Mr. Rajan (M/43) came for eye examination, complaining of deteriorating far vision in left eye after a motorcycle fall about 1-2years ago. He has some scar on top of right eye from the fall. No eye pain is reported. General and ocular history are unremarkable.
Examination shows:
R: -2.50 (6/6)
L: -2.25 (6/12) slow focus, PHNI
Add: +1.00 (N5@40cm)
For his left eye, he needs to move head slightly to be able to see one alphabet after another.
Other assessments show:
Colour Vision
R: normal
L: defect
Pupil Reflex
R: PERRLA, -ve RAPD
L: sluggish
(normal value: Pupil Equal Round Responsive to Light & Accommodation, PERRLA; Relative Afferent Pupillary Defect, RAPD)
Hirschberg Test (Examination of Eye Alignment)
Left corneal reflex is displaced nasally
(normal value: symmetry)
Confrontation (Examination of Gross Visual Field)
R: FULL
L: FULL
(normal value: FULL)
Ocular Motility Test,OMT (Examination of Eye Muscles)
R: SAFE
L: SAFE
(normal value: SAFE-smooth, accurate, full, extensive)
Amsler Grid (Examination of integrity of macula; macula is in charge of our centre vision)
R: some lines thicker, some lines thinner
L: normal
(normal value: grid lines are straight & clear)
Slit Lamp Microscope Examination
R: mild conjunctival redness & yellowish, fluorescein -ve
L: mild conjunctival redness & yellowish, fluorescein -ve
Mr Rajan has:
1. deteriorating vision in left eye that cannot be corrected with glasses
2. colour vision defect in left eye
3. abnormal pupil reflex in left eye
Referral letter has been given to him to see eye doctor/ophthalmologist for further examination.