MLing (F/34) came for eye examination, vision with existing glasses is fine seeing far & near. But she complains of glaring & difficulty driving at night. She reported that she needs to sit at the side & not in the middle of living room to watch TV. Sometimes, she notices some shadow at certain gazes. Her eyes are observed to protrude slightly with mild staring look & lid retraction.
Vision without glasses
R: 6/120
L: cannot guess 6/120
Vision with existing glasses of 5years
R: -7.00/-4.25×180 (6/7.5-)
L: -7.00/-4.25×178 (6/7.5-)
Examination shows: (Delay Fogging)
R: -6.50/-4.00×180 (6/7.5+) [PH 6/7.5+] (R: right dominant eye) R>L
L: -6.50/-4.50×170 (6/7.5+) [PH 6/7.5+]
Near: L>R (Add is not preferred)
No scissoring movement detected during retinoscopy
Other assessments show:
Examination of Eye Alignment/Vergence (Cover Test, CT)
NMD @Distance
(alternating CT: upon covering left eye, patient reported the target goes down.. when covering right eye, the target goes up)
NMD @Near
(alternating CT: upon covering left eye, patient reported the target goes to her left.. when covering right eye, the target goes to her right)
(normal value: orthophoria/NMD-No Movement Detected or small XP, fast recovery)
EP = Esophoria is misalignment of the eye, eye is deviated inwards
XP = Exophoria is misalignment of the eye, eye is deviated outwards
Examination of Eye Alignment/Posture (Howell Card) by 6^ Base Down on Right eye
Distance: 0 – 1 EP (yellow part)
Near: 0 – 2 XP (blue part)
+1.00 Near: 2 – 4 XP (blue part)
(normal value: 0-1 EP (yellow part) or 0-3 XP (blue part) @Distance; and 0-6 XP (blue part) @Near)
EP = Esophoria is misalignment of the eye, eye is deviated inwards
XP = Exophoria is misalignment of the eye, eye is deviated outwards
NRA (Accommodation analysis – ability to relax accommodation) by plus lens
+1.00
(normal value: +1.50 to +2.50)
PRA (Accommodation analysis – ability to stimulate accommodation) by minus lens
-0.75
(normal value: -1.37 to -3.37)
MEM – Monocular Estimation Method (Accommodation lag – to measure accommodation response seeing near target)
R: PL
L: +0.50
(normal value: +0.25 to +0.75)
AA (Amplitude Accommodation/Focusing – eye stamina/ability of eye to focus & sustain seeing near clearly) by RAF rule
R: 30 YO, 30 YO, 30 YO
L: 30 YO, 30 YO, 30 YO
(normal value: AA goes according to age; YO=years old)
NPC (Convergence – ability of eye to maintain a single clear near image) by RAF rule
TTN, TTN, TTN, TTN, TTN (left eye deviates outwards when TTN) [when the vertical line is pushed to her nose, she reported line has gone missing to her left]
(normal value: Break/Recovery in less than 10cm or to the nose, TTN)
Accommodation Facility – ability to change focus: far to near or near to far (by Flipper +/-1.00)
BE: 10 cycle per minit(cpm), difficult with plus lens(2nd lens)
R: 12 cycle per minit(cpm), difficult with plus lens(2nd lens) N6 target [both eyes see better than with right eye]
L: 12 cycle per minit(cpm), difficult with minus lens(2nd lens) N5 target [left eye sees better than with both eyes]
– patient has difficulty clearing +/-2.00 & +/-1.50
(normal value: 1 cycle = 2 words read
Monocular or R/L: 6cpm to 16cpm
Binocular or BE-both eyes: 4cpm to 14cpm)
Fusional Reserves (Convergent/Divergent reserve stamina) by Prism Bar
Near, Base-Out/Convergent, PFV: x/6/4
Near, Base-In/Divergent, NFV: x/8/6
Distance, Base-In/Divergent, NFV: x/10/8
Distance, Base-Out/Convergent, PFV: x/25/20
(normal value: Blur/Break/Recovery)
Near, PFV: 10-28/7-21
Near, NFV: 7-19/5-15
Distance, PFV: 4-18/5-9
Distance, NFV: 4-10/2-6
[Scheiman et al – Adult Data]
Vergence Facility – ability to make rapid repetitive vergence changes (by Prism Flipper of 12Base Out & 3Base In)
Near: 2 cpm (double with Base-In)
Distance: 9 cpm (towards the end of testing, double with Base-Out then single)
(normal value: 1 cycle = 2 times clearing target
Distance: 12-18 cpm
Near: 12-18 cpm)
Fluorescein
R: -ve
L: -ve
Interpupillary distance, IPD: 7.1cm
MLing has very high astigmatism, we asked whether or not she has her astigmatism this high since young.. she said her astigmatic power has progressed over the years. She has family history of spectacles wear but she is not sure of their power.
We advise to see eye specialist doctor/ophthalmologist but she is not keen to go now.. we will provide her a referral letter for further eye examination.