LEE JUAN ANN – 88 Optometry

Mr Lee JA (M/59) came for eye examination, with complaint of slight blurry far vision, especially difficult driving in dim surrounding with existing glasses made with us about 3 years ago. He removes glasses to see near. We observe that his Right eye seems to be deviated outwards sometimes.

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

Existing glasses
R: -4.00/-0.75×90 (6/9-)
L: -4.00/-0.50×40 (6/9)

Subjective Refraction
R: -4.50/-0.50×90 (6/7.5) PHNI
L: -4.50/-0.50×40 (6/7.5+) PHNI
Add: +2.00
Lowering DS to -4.25 OU but pt did not like it seeing far2 away

Other assessments show:

Cover Test
Distance: large XP, moderate recovery (sometimes breaking down into alternating IXT, most of the time fixing LE)
Near: large XP, moderate recovery (sometimes breaking down into alternating IXT)

Assessing Control of IXT
Subjective
Clinic Control
Distance: score 1 (fair control)
Near: score 1 (fair control)
Objective
Binocular VA
Distance: 6/18 onwards to better VA (RE is seen jiggling slightly.. but still can maintain @ centre)

Howell Card
Distance: 2 – 4 XP
Near: 16 XP
Near: 0 – 2 XP (with focus)
-1.00 Near: 0 – 2 XP
-2.00 Near: 0 – 2 XP

Maddox Rod
Distance: EP
Distance: orthophoria @H & V (focused)
Near: 10 BO
MR shows EP?

Worth 4 Dots
Distance: 4 lights
Near: 3 lights
Near: 4 lights (focused)

NPC
TTN, TTN, TTN, TTN, TTN, TTN, TTN

MEM
R: +0.25
L: +0.25

Fusional Reserves
Near, PFV: x/16/14
Near, NFV: x/20/18
Distance, PFV: x/x/x
Distance, PFV: x/18/16

Vergence Facility
Near: no double reported (no eye movement seen)
Distance: no double reported, sometimes double BO (no eye movement seen, sometimes movement seen in BE)

We repeated
Howell Card
Near: 20 XP
Near: 4 – 6 XP (focused)

Motility
SAFE

Interpupillary distance, IPD = 7.1cm

Near tests are done with Add.

Slit Lamp
R: mild cataract
L: mild cataract

Fluorescein
R: -ve staining
L: -ve staining

Amsler Grid
R: normal
L: normal

We ask Mr Lee whether or not he realises that his eye will turn out.. he said yes.. it started this 1+ year. He notices that he will see blurry sometimes especially during end of the day.. in which he blinks to bring in back his eyes, then he is able to see clearly again.

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
ACT: alternating CT

Examination of Eye Alignment
(Maddox Rod) placed on RE

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, BO/PFV: x/15-31/10-22
Near, BI/NFV: x/7-17/3-11
Adult
Near, BO/PFV: x/10-28/7-21
Near, BI/NFV: x/7-19/5-15
Distance, BO/PFV: x/4-18/5-9
Distance, BI/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/Stereopsis
12.5″

Worth 4 Dots – Binocular Perception
4 dots/lights