22/1/2021
Rmitha (F/32) came for eye examination, complaining of blurry far vision since quite some time ago. She often has headache after near work with blurry near vision sometimes. Ocular history is unremarkable and no history of trauma reported.
Vision with glasses of 3years:
R: -0.25/-0.50×5 (6/21)
L: -0.25/-0.25×180 (6/9)
Examination shows:
R: -1.50/-0.50×5 (6/6)
L: -1.00/-0.50×180 (6/6)
Additions lens is not favoured
Other assessments show:
Examination of Eye Alignment/Vergence (Cover Test)
orthophoria @Distance & Near
(normal value: orthophoria/NMD-No Movement Detected or small XP small recovery)
EP = Esophoria is misalignment of the eye, eye is deviated inwards
XP = Exophoria is misalignment of the eye, eye is deviated outwards
NPC (Convergence – ability of eye to maintain a single clear near image) by RAF rule
6cm, 6cm, 6cm
(normal value: less than 7.5cm)
AA (Accommodation/eye stamina – ability of eye to focus & sustain seeing near clearly) by RAF rule
R: 14cm, 16cm, 18cm
L: 14cm, 16cm, 18cm
(normal value: 12cm for a 32year old)
NRA (Accommodation analysis – ability to relax accommodation)
+1.00
(normal value: +1.50 to +2.50)
PRA (Accommodation analysis – ability to stimulate accommodation)
-0.50
(normal value: -1.37 to -3.37)
Facility (Accommodation facility – ability to change focus: far to near or near to far) by Flipper +/- 2.00
R: 10 cycle per minit(cpm) – difficult with minus lens
L: 10 cycle per minit(cpm) – difficult with minus lens
BE: 8 cycle per minit(cpm) – difficult with minus lens
(normal value:
Monocular or R/L: 6cpm to 16cpm
Binocular or BE-both eyes: 4cpm to 14cpm)
From the result, we know that Rmitha has Accommodation issue:
- Eye stamina/AA is low & receded with repeated testing of 3 times
- PRA is very low – she can hardly stimulate focusing/accommodation
- NRA is pretty low – ability to relax focusing/accommodation is slightly stuck
One thing has made us wonder is that Rmitha does not appreciate Relax Add like how patients with Accommodation Insufficiency will benefit seeing clear & comfortable near vision.. brought us to suspect whether or not her accommodation is stucked too or her accommodation over-accommodates?
We let Rmitha know about:
Most importantly is proper visual hygiene, to get regular break in between near work or 20-20-20 Rule, as she will use computer for very long hours every day, working on her projects gearing towards digitalisation for many industries now.
- to put cycloplegics eye drop to relax eye muscles from Eye Specialist Clinic to get true eye power
- to reassess Accommodation assessments 1week after cycloplegics
- to update spectacle lenses to new power
- to strengthen/improve his accommodation/focusing ability by vision therapy should accommodation anomaly still persists
Thank you Rmitha for your trust & support! And yes lets continue to work towards our dreams!✨
*Updated
She did not visit eye specialist clinic & asked us to prescribe her a pair of glasses first.
Modified
R: -1.00/-0.50×5
L: -0.50/-0.50×180
*Updated
Rmitha (F/33) came back for 15months follow up, with complaint of blurry far vision with existing spec of 1 year. She notices that her vision in right eye is very blur. She still spends a whole lots of hours on computer & phone, with endless of meetings.. and we literally attended her virtual meeting together.. me checking her eyes while she was listening.. although she is on MC today.. aiyo
Vision without glasses
R: 6/24
L: 6/12
Vision with existing glasses
R: -1.00/-0.50×5 (6/7.5-)
L: -0.50/-0.50×180 (6/7.5)
Examination shows: (Delay Fogging)
R: -1.25/-0.25×5 (6/6) [+1.00 blur lens test: 6/9+]
L: -0.75/-0.50×180 (6/6) [+1.00 blur lens test: 6/9-] L>R (adding up to +0.75 in left eye, still L>R)
Near: L>R (Add is not preferred – pt reported same only having Add or without)
Retinoscopy in right eye shows scissoring reflex, with +1.00: slight against movement seen
Other assessments show:
Colour Vision
R: normal
L: normal
(normal value: normal)
Examination of Eye Alignment/Vergence (Cover Test, CT)
NMD @Distance
(alternating CT: upon covering left eye, patient reported the target looks further away. when covering right eye, the target stays the same)
small XP, fast recovery @Near (alternating CT: right eye barely moves to left, left eye is seen to move to right)
(alternating CT: patient reported no movement seen)
(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 – 2 XP (blue part)
Near: 6 – 8 XP (blue part)
+1.00 Near: 10 XP (blue part)
-1.00 Near: 6 – 8 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
-0.50
(normal value: -1.37 to -3.37)
MEM – Monocular Estimation Method (Accommodation lag – to measure accommodation response seeing near target)
R: PL
L: +0.25
(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: 38 YO, 38 YO, 38 YO
L: 35 YO, 38 YO, 38 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
the vertical line did not break into 2 lines, but @12cm the vertical line starts drifting to patient’s left side before disappearing the next moment
(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 +/-2.00)
BE: 11 cycle per minit(cpm), difficult with minus lens(2nd lens)
R: 14 cycle per minit(cpm), difficult with minus lens(2nd lens) [both eyes see better than with right eye]
L: 14 cycle per minit(cpm), difficult with minus lens(2nd lens) [both eyes see better than with left eye]
(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: 6/8/6
Near, Base-In/Divergent, NFV: 4/16/12
Distance, Base-Out/Convergent, PFV: 6/14/10
Distance, Base-In/Divergent, NFV: 10/12/10
(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: 12 cpm
Distance: 12 cpm
(normal value: 1 cycle = 2 times clearing target
Distance: 12-18 cpm
Near: 12-18 cpm)
Fusional Reserves (Convergent/Divergent reserve stamina) by Prism Bar (With Add +0.50 both eyes)
Near, Base-Out/Convergent, PFV: 2/4/2
Interpupillary distance, IPD = 6.3cm
3D Vision (Random Dot 3S)
20″
12.5″ (with Add +0.75)
(normal value: 12.5″)
Worth 4 Dots
Distance: normal
Near: 3 dots seen
(normal value: 4 dots = normal; 3 dots = Right suppression; 2 dots = Left suppression; 5 dots = Double vision)
Pupil Evaluation
PERRLA, -ve RAPD
(normal value: Pupil Equal Round Responsive to Light & Accommodation,PERRLA, -ve RAPD)
Fluorescein (to assess the integrity of the front surface of eye, cornea)
R: -ve
L: -ve