ophthalmologist's chair 2 and the ophthalmologist's desk 3. The desk 3 includes an inclined lens tray 4 for mounting the various trial lenses 5, and disposed above the lens tray 4 is a small fish tank bulb light 6. Also mounted on the desk is a lensometer 7, and a projector control unit 8 through which the ophthalmologist controls the wall mounted projector 9. The projector 9 is directed to focus on a projection screen 10 disposed at the opposite end of the room, with the central lane of the room being commonly referred to the "examination lane." Fixedly secured to the desk 3 is a control unit 11 which houses the various electronic controls for interconnecting the several instruments and environmental devices embodied in the subject system, to be more fully described hereinafter. Removably mounted on the control unit 11 are the following instruments: a hand held illumination instrument 12 which does not include magnification means; a retinoscope 13; and an ophthalmoscope 14. Each instrument 12, 13 and 14 is mounted on a pivotal carrier which actuates a corresponding switch in the control unit 11, as more fully described hereinafter.

Disposed above the patient's chair 1 is an indirect background light 15, while to the patient's left is a slit lamp instrument 16, and above the patient's chair is a reading light 17.

At the opposite end of the room, adjacent the projection screen is a Worth 4-dot unit 18, and a far end white muscle or fixation light 19. Along one wall out of the path of the examination lane, is the retina table 20 which carries a second ophthalmoscope 21, as well as an indirect ophthalmoscope 22. Disposed directly above the heat rest 20' of the retina table 20 is an overhead red fixation light 23.

On the opposite side of the room from the retina table 20 is a tangent screen 24, and above the front surface of the tangent screen 24 is a tangent screen light 25 which is variably controlled by means of a wall mounted rheostat 26. Adjacent the tangent screen, and mounted on the wall is an inclined table 27, including pens 28 for the convenience of the doctor in recording the tangent screen examination results, as well as a test object 29 and an eye occluder 30.

A series of fluorescent lights 31 are provided above the examination lane, as well as a series of incandescent lights 32. The latter are variably controlled by means of a rheostat 33 forming a part of the control unit 11.

All of the electrical apparatus described above, whether environmental in nature (e.g., lights 31, 32, 15 etc.) or instrumentation (e.g., devices, 12, 13, 14, 19), are interconnected to the control unit whereby the latter constitutes a master power control for all the electrical apparatus in the room, as well as a programmable operational control to coordinate the operation of the various electrical devices thereby providing the doctor with optimum environmental conditions for the several tests which he conducts during a routine examination.

In order to more fully understand the system of the present invention, there is presented hereinafter a detailed discussion of the system with reference to a hypothetical examination of a patient, and with particular reference to the shortcomings of systems presently being employed by most ophthalmologists. The description is with respect to my observations of present systems, and my observations of the increased efficiency which is achieved employing the system of the present invention.

Coming from a residency program which was very well equipped but very scattered in the sense that the instruments were helter-skelter throughout the clinic, I decided before going into practice to investigate the available equipment and proceed from that position. In my investigation of the equipment, I found that the individual pieces of equipment as marketed by the various companies perhaps functioned but in no way was the system integrated for maximum efficiency. The basic difficulty with existing equipment and its placement was the fact that most ophthalmologist's offices are in the vicinity of 12 feet in width and of course 20 feet in length. The office which I had entertained to rent had a single room which was 15 feet by 20 feet, and yet I was faced with the problem of needing two examining rooms. The 20 feet is necessary to prevent what we call facultative accommodation because the patient, in viewing an object within close range will make the eye accomodate and thereby the amount of eyeglass that would be proscribed is less than the theoretical distance of infinity, which is the 20 feet in length, and that's aiming at maximal patient comfort in wearing the glasses. Currently available equipment usually consists of a hydraulic chair and adjacent to that, a stand onto which the various instruments are placed. If you had in addition, a trial lens-carrying case or a box, the physical structure of the hydraulic chair and stand necessitated a room of approximately 12 feet in width. The ophthalmologist or even the highly trained optomotrist requires a certain basic amount of instrumention to do an adequate examination. These consist of direct and indirect ophthalmoscopes, a retinoscopy instrument, trial lenses, slit lamp, and some means of reclining the patient. In addition, a vision chart, a means of illumination of a near vision chart and a lensometer, along with a visual field apparatus. Of course, there must be room in the office for parents to accompany their children, or to have other family in the room and not get in either the patient's or the doctor's way.

The routine examination consists of starting with the face and ending up with the optic nerve. To examine a patient's face and symmetry of the eyes, the room must be well lit. Fluorescent lighting 31 is more comfortable in my eyes for this part of the examination and hence the fluorescent lights are on. One must have a hand illuminated instrument without magnification and that is the reason for the third instrument 12 on the control unit 11. Light instrument 12 allows you to examine, for example, absence of lashes, whether a lid is scarred, red point tenderness of the eye, etc. The next part of the examination includes extraoccular motions, and when you ask a patient to follow the light 12, the doctor can determine if both eyes move together or whether or not there is a latent palsey of one of the muscles of the eye.

The next part of the examination usually consists of visual acuity. To take a patient's vision, the modern ophthalmologist will use a projector 9. I, before taking a patient's naked visual acuity that is uncorrected, first want to find out what the patient's old glasses were and therefore the lensometer 7, must be conviniently placed near me, and therefore, in my system the lensometer 7 is directly behind and on my left as I view the patient.

My next routine is to do the examination known as retinoscopy. It is an examination whereby the patient's objective optical properties of his eye are determined.

For this examination to be done, the patient fixes with the other eye on a confusing uninteresting distance fixation light. In my syste, this is muscle light 19 which is disposed below the Worth 4-dot board 18. It is located at the other end of the room or 20 feet from the patient. The retinoscope 13 must light and this examination is best done with a mildly dialated eye pupil, and therefore, the fluorescent lights 31 and the incadescent lights 32 must go out entirely. Of course, I have to be able to see my trial lenses 5, and that's the reason that the fish tank bulb light 6 is automatically activated as I remove the retinoscope 13 from its holder on the control unit 11. It allows me to see the markings on the lenses 5 and to be able to retrieve without difficulty certain lenses to be placed within the trial frame which the patient is wearing. Of course it's nice to know where the patient's face is and that's the reason for the background light 15 being also activated. The background light 15 is located directly behind the patient over his left shoulder. Light 15 is aimed toward the ceiling so that the reflection off the ceiling is not directed toward the patient's eye which could confuse the retinoscopic findings. In previous systems, the doctor would either have to get up from his chair to turn off the room lights or he would not turn out the room lights in any fashion, and therefore, his tendency toward inaccuracy in retinoscopy was more increased. In my system when I lift the retinoscope instrument 13 from its carrier, in addition to activating the retinoscope 13, the fluorescent lights 31 and incandescent lights 32 go out, the distance fixation light 19 comes on, the fish tank bulb 16 over the trial lenses 5 is activated, and the background light 15 comes on. In addition, the projector command 8 which controls the projector 9 and therefore the size of lettering presented to the patient is activated. The latter instrument is independently switched because when you are doing retinoscopy as opposed to a manifest refraction you are attempting to give the patient an uninteresting object, like that of the distance fixation light. If you give him the distant letter, the patient is made more aware, and therefore his eyes will accommodate. The projector command is not activated in my system except when the retinoscope instrument is lying off its carrying rack, and the reason for this arrangement is that the bulb in the projector has a very short life and the time required to replace that bulb is extensive. Thus, by coordinating the use of the projector 9 and the retinoscope 13, and the dark environment, I ensure that the projector is not constantly in operation which, as mentioned above, greatly shortens the useful life of the projector bulb.

The next part of the routine ophthalmological examination consists of a slit lamp examination. Most of the currently available equipment has the slit lamp attached on a rocker arm which is on the stand that is directly to the patient's left. One would use that rocker arm to move the slip lamp directly in front of the patient. My difficulty in using the chair and stand consists of attempting to adjust the relative height of the patient so that he could place his chin within the chin rest of the slip lamp. When you use a hydraulic chair, the patient usually ended up higher or lower than the chin rest, and it was a question of which one to raise first, either getting the rocker arm up or the patient's chair down. Hydraulic chairs move quite rapidly and, especially in those instances where a child is being examined, I did not like the idea of having two variables; that of the slit lamp height and the chair height. I neutralized the chair height by having a fixed chair 1. Additional advantages of not having a nydraulic chair is that the hydraulic chair looks too much like that in a dentist's office. A four year old child, for example, coming into the office and seeing this hydraulic chair, could easily be reminded of the pain associated in the dentist's office. In examining a four year old child, the ophthalmologist has to limit himself to a time period of 3 or 4 minutes. After that time, most children become tired, uncooperative, cranky and crying. If you start with a crying child, you are self-defeating. The third reason why I did not want a big, bulky, heavy chair is that in case you have a wheelchair patient, you still must have the full 20 feet with accessible equipment, and if the chair cannot be moved easily, again you are self-defeating. The fourth reason for not using a fixed chair and stand arrangement is because the space allowed between the chair and stand on the patient's left does not allow the ophthalmologist to get comfortable in between the chair and stand, and therefore you cannot examine the patient conveniently and comfortably with an direct ophthalmoscope. And with the hydraulic chair reclined the length required increases to about 25 feet.

The slit lamp 16 is a corneal microscope which allows the doctor to examine the lids, the cornea, the anterior chamber, the iris, the lens, and with various fixed attachments to the eye, the ophthalmologist is afforded a three-dimensional viewing of the retina. Of course, the application tonometer is attached to the slit lamp and allows the ophthalmologist a very accurate estimation of the interoccular pressure. In doing slit lamp examination, the doctor is occasionally looking for microscopic sized particles. In a well lit room the tyndall effect of a light going through a cloudy medium is more difficult to appreciate as opposed to the situation when the overhead lights are out. Hence, there is an accessory switch (not shown) attached to the slit lamp which allows the ophthalmologist, while still examining the patient, to turn out the overhead fluorescent lights 31, and at the same time, the very small background light 15 comes on so that he can see the patient's face, and the patient is less scared because the room is not totally dark.

Most ophthalmologists place the slit lamp in a second room, and hence, the patient is asked to leave his chair, go to a second room, the doctor has to leave his chair, go to a second room to conduct that part of the examination, only to return to the original room after that part of the examination is completed.

Attached to a pole above the patient's chair is the hand-operated, incandescent bulb reading light 17 which is readily available for testing the patient's near vision requirements with regard to glasses. That lamp 17 duplicates the approximately lighting condition of the patient while he is at home.

If the doctor does not drug dilate the pupils he will examine the retina while the patient is in the chair 1. The required instrument is ophthalmoscope 14 and for ideal examination, the patient's pupil should dilate without drugs to its maximum; the patient should have a object to look at which is uninteresting, thereby preventing accommodation and subsequent constriction of the pupils; and the doctor must be comfortable without bending his back too much to accomplish the examination. Hence, in my system, when the ophthalmoscope 14 is lifted from its carrier, the control unit 11 functions to cause the fluorescent room lights 31 to go out and the variable incandescent lights 32 to go on. In this environment, the pupil dialates more readily to approximately 5 mm as opposed to the situation where the room lights remain on and the pupilatory dilatation is only 3 to 4 mm. If the room lights were allowed to go completely out, it has been my experience, that the pupil does not dilate, without drugs, sufficiently to enable the examination to be conducted. Unless the patient has a specific complaint with regard to retinal disfunction or disease, I have found that patients appreciate not having their pupils dilated with drugs because the after-effects of the drugs continue after the patient has left the office. More particularly, if the patient has to get to work, he finds himself not being able to either read, or the lighting conditions in his own office bother him. He also has trouble driving an automobile, especially at night in the presence of on-coming headlights. Hence, patients are generally more happy if the drugs are not used.

In known systems, the environmental lighting usually consists of a single arrangement of fluorescent lighting which is manually switched by the doctor. In my system, the variable but fixed incandescent lighting 32 enables me to control directly the amount of light which is reflected into the pupil. the blue eyed patient will dilate more with a given amount of illumination than will a patient who is brown eyed. There are some patients who are extremely afraid of the dark, and if I detect that within them, I can increase the amount of incandescent light within the room by the rheostat 33 which is readily located on the control unit 11. Rheostat 33 controls the incandescent lighting. In the routine of 90 percent of patients, the amount of light in the room when the ophthalmoscope is activated is fixed, but I am allowed the liberty of modifying that without much complication. Previous systems do not have this incandescent lighting 32. If the patient has a specific complaint of either retinal disease or disfunction, then of course the examination must be carried on regardless of the patient's problems once he leaves the office. Therefore, in those cases, the pupils may be drugged and forcibly dilated.

The proper examination of the patient with retinal disease, for example, retinal detachment, includes indirect ophthalmoscopy along with scleral depression. For the the patient's and the doctor's comfort, the patient must be lying down, and the doctor standing up. Hence, the retina table 20 is provided in my system at the entrance to the lane. The table may also be used for neurological examination. The second direct ophthalmoscope 21 is connected to the automatic control unit 11, and the same environmental conditions occur when it is activated as occur when ophthalmoscope 14 is activated.

When the indirect ophthalmoscope 22 is switched on, the overhead lights 31 and 32 go completely out, the very small background light 15 (which is about 12 feet away) comes on, and the directly overhead, red ceiling fixation light 23 is activated. The overhead fixation light 23 allows the patient to fix his other eye on an object. If the patient is just asked to look at the ceiling, the intensity of the indirect ophthalmoscope lighting system is such that the lids of both eyes have a tendency to close, and the so-called Bell's phenomenum occurs. The Bell's phenomenum is the protective reflex of the eye which makes the eyes "roll up" into the top of the head, and of course if the pupil is not present, it can't be examined. The background light 15 gives just a trace of illumination in the room which allows me to retrive the ancillary hand lenses and scleral depressor which are directly near the table 20, and of course, the physician must have some means of seeing so that he does not bump into anything in the room. Of course, the psychological implications of a totally dark room are also compensated for by the indirect background light.

The direct ophthalmoscope gives a magnification of approximately 15 times, whereas the indirect ophthalmoscope give a magnification of only three to four. Hence, to adequately evaluate the patient's problem, both instruments must be available for the doctor at the same relative position of the patient so that he can utilize both magnifications.

If a separate retinal table is not available and the doctor employs a hydraulic chair for the retinal table, the length of the room must be increased by approximately 5 feet, because the chair must go back and the doctor must be able to get behind the patient's head.

The muscle examination of strabismus or other difficulty of muscle imblance in patients consists of a distance and near measurement. The office design must allow for a distance fixation target and distance sensory evaluation of the patient. Hence the distance fixation light 19 which is used in refraction of the patient does double duty in the sense that, independently switched, the distance fixation light 19 can come on and hence the amount of turn that the patient demonstrates can be elucidated. The Worth 4-dot 18, which is directly above the distance fixation light allows the doctor to have an idea of the patient's sensory ability. Of course, that too must be independently switched.

Patients who have glaucoma must have a visual field examination. There are many variables in doing this examination. First, is the distance of the patient to the testing screen. In a lane which is approximately 8 feet wide, if you use the doctor's chair 2 as the patient's chair, and it is placed adjacent to the retina table, the average patient's head ends up at one meter from the tangent screen 24. Hence the floor need not be marked for accurate placement of the chair. The second variable is the overhead lighting conditions, and ideally, this test should be carried out under seven-foot candles. Unfortunately, no light bulb will give a constant output for its life, and hence a variable rheostat 26 must be incorporated in the lighting system 25 to achieve the same amount of light each and every time the examination is done. And, of course, the basic room lighting 31 and 32 must be deactivated so that the lighting conditions of the tangent screen 24 are independent of the room lights. Switch 26, of course, must be accessible to the doctor, and hence, it is placed directly adjacent to the tangent screen. In most prior existing offices, the tangent screen examination again was accomplished in the second room. During the procedure of tangent screen evaluation, one eye is covered with an eye occluder 30. The other eye is asked to look at a central fixation target, and the doctor brings in from the periphery a small test object 29 and the patient is to report when he becomes aware of the presence of that second image. Recording the patient's findings is done during the course of the examination using table 27 which holds the extra paper and the various pens 28 of different colors.

By virtue of my system, I achieve adjustment of the lighting in the examining room without having to think about defeating a given part independently of the other. Whatever that instrument is designed to do is accomplished by the throwing of a single switch or lifting that instrument from its cradle. I have found that because I am not asking patients to go from one room to another, not only is my time per patient decreased without being affrontry, but I go home at the end of the day without extreme fatigue.

The total integration of the slit lamp, the ophthalmoscope, the indirect ophthalmoscope, the refraction equipment, the sensory adaptation equipment, the projector, background lights, incandescent lights, near vision lights and multiple fixation lights, working together in one homogeneous group affords me the priviliege of a single room; no interruption of thought to accomplish that portion of the examination; and the examination is carried out under optimal lighting conditions with little discomfort to the patient or me. Hence, the invention of my system employs the basic instruments which either an opthalmologist or an optomotrist would use. The essence of the system as adaptable to an ophthalmologist would be the retinoscope 13, the ophthalmoscopes 14, 21 and 22, and the various lighting conditions that control the environment. These lighting conditions consist of the overhead fluorescents 31, the overhead incandescents 32, the background lihght 15, the two fixation lights (the overhead 23 and the far end fixation light 19) and the control system 11 which integrates the instruments with the optimal lighting conditions associated with the instrument's used.

FIG. 2 illustrates a schematic of the overall electrical control system wherein the various environmental devices are interconnected with the various ophthalmological instruments through the medium of the control unit 11. More particularly, as shown in FIG. 2 the control unit 11 is interconnected to all of the environmental and ophthalmological instruments, and the control unit 11 is connected to the main power source for the subject system. In the initial condition, the control unit 11 is activated, and the overhead fluorescent lights are on thereby illuminating the room. All of the other instruments and environmental devices are temporarily deactivated. As illustrated, several of the instruments are directly connected to the control unit and are operated by hand operated switches, as more fully described above. These devices include the tangent screen light 25 and its associated rheostat 26, the lensometer 7, the reading light 17, the hand held illuminating instrument 12, and the Worth 4-dot device 18. The remaining portions of the subject system are arranged whereby the activation ophthalmological instrument will cause a series of environmental devices to be either activated or deactivated.

Turning first to the retinoscope 13, as illustrated by the interconnecting lines, as the retinoscope 13 is removed from its switch carrier to its activated position, the control unit 11 functions to: first, turn on the fish tank bulb light 6; secondly, turn on the background light 15; thirdly, turn off the fluorescent lights 31; fourthly, turn on the muscle light 19; and fifthly, turn on the projector command 8 and projector 9. At such time the ophthalmologist is afforded optimum environmental conditions for conducting an examination utilizing the retinoscope.

In like manner, as the ophthalmascope 14 is removed from its switch carrier, the ophthalmoscope lights control unit 11 functions to achieve the following: turn off the overhead fluorsecent lights 31; turn on the incandescent lights 32; turn on the red fixation light 23; and turn on the muscle light 19.

For conducting that portion of the examination requiring the operation of the slit lamp 16, a suitable switch mounted on the slit lamp 16 is activated thereby causing, through the medium of the control unit 11, the background light 15 to be turned on, while the overhead fluorescent lights 31 are simultaneously turned off.

The operation of the second ophthalmoscope 21 is similar to the results obtained upon actuation of the first ophthalmoscope 14 as described above.

When the patient is being examined on the retina table 20, and the doctor employs the indirect ophthalmoscope 22, the control unit 11 functions to turn on the background light 15, turn off the fluorescent lights 31, and turn on the red fixation light 23.

Although a preferred embodiment of the present invention has been described hereinabove, it will be understood that other modifications and embodiments readily apparent to those skilled in the art are contemplated to be within the scope of this invention. Therefore, this invention is not limited by the above description and drawings but rather by the following appended claims.

Claims

What is claimed is:

1. Ophthalmological apparatus for use in an examining room having a length of approximately twenty feet defining an examination lane, with a patient chair disposed at one end of the lane, said apparatus comprising:

a plurality of electrical environmental devices disposed in said room, including,

an overhead fluorescent light disposed in the ceiling of said room intermediate the length of the examination lane;

an overhead incandescent light disposed in said ceiling intermediate the length of said examination lane;

an indirect background light disposed above the patient's chair;

an overhead fixation light disposed in the ceiling of said room intermediate the length of the examination lane; and

a muscle light mounted in the wall disposed at the opposite end of the examination lane to the patient's chair;

a plurality of electrical ophthalmological instruments disposed in said room in the vicinity of the patient's chair for examining a patient, said instruments including a hand-held illuminating instrument, a retinoscope, an ophthalmoscope, and an indirect ophthalmoscope;

an electrical power and control system; and

means connecting each of said environmental devices to said electrical power and control system, and switch means connecting each of said ophthalmoscope instruments to said electrical power and control system in such manner whereby upon actuation of a switch means associated with an ophthalmological instrument, the electrical power and control system is operative to selectively actuate the environmental devices for effecting desired environmental conditions within the examining room.

2. Apparatus as in claim 1 further including additional ophthalmological instruments that are connected to the electrical power and control system, but not connected to said environmental devices, said further instruments including a tangent screen light disposed in the ceiling of said examination room intermediate the length of the examination lane, a lensometer disposed adjacent the patient's chair, and a reading light disposed above said patient's chair.

3. Apparatus as in claim 1 wherein the ophthalmoscope is connected through the electrical power and control system to the overhead fluorescent light, the overhead incandescent light, the fixation light and the wall mounted muscle light, in such manner that upon actuation of the associated switch means of said ophthalmoscope, all of the aforementioned lights are turned "on," except for the overhead fluorescent light which is switched from the initial "on" position to the "off" position.

4. Apparatus as in claim 1, further including a trial lens tray disposed adjacent the patient's chair, and a small fish tank bulb light for illuminating the trial lens tray and connected to said electrical power and control system.

5. Apparatus as in claim 4 wherein the retinoscope is connected through the electrical power and control system to the fish tank bulb light, the muscle light and the overhead fluorescent light, whereby when said switch means associated with the retinoscope is actuated, all of said aforementioned lights are activated except for the fluorescent light which, from the initial "on" condition is rendered inoperative.

6. Apparatus as in claim 1 wherein the indirect ophthalmoscope is connected through the electrical power and control system to the background light, the overhead fluorescent light and the overhead fixation light in such manner that upon actuation of the switch means associated with said indirect ophthalmoscope, the background light and overhead fixation light are also activated, whereas the fluorescent light is switched on the initial "on" position to the "off" position.

7. Apparatus as in claim 1 wherein the electrical power and control system includes means for varying the intensity of the incandescent light.

8. Apparatus as in claim 1 further including a slit lamp operatively connected to the electrical power and control system.

9. Apparatus as in claim 8 wherein the slit lamp is connected through the electrical power and control system to the background light and the overhead fluorescent light in such manner that, as said slit lamp is actuated, the background light is switched "on," whereas the overhead fluorescent light is switched from the initial "on" position to the "off" position.

10. Apparatus as in claim 1 in which said overhead fixation light is red.