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Headache Does Not Go Away With Rest?

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Lvnyaa (F/14) came for eye examination, with complaint of headache for 1month.. headache does not go away after rest/sleep. Vision is fine seeing far & near.

Vision without glasses
R: 6/6 N5
L: 6/6 N5

Unaided/without correction
R: +1.00 test: 6/21-, 6/18-
L: +1.00 test: 6/9

Subjective Refraction (Delay Fogging +2.00 OU we did twice)
R: PL/-0.25×180 (6/6) (+1.00 blur lens test: 6/12-)
L: +0.25/-0.25×180 (6/6) (+1.00 blur lens test: 6/9+)
Near: Add is not favoured

Other assessments show:

Cover Test
Distance: NMD
(alternating CT: pt reported RE sees target going down, LE sees target going up)
Near: small XP, fast recovery (LE shows XP movement, RE shows little to no XP movement)

Howell Card (8^ BD)
Distance: 0 – 1 EP
Near: 2 – 4 XP
+1.00 Near: 4 XP
-1.00 Near: 1 EP
+2.00 Near: 8 – 10 XP
-2.00 Near: 5 EP
(6^BD OD or 6^BU OS: double arrow/bar slowly disappear)

NRA
+1.00

PRA
-1.00

NPC
TTN, TTN, TTN, TTN, TTN

AA
R: 15.5D, 15.5D, 15.5D
L: 15.5D, 15.5D, 15.5D

MEM
R: +1.00
L: +1.00

Accommodation Facility (+/- 2.00)
BE: 11cpm, difficult minus lens
R: 14cpm, difficult minus lens
L: 13cpm, difficult minus lens
– BE see better than with RE
– LE sees better than with BE

Fusional Reserves (Unaided)
Near, PFV: 14/x/x
Near, NFV: x/10/8
Distance, NFV: x/8/6
Distance, PFV: 8/10/6

Vergence Facility (Unaided)
Near: 5 cpm
(double BO, blink3 & single)
Distance: 9 cpm

Fusional Reserves (+0.50 OU only)
Near, PFV: x/8/6
Near, NFV: x/6/4

Maddox Rod
Distance: LE 1 BU
Near: 2 BI, LE 1 BU

Worth 4 Dot, W4D
Distance:4 dots (but there is a shadow on top of the bottom circle)
Near: 4 dots

The bottom circle & the shadow on top (drawn by pt)

Worth 4 Dot (+0.25 in OS)
Distance: 4 dots (no shadow at top of the bottom circle seen)

3D Vision (Random Dot 3S)
12.5″ (slow)

Interpupillary distance, IPD = 5.9cm

Trial framing
R: PL/-0.25×180
L: PL/-0.25×180
Distance correction is not favoured to see far, far away.. pt prefers no correction
Add +0.25 OU/+0.50 OU is not favoured

4^BO Test
(placed on OS: movement is seen)
(placed on OD: no movement seen)

+ve 4BO test in OD but no amblyopia -> MFS? LHyperopia? V deviation?

KIV
– Amsler
– V FV
– try monocular occlusion & check LHyprphoria

We try prescribing +0.25 OU for near work with proper visual hygiene.. to relax eye systems at near first.

KIV: 2/3 Vprism?

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)