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Blurry Far Vision & Having Headache Frequently At End Of Day?

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Ren (M/19) came for eye examination, with complaint of blurry far vision.. near vision is fine. He will wear his glasses during lecture & night driving only.. and he does not wear glasses for near as he finds it uncomfortable wearing seeing near. Her mother reported that he frequently complains about having headache.. usually towards end of day. He recently lost his glasses. We observe that he holds near material pretty close.

Vision without glasses
R: 6/21-
L: 6/18-

Subjective Refraction (Delay Fogging +2.00 OU)
R: -1.50 (6/6) (+1.00 blur lens test: 6/12)
L: -0.75/-0.50×180 (6/6) (+1.00 blur lens test: 6/12-1) L>R
Add: +1.00 (R>L)
He is comfortable wearing glasses for distance & near.

Other assessments show:

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

Howell Card
Distance: 0 (slightly on yellow)
Near: 0 (pace around 0, slightly on yellow & blue)
+1.00 Near: 4 XP
-1.00 Near: 3 EP
+2.00 Near: 6 – 8 XP
-2.00 Near: 1 EP (blurry)



TTN, TTN, 6/8cm, 8/10cm, 10/12cm, 12/14cm, 14/16cm

R: 12.5D, 12.5D, 12.5D (blur @end of RAF rule, clear @36cm)
L: 12.5D, 11.5D, 10.5D (blur @end of RAF rule, clear @42cm)

R: +1.25
L: +1.25

Accommodation Facility (+/- 2.00)
BE: 12cpm, difficult minus lens
R: 13cpm, difficult minus lens
L: 13cpm, difficult minus lens
– BE sees better than with RE/LE

Fusional Reserves
Near, NFV: 14/18/16
Near, PFV: x/25/18
Distance, NFV: x/12/8
Distance, PFV: x/30/20

Vergence Facility
Near: 12 cpm
Distance: 7 cpm (double BO, blink & single)

Interpupillary distance, IPD = 6.8cm

+gradient AC/A: 4:1
-gradient AC/A: 3:1

Lower AA, diff -ve lens, low PRA, high MEM

We prescribe added plus for near.

Own glasses (brought in during collection)
R: -1.50/-0.25×180
L: -0.50/-0.75×180


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
– 0-3 XP (blue part) or
– 0-1 EP (yellow part)
– 0-6 XP (blue part)

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

Accommodation/Focusing analysis – ability to focus
-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)
Children 7-12yo
Near, PFV: x/15-31/10-22
Near, NFV: x/7-17/3-11
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)

AC/A (Accommodation Convergence/Accommodation ratio)
2:1 to 6:1