Lim Li Meng – 88 Optometry

Ms Lim LM (F/38) came for eye examination, with complaint of sometimes blurry far & near vision with existing glasses of 2+ years. She had an accident 10+ years ago, in which she hurt her neck & nerves.. she had double vision for a while back then. She also had another accident a few years ago, her car was hit from the back & she was hospitalised for a few days due to some balance disorder. Whenever she sees blurry, she will blink her eyes as well as pace her head to the front & back to see better.. she often gets asked about her frequent eye blink & head pace.. and they thought she is weird. Right up until now, she will still feel dizzy whenever she gets to higher floor.. in which she will take her medicine for dizziness to relieve. When she rushes her drawing jobs, she tends to have headache too.

Vision without glasses
R: 6/12
L: 6/30 (1st time), 6/18- (2nd time)

Vision with existing glasses
R: -0.50/-0.50×40 (6/6-)
L: -0.75/-0.50×5 (6/6-)

Subjective Refraction
R: -0.75/-0.50×40 (6/6) (+1.00 blur lens test: 6/9) (Retinoscopy shows WTR DC)
L: -1.00/-0.25×5 (6/6) (+1.00 blur lens test: 6/15-)
Near: L>R (adding +0.50 in RE: R>L)

Other assessments show:

Cover Test
Distance: NMD
Near: small XP, fast recovery (OS shows bigger XP movement than in OD)

Howell Card
Distance: 0 – 2 – 4 XP
Near: 8 – 10 XP (blink), 10 – 12 XP (no blink)
+1.00 Near: 16 XP
-1.00 Near: 0 – 2 XP
+2.00 Near: 16 XP
-2.00 Near: 0

NRA
+1.25
(blurry bino, clear mono)

PRA
-0.50
(repeated twice)

NPC
6/8cm, 6/8cm, 8/10cm, 8/10cm, 10/12cm 10/12cm, 12/14cm

AA
R: 35yo, 35yo, 35yo
L: 35yo, 38yo, 38yo

MEM
R: +0.50
L: +0.50

Accommodation Facility (+/- 2.00)
BE: 17 cpm, difficult minus lens
R: 14 cpm, difficult minus lens
L: 17 cpm, difficult minus lens

Fusional Reserves
Near, PFV: 14/18/14
Near, NFV: 10/25/18
Distance, PFV: 8/25/16
Distance, NFV: x/12/8

Vergence Facility
Near: 12 cpm
Distance: 12 cpm

We repeated
Fusional Reserves
Near, PFV: 12/25/14

Maddox Rod
Distance: R 2BD, 4BI
Near: R 3BD, 8BI

Vertical Fusional Reserves
Near, BD: x/6/4
Near, BU: x/6/5
Distance, BD: x/4/2
Distance, BU: x/3/1

Random Dot 3S
12.5″ (slow.. her head will pace front & black, left & right to see)

Motility
Pt reported double @Left gaze
+2 overaction RIO @Laevoelevation

We tried
R: -0.50/-0.50×40 1BD
L: -0.75/-0.25×5

With prism, Ms Lee reported testing alphabets look better.. eg. O looks clear & roundy. Once removed, she said the alphabets look “fat” vertically.

Ms Lee also told us that her drawing (eg. cabinet) is thicker on the right side.. thinner on left side. Not that she realises it, only until her friends told her that she notices it. When she rushes her drawing jobs, she tends to have headache too.

We refer her to co-manage with ophthalmologist & orthoptist.

Interpupillary distance, IPD = 6.2cm

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 Alignment
(Maddox Rod) placed on RE

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)

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 dots/lights