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Dim Vision With No Pain In One Eye?

Mr Chua (M/44) came for eye examination, with complaint of dim vision with no pain in his right eye since about a month ago. No recent trauma is reported.

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

Subjective Refraction
R: PL/-1.00×90 (6/18- slow) PHNI Add +1.50 N16
L: PL/-1.00×75 (6/9) PHNI Add +1.50 N5
Pt reported seeing shadow/double with both eyes.. no shadow seen monocularly
Pt reported seeing green as white colour in RE (during duochrome test)

Other assessments show:

Colour Vision
R: defect
L: normal

Cover Test
Distance: small exotropia & hypotropia (very subtle) (RE mild ptosis)
(cover LE: pt reported target goes slanting 7o’clock to 1o’clock & smaller)
(uncover LE: pt reported target goes slanting 1o’clock to 7o’clock & bigger)

R: -ve
L: -ve

Pupil Reflex
R: -ve RAPD (pupil is not dilated)
L: -ve RAPD

Amsler Chart
R: black patches & distorted lines (inferior-nasal quadrant spared)
L: normal

Amsler RE (drawn by pt)
Worth 4 Dots @Distance (drawn by pt)

Mr Chua has diabetes & taking medication since 8years ago.

3rd NP, DME?

We refer promptly to ophthalmologist.


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)