Mr Lay (M/75) came for eye examination, with complaint of blurry far & near vision recently. He
wears a pair of ready-made reading glasses. Previously, he was told to have cataract already. Daughter reported that he has no diabetes.
Vision without glasses
R: 6/18-
L: 6/15-
Examination shows:
R: PL/-0.75×80 (6/12+) PH 6/9+
L: PL/-0.75×110 (6/12+) PH 6/9+
Add: +2.50 (N6@40cm)
Other assessments show:
Examination of Eye Alignment/Vergence (Cover Test, CT)
NMD @Distance
(alternating CT: upon covering left eye, patient reported the target stays centre.. when covering right eye, the target goes up & to his right @45°)
NMD @Near
(alternating CT: upon covering left eye, patient reported the target is blurry & smaller.. when covering right eye, the target is clearer & bigger)
(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
Near: 0 – 2 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
Colour Vision
R: normal
L: normal
(normal value: normal)
Amsler Chart (assess integrity of macula)
R: some light, brownish patches
L: all lines are straight
(normal value: lines are straight with equal gaps in between lines & no brown/black patch/spot)
Pupil Reflex
R: PERRLA, -ve RAPD
L: PERRLA, -ve RAPD
(normal value: PERRLA, -ve RAPD)
Fluorescein
R: -ve staining
L: -ve staining
We refer him to see eye doctor/ophthalmologist.