HOWARD TANG ZHE YU – 88 Optometry

16/4/2022

Howard (M/15) came for eye examination, vision with existing glasses is fine seeing far & near. He wants to try wearing contact lenses to school and he has sinus.

Vision without glasses
R: 6/45
L: 6/45-1

Vision with existing glasses
R: -3.25/-1.75×15 (6/7.5-)
L: -3.75/-1.75×165 (6/6-) he reported vision in left eye is very bright(over power may give us this uncomfortable brightness)

Examination shows: (Delay Fogging)
R: -3.50/-1.75×15 (6/6) [+1.00 blur lens test: 6/12-1] (R: right dominant eye) R>L
L: -3.50/-1.75×165 (6/6) [+1.00 blur lens test: 6/12]
Near: L>R
Upon removing astigmatism in both eyes, patient can see 6/9 binocularly

Other assessments show:

Examination of Eye Alignment/Vergence (Cover Test, CT)
NMD @Distance
(alternating CT: upon covering left eye, patient reported the target goes to his left.. when covering right eye, the target goes to his right)
small XP, fast recovery @Near
(alternating CT: upon covering left eye, patient reported the target goes to his left.. when covering right eye, the target goes to his right)
(normal value: orthophoria/NMD-No Movement Detected or small XP, fast recovery)
EP = Esophoria is misalignment of the eye, eye is deviated inwards
XP = Exophoria is misalignment of the eye, eye is deviated outwards

Examination of Eye Alignment/Posture (Howell Card) by 6^ Base Down on Right eye
Distance: 0 – 2 XP (blue part)
Near: 2 – 4 XP (blue part)
+1.00 Near: 4 – 6 XP (blue part)
(normal value: 0-1 EP (yellow part) or 0-3 XP (blue part) @Distance; and 0-6 XP (blue part) @Near)
EP = Esophoria is misalignment of the eye, eye is deviated inwards
XP = Exophoria is misalignment of the eye, eye is deviated outwards

NRA (Accommodation analysis – ability to relax accommodation) by plus lens
+1.25
(normal value: +1.50 to +2.50)

PRA (Accommodation analysis – ability to stimulate accommodation) by minus lens
-1.50
(normal value: -1.37 to -3.37)

MEM – Monocular Estimation Method (Accommodation lag – to measure accommodation response seeing near target)
R: +1.00
L: +1.00
(normal value: +0.25 to +0.75)

AA (Amplitude Accommodation/Focusing – eye stamina/ability of eye to focus & sustain seeing near clearly) by RAF rule
R: 15 YO, 20 YO, 25 YO, 20 YO
L: 15 YO, 20 YO, 25 YO, 20 YO
(normal value: AA goes according to age; YO=years old)

NPC (Convergence – ability of eye to maintain a single clear near image) by RAF rule
6/8cm, 8/10cm, 10/12cm, 12/14cm, 14/16cm
(normal value: Break/Recovery in less than 10cm or to the nose, TTN)

Fluctuation in AA is noted & NPC is receded. We asked whether or not he sees blurry near vision sometimes, he said that he sees blurry computer vision after some time with stinging pain & dryness since mid last year.. after having a new computer at home. He does not use computer that much now, and the dryness lessens.

Accommodation Facility – ability to change focus: far to near or near to far (by Flipper +/-2.00)
BE: 13 cycle per minit(cpm), difficult with minus lens(2nd lens)
R: 14 cycle per minit(cpm), difficult with minus lens(2nd lens) [both eyes see better than with right eye]
L: 14 cycle per minit(cpm), difficult with minus lens(2nd lens) [both eyes see better than with left eye]
– patient reported vision is zoomed bigger with plus lenses
(normal value: 1 cycle = 2 words read
Monocular or R/L: 6cpm to 16cpm
Binocular or BE-both eyes: 4cpm to 14cpm)

Fusional Reserves (Convergent/Divergent reserve stamina) by Prism Bar
Near, Base-Out/Convergent, PFV: 18/30/25
Near, Base-In/Divergent, NFV: 14/18/16
Distance, Base-Out/Convergent, PFV: 14/20/18
Distance, Base-In/Divergent, NFV: 10/12/10
(normal value: Blur/Break/Recovery)
Near, PFV: 10-28/7-21
Near, NFV: 7-19/5-15
Distance, PFV: 4-18/5-9
Distance, NFV: 4-10/2-6
[Scheiman – Adult Data]

Vergence Facility – ability to make rapid repetitive vergence changes (by Prism Flipper of 12Base Out & 3Base In)
Near: 6 cpm (double Base-Out.. upon repeated testing, double with Base-In too)
Distance: 5 cpm (double with Base-In)
(normal value: 1 cycle = 2 times clearing target
Distance: 12-18 cpm
Near: 12-18 cpm)

With Add +0.50 in both eyes,BE

NPC (Convergence – ability of eye to maintain a single clear near image) by RAF rule
6/8cm, 8/10cm, 10/12cm, 10/12cm, 10/12cm
(normal value: Break/Recovery in less than 10cm or to the nose, TTN)

Fluorescein test is positive, he has some corneal staining/dry eyes.

We prescribe non-preserved artificial tears (gel) for 2weeks.

We are not sure whether or not his reduced AA & receded NPC are due to dry eyes.. as dry eyes may cause blurring of vision too. We will assess his AA & NPC again after his dry eyes have recovered.

Interpupillary Distance = 6.8cm

*Updated

We fit:
R: -3.50/-1.25×10
L: -3.50/-1.25×160
Vision with both eyes 6/6- slow

Over Rx
R: -0.25
L: -0.25
Vision with both eyes 6/6

Examination of Eye Alignment/Posture (Howell Card) by 6^ Base Down on Right eye
Distance: 0
Near: 4 – 6 – 8 XP (blue part)
(normal value: 0-1 EP (yellow part) or 0-3 XP (blue part) @Distance; and 0-6 XP (blue part) @Near)
EP = Esophoria is misalignment of the eye, eye is deviated inwards
XP = Exophoria is misalignment of the eye, eye is deviated outwards

AA (Amplitude Accommodation/Focusing – eye stamina/ability of eye to focus & sustain seeing near clearly) by RAF rule
R: 20 YO, 20 YO, 20 YO
L: 20 YO, 20 YO, 20 YO
(normal value: AA goes according to age; YO=years old)

NPC (Convergence – ability of eye to maintain a single clear near image) by RAF rule
6/8cm, 6/8cm, 8/10cm, 8/10cm, 10/12cm, 10/12cm
(normal value: Break/Recovery in less than 10cm or to the nose, TTN)

Fusional Reserves (Convergent/Divergent reserve stamina) by Prism Bar
Near, Base-Out/Convergent, PFV: x/14/12
Near, Base-In/Divergent, NFV: x/10/8
Distance, Base-In/Divergent, NFV: x/10/8
Distance, Base-Out/Convergent, PFV: 20/18
(normal value: Blur/Break/Recovery)
Near, PFV: 10-28/7-21
Near, NFV: 7-19/5-15
Distance, PFV: 4-18/5-9
Distance, NFV: 4-10/2-6
[Scheiman – Adult Data]

When we ask Howard to look far, far away, he said that he sees shadow sometimes.. despite adding -0.25 in both eyes. He reported that he also sometimes sees blurry/with shadow at far with his own glasses.. in which he blinks his eyes to see clear again.

We prescribe eye exercise for him to strengthen his convergence and we will see him in 4-6 weeks.