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Blurry Far Vision For A Long Time?

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WSan (F/12) came for eye examination, with complaint of blurry far vision looking at whiteboard for a long time.. she sat at the first row last year but her seat is at the back row this year. She sometimes has some headache.

Vision without glasses
R: 6/15-
L: 6/15- (better)

Subjective Refraction (Delay Fogging +2.00 OU)
R: -1.00 (6/6) (+1.00 blur lens test: 6/15-)
L: -1.00 (6/6) (+1.00 blur lens test: 6/15-) L>R
Near: L>R (adding +0.50 in OD, R>L)

Retinoscopy
R: PL
L: PL

Other assessments show:

Cover Test
Distance: NMD
Near: small XP, fast recovery <-> moderate XP, moderate recovery

We repeated
Prolonged Alternating Cover Test
Distance: small XP, fast recovery <-> moderate XP, moderate recovery
Near: small XP, fast recovery <-> moderate XP, moderate recovery

We ask WSan whether or not she realises that her eyes can take turn to deviate out alternatingly.. and she said yes & she can bring in her eyes. Mother recalled that she saw her eyes turn out at times when she was little. No family history of squint eye reported.

WSan has good control over the deviation. We did not see her deviated eyes at all before we started checking.

Modified
R: -0.75
L: -0.75
VA OU: 6/6 slow

IXT Subjective Clinic Control Scale
0 (good control)

Howell Card
Distance: 0 – 2 XP
Near: 2 XP
+1.00 Near: 4 – 6 XP
-1.00 Near: 4 – 6 XP
+2.00 Near: 6 XP
-2.00 Near: 6 XP

NRA
+2.50

PRA
-1.75

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

Jump Convergence
sluggish convergence OS after numerous repeated jumps

AA
R: 15.5D, 14.5D, 13.5D
(N5 blur @end of RAF rule, clear @34cm)
L: 15.5D, 14.5D, 13.5D
(N5 blur @end of RAF rule, clear @36cm)

MEM
R: PL
L: PL

Accommodation Facility (+/- 2.00)
BE: 8cpm, difficult minus lens
R: 10cpm, difficult minus lens
L: 10cpm, difficult minus lens
– RE sees better than with BE
– LE sees better than with BE

Fusional Reserves
Near, PFV: 12/14/12
Near, NFV: 18/25/20
Distance, PFV: 16/x/x
Distance, NFV: 18/30/18

Vergence Facility
Near: 6 cpm
(initially was fine.. then double BO – double did not go closer with blink)
Distance: 12 cpm (no double reported)

3D Vision (Random Dot 3S)
12.5″

Patch Test/Monocular Occlusion (15mins)
+3.00 OU
ACT: large XP, slow recovery @ N
(we did not see ACT @D)

Interpupillary distance, IPD = 5.6

Calculated AC/A = 5.4:1
+Gradient AC/A = 2:1
-Gradient AC/A= 2:1

Pseudo DE?

Fatigued AA.. LHyperopia?

We prescribe -0.75 OU to be worn at school & when she sees better with her glasses.

KIV

– IXT Objective Binocular VA

We will see WSan in 6-8weeks.


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)

AA(Amplitude Accommodation) – eye stamina (Dioptre, D) (RAF rule)
6yo – 16.5D | 6cm
9yo – 15.5D | 6.5cm
12yo – 14.5D | 7cm
15yo – 13.5D | 7.5cm
18yo – 12.5D | 8cm
21yo – 11.5D | 9cm
24yo – 10.5D | 10cm
27yo – 9.5D | 11cm
30yo – 8.5D | 12cm

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)