Tnish (M/14) came with complaint of headache & eye pain OU since 1week ago, it goes away with sleep. We observe that he looks like having subtle esotropia.
Vision without glasses
R: 6/21 slow
L: 6/15- vy3 slow
Vision with existing glasses 4yrs (older pair)
R: -0.50 (6/18-)
L: -0.25 (6/15 slow)
Vision with existing glasses 1+yr (newer pair)
R: -1.00/-0.25×180 (6/15- slow)
L: -0.75/-0.25×180 (6/12- slow)
Add: +1.00
Examination shows: (Delay Fogging)
R: +0.75 (6/15) [PH 7.5] N5@35cm
L: +1.25 (6/18) [PH 7.5] N5-@35cm
Other assessments show:
Random Dot 3S
900″
900″ (with Add +1.00)
Cover Test
Distance: alternating ET (mostly fixing OD) [very slow recovery.. s/times esotropic eye did not take up fixation]
Near: alternating ET [very slow recovery.. s/times esotropic eye did not take up fixation]
Delay Fogging (a few more times)
R: +1.50 (6/12+)
L: +1.50 (6/15-)
We tried (adding 1BD OU at a time)
R: +1.50 3BD (6/9+)
L: +1.50 3BD (6/12-) [BCVA OU: 6/7.5+]
Add: +1.00 (N5@35cm)
Pt can read faster @D & N
We also tried 1BO OU on top, but pt did not like it
Maddox Rod
Distance: 8BO, L 1.5BU
Near: 14BO
Worth 4 Dots
Distance: 4 dots?
Near: 4 dots? (1 red dots @top, 2 red dots @side, 1 green dot @bottom)
Near: 2 dots (prism removed)
– when we put the prism back in, it was still 2dots @N
We refer for cycloplegic refraction & co-manage with ophthalmologist & orthoptist.
