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Introduction to the entrance tests
The entrance tests are the first procedures performed following the case history．The intelligent selection of the procedures to be included in this sequence and the ongoing interpretation of the data gathered can make the difference in whether or not an efficient and accurate differential diagnosis is obtained at this point in the examination．
With the increasing pressures of health care economics，providers are adapting examination strategies that are primarily directed by symptomatology or positive test findings to maximize the efficiency of care and minimize the costs of delivery．The resulting decrease in the overall number of examination procedures performed on any given patient increases the importance of entrance test selection and their role of screening for visual disorders．
The entrance test sequence is usually composed of eight to twelve procedures that have a low cost／benefit ratio，can be performed quickly，and are not dependent on technologically sophisticated equipment．Typically，these tests have been used to elicit information that helps to define the status of each of the primary problem areas：health, refraction，and functional vision．Frequently，entrance tests apply across categories and screen for problems in more than one area(see Table 2-l)．
Considered a part of the minimum defined data base, the entrance tests provide valuable information by screening for the presence of ocular anomalies in the absence of patient symptoms．Examples include neurological deficits as revealed by pillary testing and visual field screenings, accommodative insufficiency identified by accommodative amplitude testing, or a muscle imbalance as noted by cover test．The information obtained from this testing sequence also provides a baseline of diagnostic information for future comparison．
It is critical to emphasize that there is no one right set of entrance tests．Ask a number of eye care providers what they include in this sequence and you are likely to get a variety of answers．In fact，it is reasonable，and probably desirable，to expect that a given provider will have two or three lists that are age referenced．A test such as amplitude of accommodation serves a valuable role among children，young adults，and early presbyopes，yet provides little useful information for the elderly．For the elderly, it may be far more useful to include an Amsler grid test to eva luate macular function as a part of the preliminary exam．The selection of tests for inclusion in the entrance test sequence must be based on a careful consideration of the cost of performing the test in terms of practitioner time and the return in terms of the usefulness of the information．
In this text, sixteen procedures are included under the entrance tests section．Two of these, screening visual fields and finger counting fields，serve the same function．They are offered as alter natives．Pinhole acuity is measured only in the event of decreased visual acuity．The Worth 4 Dot is done only if there is a significant decrease in a patient’s stereoacuity．The Brückner test is included as an alternative to the Hirschberg test，and can be invaluable in screening infants and young children for strabismus and anisometropia．
There are tests included in other chapters that could be considered for inclusion as entrance tests．One of these, blood pressure measurement, is included as an entrance test with increasing frequency as optometrists assume responsibility for the detection of systemic diseases with related ocular manifestations．Other procedures to consider include the Amsler grid test，accommodative facilily，associated phoria，and the dominance sighting test．
Once the decision as to what constitutes the entrance tests is made，thought must be given to the testing sequence．By definition the entrance tests sequence is intended to be efficient．Factors that affect the sequencing include the equipment needed(many of the entrance tests use common equipment)and whether the test is done with or without the patient’s correction．The flowchart in Figure 2-1 illustrates a recommended sequence of entrance tests for an adult patient． |
