CASE DISCUSSION and Prescribing aspects

CASE DISCUSSIONand

Prescribing aspects

Anshika Shah200525TS012

1

Case 1• A 40 year old man presented for a routine eye examination.

• No specific complaints for distance or near vision.

2

Clinical findings• UNAIDED VA:

OD: 6/5, N6 @ 40 cm

OS: 6/5, N6 @ 40 cm (habitual reading distance)

• Cover test: Distance : Ortho

Near : 4 prisms Exophoria

3

Clinical findings

• Retinoscopy:

OD: +0.75DS

OS: +0.75 DS

• Acc:

OD: +0.50 DS (6/5)

OS: +0.50 DS (6/5)

• ADD: OU: Plano (N6) @ 40 cm

• NRA/PRA: +1.75/ -2.00 DS

4

Diagnosis

Management

5

Treatment plan• Patient was asked to compare vision for distance and

near, with and without glasses. No significant difference in vision observed subjectively.

• Diagnosis: OU: Hyperopia• Management: No intervention required• Reasons: Exophoria for near and good

accommodative amplitudes for age

6

CASE 2• 2 yr old child with the c/o suspicious less vision (parents version )

• Vision (PLT): OD: 6/18

OS:6/18

• Cycloplegic Flash: OD: +4.50 DS

• OS: +4.00 DS

• Cover Test : Ortho Distance / Near

• Management : ?

• Full cycloplegic correction

7

Case 3• A 6 year old school girl was referred since she failed in the school

screening. No visual complaints noticed so far.

8

Clinical findings• Vn (OU) 6/60, N6 @ 40 cm

• Retinoscopy:

OD: +5.25 DS/ -1.00 x 90

OS: +4.75 DS/ -0.75 x 90

• Acc:

OD: +5.25 DS/ -1.00 x 90 (6/7.5)

OS: +4.75 DS/ -0.75 x 90 (6/7.5)

• ADD: OU: Plano (N6) @ 40 cm

• NRA/PRA: +1.75/ -2.00 DS

9

Clinical findings• Cycloplegic Refraction:

OD: +6.75 DS/ -1.00 x 90 (6/7.5)

OS: +6.25 DS/ -0.75 x 90 (6/7.5)

• Keratometry:

OD: 43.37/ 41.75 @ 900

OS: 43.87/ 42.25 @ 900

• Post Mydriatic Test: Acc:

OD: +5.25 DS/ -1.00 x 90 (6/7.5), N6

OS: +4.75 DS/ -0.75 x 90 (6/7.5), N6  

10

Diagnosis

Management

11

Treatment plan• Diagnosis: OU: Compound Hyperopic astigmatism• Management: PMT value can be given as glasses to

ensure compliance.• Plastic lenses• Follow-up 3/12• Follow-up examination at 3 months with glasses: OU:

6/7.5, N6• CT- Ortho for distance and near• Stereo: 70 arc seconds

12

Case 4• A 38 year old software professional came for a routine eye

examination. He had no complaints regarding vision for

distance or near.

• He also reported that his left eye vision is always poorer than

the right eye since childhood.

• He was prescribed glasses thrice between 10 and 25 years

and he never felt comfortable with glasses and it did not

improve his vision also. He wants to know the further

management that can be done to improve his vision in the left

eye.

13

Clinical findings• UNAIDED VA:

OD: 6/6, N6 @ 30 cm

OS: 3/60 with ph NI, N36 @ 40 cm

• Cover test: Ortho for Distance and near

• Stereo acuity at near: 100 arc seconds

• Retinoscopy: OD: +1.00 DS

OS: +6.75 DS/ -3.00 x 30

• Acc: OD: +1.00 DS (6/5, N6)

OS: +6.75 DS/ -3.00 x 30 (6/60, N12 at 20 cm) with ph NI

14

Diagnosis

Management

15

Treatment plan• Diagnosis: • OD: Hyperopia OS: Compound hyperopic astigmatism • Anisometropia • OS: Refractive amblyopia• Management:• Polycarbonate protective glasses in a safety frame• Prescribe: OD: +1.00 DS; OS: +1.00 DS (Balance

lens)• Patient explained about the condition and the need to

protect his spare eye.

16

Case 5• A 39 year old school teacher reported for an annual eye

examination and expressed an interest for contact lenses. She was

comfortable with her old glasses.

17

Clinical findings

• Visual acuity with glasses:

OD: 6/6-4, N6 @ 35 cm

OS: 6/6-3, N6 @ 35 cm

OU: 6/6, N6 @ 30 cm.

• Glass prescription: OD: -6.00 DS

OS:-6.50 DS

• Cover test (With glasses): Ortho for distance and 4 prisms

Exophoria for near.

18

Clinical findings• Retinoscopy:

OD: -6.75 DS

OS:-7.00 DS

• Acceptance:

OD:-6.50 DS (6/5), N6 @ 40 cm

OS:-7.00 DS(6/5), N6 @ 40 cm

• NFV: D: X/8/4 N: 16/24/18

• PFV: D: 12/24/15 N: 28/32/14

• NRA/PRA: +2.25/-1.00

19

Diagnosis

Management

20

Treatment Plan• Diagnosis: High myopia• Approaching presbyopia

• Discussion:• Low PRA can be attributed to approaching presbyopia.

• The new correction for distance can cause near vision difficulties. Binocularly patient does not have any complaints for distance or reading with old glasses.

21

• The patient’s fusional ranges are normal and the blur values for PFV are more than twice the Phoria.

• Hence the need for increasing the minus for distance is not necessitated.

• Near PFV is according to Morgan’s normal values.

• Contact lenses might increase the accommodative demand of the visual system for reading.

• Patient has to be educated about this and add for reading can be prescribed over the CL if required.

22

Case 6• A 9 year old school going girl had been wearing glasses since past

3 years.

• No complaints regarding vision with glasses for distance and near.

• But she complained of discomfort while reading for more than 20

minutes. Mother had noticed occasional deviation of the eye

inwards while concentrating at near.

23

Clinical findings

• UNAIDED VA:

OD: 6/12, N8 @ 40 cm

OS: 6/15, N8 @ 40 cm

• Cover test: Distance- 10 prisms Esophoria

• Near - 4 prisms Esophoria

• Stereo acuity at near: 100 arc seconds

24

Clinical findings• Visual acuity (with glasses): OU: 6/6, N6 @ 30 cm

• Glass prescription: OU: +5.00 DS

• Cover test with glasses: Dist: Ortho.

Near: 15 prisms Esotropia

• Stereo: 140 arc seconds

• Retinoscopy:

OD: +5.00 DS

OS: +5.00 DS

• Acc: Same as old glasses (OU) (6/6, N6)

• Cycloplegic Refraction: 0U:+5.00 DS

25

Diagnosis

Management

26

Treatment Plan• Diagnosis: OU: Hyperopia with Accommodative

Esotropia• Management: • Cover test for near repeated with +2.00 DS: Ortho for

near:• With +2.50 DS: Exophoria• Impression: Accommodative Esotropia with high AC/A

Ratio

27

• Advice: Plastic lenses/ Polycarbonate executive bifocal lenses with the segment line at mid – pupil to ensure that the patient sees through the addition for near works.

• Need for bifocals and full time wear of the glasses explained to the parents.

• Follow-up 3/12• Follow-up examination at 3 months with glasses: OU:

6/6, N6• CT- Ortho for distance and near• Stereo: 70 arc seconds

• A review with the bifocal glasses should always be advised to avoid any overcorrection in the addition leading to consecutive deviations.

28

Case 7• 12 year old with aversion for doing reading but love to watch TV

with unaided Vision of 6/6; N6 in both eyes

• Flash : OU : +1.50 DS (6/6) N6

• Ortho – Distance and Near

• Vergence : Normal

• Management : ?

• Prescribe only for reading and near work.

29

Case 8• A 28 year old woman came with complaints of driving difficulty at

night. No other specific complaints.

30

Clinical findings

• UNAIDED VA:

OD: 6/7.5, N6 @ 30 cm

OS: 6/60 with ph NI, N6 @ 30 cm

• Cover test: 3 prisms Exophoria for Distance and 4 prisms Exophoria

for near

• Stereo acuity at near: 60 arc seconds

31

Clinical findings• Retinoscopy:

OD: +0.25 DS/ -1.00 x 175

OS: -1.50 DS/-1.00 X 180

• Acc:

OD: +0.25 DS/-0.50 X 180 (6/5, N6)

OS: -2.00 DS/ -0.50 x 180 (6/5, N6)

• Even though visual acuity ahs improved with correction, patient does not

want glasses.

32

Diagnosis

Management

33

Treatment Plan• Diagnosis:• Anisometropia with mixed astigmatism (OD) • Compound myopic astigmatism (OS)• Antimetropia

• Management:• Contact lenses to reduce anisekonia 

34

Case 9• A 10 year old boy was brought with the complaint of left eye drifting

outwards. Mother felt that the problem is getting worse. There were

no other specific complaints.

•

35

Clinical findings• UNAIDED VA:

OD: 6/9, N6 @ 30 cm

OS: 6/9, N6 @ 30 cm

• Cover test: 20 prisms intermittent left Exotropia for Distance and 5

prisms Exophoria for near

• Stereo acuity at near: 60 arc seconds

• Calculated AC/A Ratio: 12/1

• NPC: 7 cm

36

Clinical findings

• For near: NFV: 10/16/12 PFV: X/15/10

• Retinoscopy:

OD: +0.00 DS/ -1.50 x 180

OS: -0.50 DS/-0.50 X 180

• Acc:

OD: +0.00 DS/ -1.50 x 180 (6/5, N6)

OS: -0.50 DS/-0.50 X 180 (6/5, N6)

37

Diagnosis

Management

38

Treatment Plan• Diagnosis:• Low myopia (OS) with Astigmatism (OU) • Divergence Excess

• Management:• Full correction of myopia and astigmatism• Review with glasses• Vision therapy

39

Case 10• A 9 year old school girl complained of distance blur with the present

glasses. She has been wearing glasses for the past 1 year. She

reads extensively.

40

Clinical findings• Visual acuity (with glasses):

OD: 6/9, N6 @ 40 cm

OS: 6/12, N6 @ 40 cm.

• Glass Prescription:

OD: -2.25/ -0.25 X 80

OS: -2.00/-0.25 X 95

• Phoria measurements: Ortho for Distance and 5 prisms Esophoria

for near

41

Clinical findings

• Stereo acuity at near: 100 arc seconds

• Retinoscopy:

OD: -3.00 DS/-0.25 x 90

OS: -3.00 DS/-0.25 x 90

• Acc:

OD: -3.00 DS/-0.25 x 80 (6/5, N6)

OS: -3.00 DS/-0.25 x 100 (6/5, N6)

42

Clinical findings• Gradient AC / A Ratio: 6/1

• PFV: D: 10/20/10 N: 24/32/15

• NFV: D: X/8/3 N: 6/18/4

• NPC: 3 cm

• Amplitude of accommodation: 15.00 D

43

Diagnosis

Management

44

Treatment Plan• Patient felt that the distance vision is better with the

new glasses but felt that the near vision is better with the old glasses.

• DIAGNOSIS:• Increase in myopia• Convergence Excess• Low Base-in fusional vergence and low PRA at near  

45

• Management:• Add of +1.00 DS can be prescribed to shift the near Phoria

range into the normal range.• Explained the need for bifocals and increasing myopia.

Option of Contact lenses for Distance and reading glasses over the lenses suggested.

• Review with bifocal glasses after 2 weeks:• Patient felt very comfortable for reading.• Cover test: Ortho for distance and near with bifocals.

• A plus add is the treatment of choice for convergence excess. Any latent Hyperopia should be identified using cycloplegic refraction and should be prescribed.

46

Thank you

47

Hyperopia Guidelines• Upto 6 yrs

• 6 -20 yrs

• No compensation (2 -

3D)

• Except Strabismus,

suppression or poor

school performance

• No compensation

• Except near

asthenopia or ↓ Vn

• Liberal cut Plus Cx

Hyperopia Guidelines

• 20 yrs and above • Compensation for

complaints +

Moderate Plus cut

distance + full

compensation for

near

Hyperopia Guidelines

• Low Hyperopia + Symptom +/- eso: Full to

Partial correction – age dependent

• High Hyperopia + ↓ Vn - Cx

• Initial Mx for Hyperopia + eso – full cyclo.

Cx

• Reduction of Cx – School going children and

adults

Myopia Guidelines• Cycloplegic refractions are mandatory-

infants ,esotropic children , high Myopes

• Prescribe full amount of refractive error

including cylinder. Young will tolerate well

• Intentional undercx of a myopia esotropic to

decrease angle of deviation is rarely tolerated

• < 30 yrs full cx; > 30 yrs go in steps

Astigmatism

• Low with the rule + asymptomatic: No Cx

• Low with the rule + symptomatic : Cx

• Low against the rule : Cx

• High with the Rule : Cx

• Oblique astigmatism + symptomatic: Cx

• High Spherical + low astigmatism : Based on

Vision clarity

• > 2.50 D : Amblyopia

Presbyopia Guidelines▫Based on Amplitude of Accommodation

▫½ or 1/3rd AA reserve

▫Exophoria with add : plan for prism if less PFV

Prism Prescribing Guidelines• Morgan’s Criterion : Based on Morgan’s Normative

Values

• Clinical Wisdom : 1/3rd of measured angle of deviation

• Sheard’s Criteria: 2/3(Phoria) – 1/3(Fusional

vergence) - eso look BI ; exo look BO

eg : 6 prism exo, BO to blur 6 prism Amount of prism

will be 2 prism BI ( 1 prism each eye)

• Percival Criteria : 1/3( greater limit of BI or BO

range) – 2/3(lesser limit of BI or BO range)