CHONG ZHI QING – 88 Optometry

15/4/2022

ZQing (F/13) came for eye examination, with complaint of slight blurry far vision with existing glasses of 1+ year. Her near vision is fine, but she reported blurry near vision sometimes in which she will wash her face & it will be fine then. We observe that she has her head tilted up to see far, when we asked.. she said that her vision is better like this. She also will tilt her head left or right to see if it is better. No headache is reported.

Vision without glasses
R: 6/60+1
L: 6/45-1

Vision with existing glasses
R: -3.50/-1.25×175 (6/7.5-, slow guess 6/6-)
L: -3.25/-1.25×160 (6/7.5-, slow guess 6/6-)

Examination shows:
R: -3.75/-1.25×175 (6/6) [+1.00 blur lens test: 6/18] (R: right dominant eye)
L: -3.50/-1.25×160 (6/6) [+1.00 blur lens test: 6/12-] L>R
Adding +0.50 in OS, R>L but she did not like it
Near: R>L {adding +0.50 in OS, L>R but she did not like it}

Other assessments show:

Cover Test
Distance: NMD
Near: small EP, fast recovery

Howell Card (6BD on OD)
Distance: 1 – 3 – 5 EP (yellow part)
Near: 11 – 13 – 15 EP (yellow part)
+1.00 Near: 3 – 5 – 7 EP (yellow part)

Maddox Rod
Distance: horizontal white line touches red spotlight but horizontal white line is slanting (patient left is higher, right is lower) & 5 Base-Out (touch then drift apart) [with head tilt to left, horizontal line becomes straight]
Near: same like Distance

NRA
+2.75

PRA
-0.75

MEM
R: +1.25
L: +1.25

AA (RAF rule)
R: 6 YO, 6 YO, 6 YO
L: 8 YO, 8 YO, 8 YO

NPC (RAF rule)
TTN, TTN, TTN, TTN, TTN, TTN

Accommodation Facility (Flipper +/-1.00)
BE: 10 cycle per minit(cpm), difficult minus lens
R: 12 cycle per minit(cpm), difficult minus lens[OU see better than with OD]
L: 12 cycle per minit(cpm), difficult minus lens[OU see better than with OS]
– patient cannot clear -2.00 & -1.50

Fusional Reserves (Prism Bar)
Near, NFV: x/6/2
Near, PFV: x/12/10
Distance, NFV: 8/10/8
Distance, PFV: 12/30/20

Vergence Facility (Prism Flipper 12BO & 3BI)
Near: 6 cpm (slow BO.. upon repeated testing, slow BI too)
Distance: 5 cpm [slow BO & BI(more difficult)]

Random Dot 3S
20″
16″ (with Add +1.00)

Interpupillary Distance = 6.0cm

ZQing also told us that she sometimes sees double vision when eyes are tired. We refer her for cycloplegic refraction.

*UpdatedA 10/8/2022

ZQing had cycloplegia last week. She came back for follow up.

Vision without glasses
R: 6/60+1
L: 6/45-

Vision with existing glasses
R: -3.50/-1.25×175 (6/9)
L: -3.25/-1.25×160 (6/7.5-)

Cycloplegic Refraction
R: -4.00/-1.00×170 (6/6)
L: -3.25/-1.50×160 (6/6)

Subjective Refraction
R: -4.25/-0.75×170 (6/6)
L: -3.75/-0.75×160 (6/6-)
Add: +1.50

Other assessments show:

Cover Test
Distance: small EP, fast recovery
Near: small EP, fast recovery

Howell Card
Distance: 3 – 5 EP
Near: 11 – 13 – 15 EP
+1.00 Near: 11 – 13 EP
-1.00 Near: 15 – 17 EP
+2.00 Near: 5 – 7 EP
-2.00 Near: >21 EP
(higher/lower than 075DC yields higher EP.. we tested @Near)
(2BO OU) Distance: 1 EP
(2BO OU) Near: 3 – 5 EP
(2BO OU + Add +1.00) Near: 1 – 3 EP (no blink: 7 – 9 EP)

NRA
+1.25

PRA
-0.25

AA (RAF rule)
R: 16D, 16D, 16D (blur @end of RAF rule, clear @38cm)
L: 16D, 16D, 16D (blur @end of RAF rule, clear @34cm)

MEM
R: +1.25
L: +1.25

Accommodation Facility (+/- 1.50)
BE: 7cpm, difficult minus lens
R: 9cpm, difficult minus lens
Accommodation Facility (+/-1.00)
L: 12cpm, difficult plus lens
– BE see better than with RE/LE

Fusional Reserves (Prism Bar)
Near, NFV: x/8/6
Near, PFV: x/30/25
(Add +1.00) Near, NFV: x/8/6
(Add +1.00 + 2BO OU) Near, NFV: x/10/6
(Add +1.00 + 3BO OU) Near, NFV: x/12/6
(Add +2.00) Near, NFV: x/6/4

ZQing reported that far vision is clearer with 1BO OU.

We still notice that she will tilt up/chin up.. she said vision is clearer seeing far. She also reported vision is worse with head tilted to left.

B EP?

ZQing came at night, so we ask her to come earlier another day to confirm a few eye findings.

KIV
Maddox Rod slanting H line

We prescribe
Cycloplegic Refraction
R: -4.00/-1.00×170 1BO
L: -3.25/-1.50×160 1BO
Add: +0.50

*UpdatedB

23/12/2022

Vision with existing new glasses
R: -4.00/-1.00×170 1BO (6/6)
L: -3.25/-1.50×160 1BO (6/6)
Add: +0.50

Other assessments show:

Cover Test
Distance: NMD
Near: small EP, fast recovery

Howell Card (6BD on OD)
Distance: 1 EP
Near: 1 EP
+1.00 Near: 0 – 1 EP
-1.00 Near: 11 EP

NRA
+2.50

PRA
-1.75

Accommodation Facility (Flipper +/-2.00)
BE: difficult minus lens
R: difficult minus lens
L: difficult minus lens

MEM
R: +0.50
L: +0.50

Fusional Reserves (Prism Bar)
Near, NFV: x/12/10
Near, PFV: x/35/30
Distance, NFV: x/10/8
Distance, PFV: x/25/20

TCA 3-4/12

Notes

Vision without glasses
6/6 – smallest testing line
6/7.5 – 2nd smallest line
6/9 – 3rd smallest line
6/12 – 4th smallest line
6/15 – 5th
6/18 – 6th
6/21 – 7th
6/24 – 8th

Examination of Eye Alignment
Cover Test, CT @ Distance & Near
– NMD(No Movement Detected) or
– small XP, fast recovery
EP = Esophoria is misalignment of eye, eye is deviated inwards
XP = Exophoria is misalignment of eye, eye is deviated outwards

Examination of Eye Posture
(Howell Card) by 6^ BD OD
Distance:
– 0-3 XP (blue part) or
– 0-1 EP (yellow part)
Near:
– 0-6 XP (blue part)

Accommodation/Focusing analysis – ability to relax
NRA
+1.50 to +2.50

Accommodation/Focusing analysis – ability to focus
PRA
-1.37 to -3.37

Convergence, NPC – ability of eye to maintain a single clear near image (RAF rule)
Break/Recovery – within 10cm or TTN(to the nose)

MEM(Monocular Estimation Method) – measure accommodation response seeing near target
+0.25 to +0.75 (with movement)

Accommodation Facility – ability to change focus: far to near or near to far) by Flipper +/- 2.00
Monocular: 6cpm – 16cpm
Binocular: 4cpm – 14cpm
(1 cycle per minute, cpm = 2 words)

Fusional Reserves –
Convergent/Divergent reserve stamina (Prism Bar)
Blur/Break/Recovery
Children 7-12yo
Near, PFV: x/15-31/10-22
Near, NFV: x/7-17/3-11
Adult
Near, PFV: x/10-28/7-21
Near, NFV: x/7-19/5-15
Distance, PFV: x/4-18/5-9
Distance, NFV: x/4-10/2-6

Vergence Facility – ability to make rapid repetitive vergence changes (Prism Flipper 12BO & 3BI)
Distance: 12-18 cpm
Near: 12-18 cpm)
(1 cycle = 2 times clearing target)

Random Dot 3S – 3D Vision
12.5″