Il n’y a pas une consultation d’ophtalmologie typique, mais des consultations, différentes les unes des autres en raison de multiples facteurs : demande du patient venant consulter, type de pathologie présentée, ancienneté du consultant ou nouveau patient, âge de ce dernier, spécificité du médecin ophtalmologiste consulté… A chaque patient peut correspondre une consultation spécifique !
Chaque médecin ophtalmologiste reste maître de ce qu’il va entreprendre auprès du patient qu’il a devant lui et il adapte sa consultation en fonction de ses constatations dans le déroulement de celle-ci.
Actuellement, beaucoup d’ophtalmologistes se font aider dans le déroulement de leur consultation : secrétaires, orthoptistes, infirmières, personnel formé. Ces aides peuvent réaliser un certain nombre de gestes – sous la responsabilité du médecin – gestes qui, colligés dans le dossier du patient, serviront à la synthèse et à la conclusion de cette consultation par l’ophtalmologiste.
Il n’y a pas de temps imparti pour chaque consultation : elle peut être de courte durée chez un patient connu nécessitant un contrôle régulier pour une pathologie connue ; à l’opposé, elle peut être plus longue et détaillée chez un patient vu pour la première fois pour une pathologie complexe.
Pour simplifier, il est possible de définir une consultation standard (dite « de base ») sur laquelle viendra se greffer un certain nombre d’examens complémentaires, examens pouvant être variables selon la pathologie présentée ou recherchée.
Une consultation standard :
Après l’ouverture du dossier, en général réalisé par le secrétariat du médecin : identification du patient et recueil des différentes coordonnées de celui ci, la consultation démarre par un interrogatoire permettant de relever les antécédents familiaux et personnels du patient, en particulier dans le domaine ophtalmologique. L’objet de la consultation est alors bien sûr précisé.
Vient ensuite le temps de l’examen proprement dit :
– il démarre le plus souvent par la vérification de l’acuité du patient, en vision éloignée et/ou rapprochée, sans correction et/ou avec la correction portée. Après une phase de recherche du défaut concerné (examen à l’ophtalmomètre de Javal, skiascopie, examen à l’auto-réfracteur automatisé …), un essai de verres correcteurs est entrepris à la recherche de la meilleure acuité visuelle possible, tant de loin que de près. Cet examen définit ainsi une formule de réfraction, base de l’ordonnance verre délivrée.
– il se poursuit par un examen des différents milieux oculaires à l’aide du biomicroscope ou « lampe à fente ». Cet examen permet de renseigner le praticien sur l’état de la cornée, de la chambre antérieure et du cristallin.
– vient ensuite la mesure du tonus oculaire ou « pression intra oculaire » à l’aide du tonomètre à air ou du tonomètre à aplanation (nécessitant l’instillation d’un anesthésique et d’un colorant).
– l’examen standard se termine le plus souvent par l’examen des fonds d’yeux à l’aide de l’ophtalmoscope permettant au praticien de se renseigner sur l’état de la papille optique, de la zone maculaire et du réseau vasculaire du pôle postérieur rétinien.
La consultation se conclut par l’énoncé des constatations du médecin et par l’élaboration d’une prescription, quelle soit optique ou médicamenteuse.
Des examens complémentaires :
Un certain nombre d’examens, complémentaires à ceux décrits plus haut, peut être entrepris, soit au cours de la consultation proprement dite, soit dans un second temps. La liste en est longue et non exhaustive : elle dépend de l’équipement du médecin consulté.
Il peut s’agir de l’examen de la vision binoculaire (croix ou aile de Maddox, stéréoscopie) ; de l’examen de la vision des couleurs (planches d’Ishihara ou test plus spécifiques) ; de l’examen du fond d’œil après dilatation pupillaire par mydriatique ; de la gonioscopie visualisant l’angle irido-cornéen ; de l’examen du champ visuel sur périmètre automatisé ou sur coupole de Goldmann ; de la pachymétrie permettant d’évaluer l’épaisseur cornéenne ; de l’OCT donnant un examen fin de la zone maculaire ou de la papille optique ; d’une rétino-photographie sans mydriatique ; de l’angiographie à la fluorescéine ou au vert d’indocyanine selon la pathologie recherchée ; d’une échographie …
Des consultations plus spécifiques :
Elles dépendent de l’âge du patient, de la pathologie présentée ou suivie ; de la demande spécifique du patient. Elles sont adaptées par le praticien en fonction des éléments trouvés au cours de son examen. Quelques exemples :
– Chez le jeune enfant consultant pour suspicion de strabisme ou strabisme avéré : recherche d’une amblyopie (mauvaise vision d’un œil), examen sous cycloplégie médicamenteuse (blocage de l’accommodation), examen de la vision binoculaire et de la stéréoscopie, examen du fond d’œil à la recherche d’une cause organique.
– Chez le jeune en âge scolaire : recherche d’une amétropie et/ou suivi de son évolution, examen de la vision binoculaire, de la vision des couleurs, de la stéréoscopie, examen du fond d’œil.
– Chez l’adulte autour de la quarantaine : recherche d’une amétropie, de loin et de près ; prise du tonus oculaire systématique, avec les examens complémentaires qui en découlent si tonus élevé (gonioscopie, pachymétrie, examen des papilles optiques, des champs visuels…), examen du fond d’oeil.
– Chez l’adulte autour de la soixantaine et plus âgé : recherche d’une modification de la transparence des milieux, d’une hypertonie oculaire, des anomalies du vieillissement au niveau de la zone maculaire.
Conclusions :
Il est difficile d’établir des règles précises dans le déroulement d’une consultation en ophtalmologie. Chaque médecin bâtit sa consultation en fonction de ce qu’il connaît du patient, de ce qu’il trouve à chaque étape, de son aptitude diagnostique et thérapeutique. Il peut à tout moment se faire aider par un confrère afin de trouver le moyen de satisfaire le patient qui le consulte. Son expérience médicale générale et spécialisée est le garant du bon diagnostic et de la meilleure thérapeutique pour chaque patient qui le consulte.
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