21/10/2021
PYi (F/29) came for eye examination, complaining sometimes blurry far vision with existing glasses of more than 6-7years, especially after long hours of computer work or when eyes are very tired. She has worn the same power since she was 13years old.
Vision without glasses
R: 6/60-
L: 6/60
Vision with existing glasses
R: -2.50 (6/9)
L: -2.50 (6/9)
Examination shows:
R: -3.00/-0.50×165 (6/6) (R: dominant right eye)
L: -3.00/-0.50×180 (6/6)
Slight vision fluctuation in both eyes after +1.00 blur lens test
Better computer vision with astigmatism correction
Near vision is better without astigmatism correction
Other assessments show:
Examination of 3D Vision (Random Dot 3S)
12.5
(normal value: 12.5″)
Examination of Eye Alignment (Cover Test)
NMD @Distance
NMD @Near
(normal value: orthophoria/NMD-No Movement Detected or small XP, fast recovery)
EP = Esophoria is misalignment of the eye, eye is deviated inwards
XP = Exophoria is misalignment of the eye, eye is deviated outwards
Examination of Eye Alignment/Posture (Howell Card) by 6^ Base Down on Right eye
Distance: 7 – 9 EP (yellow part)
Near: 9 – 11 EP (yellow part)
+1.00 Near: 5 – 7XP (yellow part)
+2.00 Near: 3 – 5 EP (yellow part)
(normal value: 0-1 EP or 0-3 XP @Distance and 0-6 XP @Near)
EP = Esophoria is misalignment of the eye, eye is deviated inwards
XP = Exophoria is misalignment of the eye, eye is deviated outwards
NRA (Accommodation analysis – ability to relax accommodation/focusing)
+3.75
(normal value: +1.50 to +2.50)
PRA (Accommodation analysis – ability to stimulate accommodation/focusing)
-0.75
(normal value: -1.37 to -3.37)
MEM (Accommodation lag – to measure accommodation response seeing near target)
R: +1.50
L: +1.50
(normal value: +0.25 to +0.75)
Facility (Accommodation facility – ability to change focus: far to near or near to far in 1 minute) by Flipper +/- 2.00
R: 0 cycle per minit(cpm) failed -ve lens
L: 0 cycle per minit(cpm) failed -ve lens
BE: 0 cycle per minit(cpm) failed -ve lens
(normal value:
Monocular or R/L: 6cpm to 16cpm
Binocular or BE-both eyes: 4cpm to 14cpm)
Examination of Fusional Reserves (Convergent/Divergent reserve stamina) by Prism Bar
Near, Base-In/Divergent, NFV: x/x/x
Near, Base-Out/Convergent, PFV: 10/x/x
Distance, Base-In/Divergent, NFV: x/x/x (30^ & above cannot see target already)
Distance, Base-Out/Convergent, PFV: x/x/x
(normal value: Blur/Break/Recovery)
Near, NFV: 13/7-17/3-11
Near, PFV: 16/15-31/10-22
[Scheiman et al, 1989]
Examination of Eye Power Objectively (Without Patient’s Response) by Retinoscopy
R: -2.00/-0.50×165 (6/9-)
L: -2.00/-0.50×180 (6/9-)
Vision with both eyes 6/7.5
Examination of Eye Power (Cyclodamia)
R: -2.25/-0.50×165
L: -2.25/-0.50×180
Vision with both eyes 6/6-
We prompt further whether or not she has any headache, she reported no headache. She has been wearing the same power for the last 15years, she most probably has adapted to the esophoric condition or she may have developed suppression in either eye. We notice that her eyes flutter upwards sometimes.
Since there is vision fluctuation, we will refer her for cycloplegic refraction (to put eye drop at eye specialist clinic to temporarily paralyse eye muscles) and we will see her again soon.
Eyes & vision enable us to perceive our surroundings, enriching our sense of belonging & purposes.
Let us all schedule an annual eye examination with your nearby eye care practitioner, to love your eyes the way like we love your eyes❤️
#WorldSightDay #LoveYourEyes
*Updated
PYi (F/30) came with prescription of cycloplegic refraction dated 9/11/2021 from eye specialist clinic.
Cycloplegic Refraction
R: -1.00/-1.00×115 (6/12-) N5
L: -1.25/-1.25×45 (6/12-) N5
With instruction as temporary glasses
Examination shows: (Delay Fogging)
R: -2.00/-1.00×115 [R: right dominant eye] R>L
L: -1.75/-1.25×45 [BCVA BE 6/6-]
Near: L>R
Other assessments show:
Examination of Eye Alignment/Vergence (Cover Test)
NMD @Distance
NMD @Near
(normal value: orthophoria/NMD-No Movement Detected or small XP, fast recovery)
EP = Esophoria is misalignment of the eye, eye is deviated inwards
XP = Exophoria is misalignment of the eye, eye is deviated outwards
Examination of Eye Alignment/Posture (Howell Card) by 6^ Base Down on Right eye
Distance: 5 – 7 EP (yellow part)
Near: 1 –> 3 –> 5 –> 7 EP (yellow part)
+1.00 Near: 1 –> 3 –> 5 –> 7 EP (yellow part)
+2.00 Near: 1 EP <–> 0 <–> 2 XP (top arrow paces around 0, slightly move to yellow & blue)
(normal value: 0-1 EP or 0-3 XP @Distance; and 0-6 XP @Near)
EP = Esophoria is misalignment of the eye, eye is deviated inwards
XP = Exophoria is misalignment of the eye, eye is deviated outwards
NRA (Accommodation analysis – ability to relax accommodation) by plus lens
+1.25
(normal value: +1.50 to +2.50)
PRA (Accommodation analysis – ability to stimulate accommodation) by minus lens
-1.00
(normal value: -1.37 to -3.37)
MEM (Accommodation lag – to measure accommodation response seeing near target)
R: +1.25
L: +1.25
(normal value: +0.25 to +0.75)
AA (Amplitude Accommodation/Focusing – eye stamina/ability of eye to focus & sustain seeing near clearly) by RAF rule
R: 30 YO, 30 YO, 30 YO, 32 YO
L: 30 YO, 30 YO, 30 YO, 32 YO
(normal value: AA goes according to age; YO=years old)
NPC (Convergence – ability of eye to maintain a single clear near image) by RAF rule
TTN, TTN, TTN, TTN, TTN
(normal value: Break/Recovery in less than 10cm or to the nose, TTN)
Facility (Accommodation facility – ability to change focus: far to near or near to far) by Flipper +/- 1.00
BE: 9 cycle per minit(cpm), difficult with minus lens(2nd lens)
R: 9 cycle per minit(cpm), difficult with minus lens(2nd lens)
L: 9 cycle per minit(cpm), difficult with minus lens(2nd lens)
* cannot clear -2.00 & -1.50
(normal value: 1 cycle = 2 words read
Monocular or R/L: 6cpm to 16cpm
Binocular or BE-both eyes: 4cpm to 14cpm)
Fusional Reserves (Convergent/Divergent reserve stamina) by Prism Bar
Near, Base-In/Divergent, NFV: x/x/x
Near, Base-Out/Convergent, PFV: x/4/-1
Distance, Base-In/Divergent, NFV: x/x/x
Distance, Base-Out/Convergent, PFV: 12/x/x
(normal value: Blur/Break/Recovery)
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
[Scheiman – Adult Data]
Worth 4 Dots
Distance: 3 dots (right eye suppression)
Near: only 1 dot?
(normal value: 4 dots = normal fusion)
3D Vision (Random Dot 3S)
12.5″ (incorrect 20″ & 16″)
(normal value: 12.5″)
Modified Power
R: -1.50/-1.00×115
L: -1.50/-1.25×45 [BCVA BE 6/7.5-]
Add: +0.75
Examination of Eye Alignment/Posture (Howell Card) by 6^ Base Down on Right eye
Distance: 5 – 7 EP (yellow part)
With Add Near: 2 XP (blue part) –> 0 –> 1 –> 3 EP (yellow part)
(normal value: 0-1 EP or 0-3 XP @Distance; and 0-6 XP @Near)
EP = Esophoria is misalignment of the eye, eye is deviated inwards
XP = Exophoria is misalignment of the eye, eye is deviated outwards
Interpupillary Distance = 6.3cm
PYi has astigmatism that was not corrected for the last 15years, making her eye systems – accommodation/focusing & vergence to work extra hard to bring about better vision.. this probably leads to her Basic Esophoria her eyes driving extra accommodation/convergence contributing to her esophoric eye posture. Her shortsightedness/myopia is much lower, but if we bring down her power abruptly, she will see blurry far vision as eyes are very used to the esophoric posture & exerting that level of focusing, if we suddenly bring down the power, eyes would not be able to relax completely. Her eye has developed suppression, brain no longer takes signal from the affected eye.
We prescribe relax lenses to support & loosen her eye systems. We will see her again after 1 month of full-time wear of new power and subsequent appointments:
1) to check for eye posture
2) to treat suppression
3) normalise fusional reserves
– we plan on prescribing Brock String vision therapy (to let her feel her eyes diverging & normalise NFV).. but she reported not seeing the double string.. we will check again when she comes in after 1 month fulltime wear of new power
Let us all remind one another to have an annual eye examination, if not every two years. By correcting our eye power optimally, will our eyes be able to do what they do best!
Otherwise, eyes may have accommodation or convergence related anomolies.. be it in excess or insufficiency or instability with visual complaint.. to the extent of developing suppression, lazy eye/amblyopia to permanent reduced vision
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knowing that all these are avoidable.
– we will also try with horizontal prism the next visit (prism BO of one-third the distance phoria)