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CASE DISCUSSION and Prescribing aspects

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

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CASE DISCUSSION and Prescribing aspects

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  1. CASE DISCUSSIONandPrescribing aspects Anshika Shah 200525TS012

  2. Case 1 • A 40 year old man presented for a routine eye examination. • No specific complaints for distance or near vision.

  3. 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

  4. 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

  5. Diagnosis • Management

  6. 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

  7. 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

  8. Case 3 • A 6 year old school girl was referred since she failed in the school screening. No visual complaints noticed so far.

  9. 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

  10. 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  

  11. Diagnosis • Management

  12. 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

  13. 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.

  14. 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

  15. Diagnosis • Management

  16. 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.

  17. 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.

  18. 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.

  19. 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

  20. Diagnosis • Management

  21. 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.

  22. 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.

  23. 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.

  24. 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

  25. 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

  26. Diagnosis • Management

  27. 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

  28. 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.

  29. 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.

  30. Case 8 • A 28 year old woman came with complaints of driving difficulty at night. No other specific complaints.

  31. 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

  32. 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.

  33. Diagnosis • Management

  34. Treatment Plan • Diagnosis: • Anisometropia with mixed astigmatism (OD) • Compound myopic astigmatism (OS) • Antimetropia • Management: • Contact lenses to reduce anisekonia

  35. 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.

  36. 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

  37. 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)

  38. Diagnosis • Management

  39. Treatment Plan • Diagnosis: • Low myopia (OS) with Astigmatism (OU) • Divergence Excess • Management: • Full correction of myopia and astigmatism • Review with glasses • Vision therapy

  40. 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.

  41. 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

  42. 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)

  43. 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

  44. Diagnosis • Management

  45. 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

  46. 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.

  47. Thank you

  48. 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

  49. Hyperopia Guidelines • 20 yrs and above • Compensation for complaints + Moderate Plus cut distance + full compensation for near

  50. 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

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