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Droopy Eyelid/”Eye Looks Like No Energy”?

EYi (F/9) came for follow up. She can copy from whiteboard, now that she sits in the middle row of her class. She feels that her eyes are tired. Previously, we prescribed her eye patch (to patch Left eye) but no improvement in vision of Right eye obtained.

Vision without glasses
R: 6/45-
L: 6/15-

Existing Glasses
R: -3.25/-1.50×165 (6/18-)
L: -0.75/-1.50×180 (6/9- 6/7.5- 6/6-)

Subjective Refraction
R: -3.00/-1.25×165 (6/18-) PH 6/12
L: -0.75/-1.25×10 (6/9- 6/7.5- 6/6-)

Other assessments show:

Hirschberg
RE hypertropia (reflex in RE is downwards, nearer to lower pupil margin)

Cover Test
Distance: RE hypertropia
Near: alternating exotropia

Maddox Rod
Distance: 2 Base In
Near: 2 Base In

MEM
R: -0.50
L: +0.50

Worth 4 Dots
Distance: 3 lights
Near: 1 light?

Random Dots 3S
400″

Lid & Adnexa
R: ptosis
L: heavy upper lid

We refer EYi for cycloplegic refraction and to co-manage with eye doctor/ophthalmologist and orthoptist.

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
ACT: alternating CT

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)

Random Dot 3S – 3D Vision/Stereopsis 
12.5″

Worth 4 Dots – Binocular Perception 4 lights