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Eyes Are Heavy & Cannot Open Eyes?

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Alice (F/47) came for eye examination, with complaint of tired eyes & she feels her eyes are heavy that she cannot open her eyes. She is full time contact lens wearer.. she wears glasses when she is at home only.. but she cannot see her laptop in her glasses.. in which she needs to remove glasses & go nearer to see.

Vision without glasses
R: 6/60
L: 6/60-2

Contact lens
R: -3.75 Low Add
L: -3.75/-1.75×180

Own SV glasses >3yrs
R: -3.00/-1.00×160 (6/7.5)
L: -3.50/-2.00×180 (6/7.5)

Subjective Refraction (Delay Fogging +2.00 OU)
R: -3.00/-1.25×160 (6/6) (+1.00 blur test: 6/12)
L: -3.50/-2.25×180 (6/6) (+1.00 blur test: 6/12) (L>R)
Add: +1.50 (L>R)

Other assessments show:

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

Howell Card
Distance: 0
Near: 6 XP
-1.00 Near: 4 – 6 XP

NRA
+1.50

PRA
-0.25

NPC (Add +1.50)
9/14cm, 9/14cm, 9/14cm, 9/14cm, 9/14cm, 9/14cm

NPC (Add +2.00)
8/12cm, 8/12cm, 8/12cm, 8/12cm, 8/12cm

Modified
R: -3.00/-1.25×160
L: -3.50/-2.25×180
Add: +1.75

MEM
R: +0.50
L: +0.50

Accommodation Facility (+/- 0.50)
BE: 13cpm, difficult minus lens
R: cannot clear minus lens
L: cannot clear minus lens

Fusional Reserves
Near, PFV: x/18/16
Near, NFV: 8/12/10
Distance, NFV: x/10/8
Distance, PFV: x/25/16 (above 12^ double then single)

Vergence Facility
Near: 2 cpm
(double BO, double did not go closer with blink)
Distance: 0 cpm
(double BO, double did not go closer with blink)

Fluorescein
R: -ve
L: -ve

Interpupillary distance, IPD = 6.5cm

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

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, PFV: x/15-31/10-22
Near, NFV: x/7-17/3-11
Adult
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)