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CASE DISCUSSION and Prescribing aspects. Anshika Shah 200525TS012. Case 1. A 40 year old man presented for a routine eye examination. No specific complaints for distance or near vision. Clinical findings. UNAIDED VA: OD: 6/5, N6 @ 40 cm - PowerPoint PPT Presentation
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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)