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Dry, Blurry Near Vision With Contact Lens?

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Andrea L (F/22) came for eye examination, vision with contact lenses is fine seeing far & near. She reported having dry eyes especially when she uses computer/phone.. despite using artificial tears. She has a pair of glasses but was broken 3months ago.. she has been on contact lens full time for the last 3months.

Vision without glasses
R: 6/60-2
L: 6/60- (better)

Contact lens
R: -4.25 (6/6)
L: -3.75 (6/6)

Other assessments show:

Subjective Refraction
R: -4.00 (6/6) (+1.00 blur lens test: 6/18- 6/15- 6/12- 6/9-)
L: -3.75 (6/6) (+1.00 blur lens test: 6/12)

Cover Test
Distance: small XP, fast recovery
Near: moderate XP, moderate recovery

Howell Card
Distance: 2 – 4 XP
Near: 14 XP
+1.00 Near: 18 XP
-1.00 Near: 2 – 4 XP
+2.00 Near: 16 XP
-2.00 Near: 0 – 2 XP

NRA 
+1.50
(upon +1.50 OU, she reported blurry.. but when occlude alternatingly, she sees clear monocularly)

PRA 
-2.50

NPC
TTN, TTN, TTN, TTN, TTN, TTN

AA
R: 16D, 16D, 16D
L: 16D, 16D, 16D

Accommodation Facility (+/- 2.00) 
BE: 9 cpm, difficult plus lens
R: 9 cpm, difficult plus lens
L: 8 cpm, difficult minus lens

MEM
R: PL
L: +0.50

Fusional Reserves
Near, PFV: x/8/6
Near, NFV: 14/16/10
Distance, PFV: x/x/x
Distance, NFV: 12/14/8

Vergence Facility
Near: 5 cpm (slow BI & BO)
Distance: 13 cpm

Interpupillary distance, IPD = 6.1cm

Fluorescein
R: +ve staining
L: +ve staining

Right eye

We ask Andrea whether or not her near vision is fine, she reported seeing blurry & feeling dry eyes while using computer. Despite putting eye drop, she still sees blurry vision on computer, and she will need to keep blinking her eyes to see better before becoming blurry again the next moment. She also feels strain in her right eye. Previously, when she was on glasses, the dry, blurry near symptoms were not that frequent.. it gets worse recently with contact lens.

We know that contact lens wear will make her exophoric eye posture worse.. hence experiencing more dry eye symptoms-like during her full-time contact lens wear recently?

However, she has some staining(dry part) on her cornea.. we advise her to lay off contact lens temporarily & use non-preservative artificial tears every day to lubricate her eyes.

We will see her again after she finishes the whole box of artificial tears.. and to monitor her near visual symptoms.

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 
12.5″