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Liana Al-Labadi, O.D. Case Analysis I- Lecture 5. If you hear hoof beats, think horses—not zebras. Case 5: The Distance Blur. A 59yo PF, an established patient, c/o blur at distance & difficulty driving at night F requency: Constantly (all the time, everyday) O nset: During the past year
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Liana Al-Labadi, O.D. Case Analysis I- Lecture 5
Case 5: The Distance Blur • A 59yo PF, an established patient, c/o blur at distance & difficulty driving at night • Frequency: Constantly (all the time, everyday) • Onset: During the past year • Location: Both eyes • Duration: Notices it all the time • Associated Factors: • No other symptoms of near vision blur or headaches or glare • Relief: None • Severity: N/A
Case 5: The Distance Blur • POH: • Negative for HA, DIPL, asthenopia, surgery, trauma, pain, F&F • Ophthalmic auras without migraines; No DR/Glc/AMD/Cat • Usually takes off specs to read • She reported previously blurry vision with uncontrolled HTN • Reported an episode of panic attack in the past while driving- could not focus properly • LEE: Last year by Dr. Curtis • FOH: Negative for AMD, DR, Glc, Cat • LPE: Last year by Dr. Nixon • PMH: (+) HTN- controlled with medsa; recently added changed meds (+)Anxiety- Have recently been increasing in frequency (+) Basal cell carcinoma on nose- diagnosed a year ago; treated • FMH: (+) HTN- parents; (+) DMII- father • MED: (+) Lotrel (+) Lorazepam • Allg: NKDA; No seasonal allergies • SH: Reading • Occupation: Clerk • No alcohol consumption & no smoking
Case 5: The Distance Blur • Entrance Testing: • Lensometry: • OD: -1.50 -0.50x 010 • OS: -1.50 -0.50x 160 • DVA (c): 20/50 OD; 20/50 OS • NVA (s): 20/25 OU • Motility: S&F OD, OS • Confrontations: Full OD, OS • Pupils: 4mm/4mm RRL OD, OS; No APD
Case 5: The Distance Blur • Cover Test: • (D) : 2pd XP • (N): 4pd EP • Retinoscopy: • OD: -1.00 -1.25x 030 • OS: -1.50 -2.00x 156 • Manifest Refraction: • OD: -1.00 -1.00x 030 VA: 20/20 • OS: -1.00 -1.50x 160 VA: 20/20
Case 5: The Distance Blur • Lensometry: • OD: -1.50 -0.50x 010 VA: 20/20 • OS: -1.50 -0.50x 160 VA: 20/20 • Manifest Refraction: • OD: -1.00 -1.00x 030 VA: 20/20 • OS: -1.00 -1.50x 160 VA: 20/20
Case 5: The Distance Blur • SLE: • L/L: Quiet OD, OS • Conj: No injections OD, OS • K: Clear OD, OS • Iris: Flat & brown OD, OS • AC: No cell & no flare/ D&Q OD, OS • Lens: Clear OD, OS (dilated) • IOP (TA): • 15mmHg OD; 15 mmHg OS @ 1:30pm • DFE: Unremarkable OD, OS
Case 5: The Distance Blur • Assessment: • Compound myopic astigmatism/ Presbyopia OU • Pt accepted new spec Rx with TF • Internal & external ocular health unremarkable OU • Plan: • Release final distance spec Rx • Pt prefers to take off specs to read • RTC in 1 year for CEE
Case 5: The Distance Blur • 1 month later pt returns to clinic c/o: • Problems with new specs- cannot describe her problem exactly • Frequency: • Notices that when she is looking straight ahead, everything seems fine. As soon as she looks around or begins to walk, things feels disturbing • Onset: Ever since she got the new glasses • Location: Both eyes • Duration: As long as she wears the specs • Associated Factors: None • Relief: Feels better when takes specs off & wears old glasses; Could not wear specs for more than 15-20 minutes • Severity: N/A
Case 5: The Distance Blur • Lensometry: • OD: -1.00 -1.00x 030 • OS: -1.00 -1.50x 160 • DVA (c): 20/20 OD; 20/20 OS • NVA (s): 20/20 OU • Motility: S&F OD, OS • Confrontations: Full OD, OS • Pupils: 4mm/4mm RRL OD, OS; No APD
Case 5: The Distance Blur • Cover Test: • No significant change • Manifest Refraction: • No significant change
Case 5: The Distance Blur • Change in frame size or shape • Not a factor; pt used the same frame she purchased previously • Base curves • PD • Lens material • Pantoscopic tilt • Glasses adjustment
Case 5: The Distance Blur • CASE HISTORY!!! • Patient has been an established patient for 7 years • The new prescription does not seem to be that different from LAST YEAR’S prescription • Patient sheepishly admits that she had been unable to wear last year’s specs because of similar difficulties
Case 5: The Distance Blur • 2 years ago: • MR OD: -1.50 -0.50x 010 OS: -1.50 -0.50x 160 • 1 year ago: • MR OD: -1.00 -1.00x 020 OS: -1.25-1.00x 160 • This year: • MR OD: -1.00 -1.00x 030 OS: -1.00 -1.50x 160
Case 5: The Distance Blur • Assessment: • Compound myopic astigmatism/ Presbyopia OU • Difficulty adapting to increased astigmatic Rx • Plan: • Release final distance spec Rx • OD: -1.25-0.75x 020 • OS: -1.25-0.75x 160 • Pt education on adaptation period with new spec Rx • TF new spec Rx in office- pt accepted • RTC in 1 year for CEE or PRN
Case 5: The Distance Blur • Clinical Tips: • Patients who don’t wear specs full time have more difficulty adapting to a change in prescription • A patient with low to moderate CHA may wear specs only when working on the computer • A patient with low to moderate CMA may use the prescription only for driving • For these patients each time they put on their specs, they have to make spatial adaptation to the cylindrical or axis change all over again • Reassure patients that they will adapt to the new Rx – usually works