You are currently viewing Sometimes See Double When Eyes Are Tired? *Updated

Sometimes See Double When Eyes Are Tired? *Updated

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15/4/2022

ZQing (F/13) came for eye examination, with complaint of slight blurry far vision with existing glasses of 1+ year. Her near vision is fine, but she reported blurry near vision sometimes in which she will wash her face & it will be fine then. We observe that she has her head tilted up to see far, when we asked.. she said that her vision is better like this. She also will tilt her head left or right to see if it is better. No headache is reported.

Vision without glasses
R: 6/60+1
L: 6/45-1

Vision with existing glasses
R: -3.50/-1.25×175 (6/7.5-, slow guess 6/6-)
L: -3.25/-1.25×160 (6/7.5-, slow guess 6/6-)

Examination shows: (Delay Fogging)
R: -3.75/-1.25×175 (6/6) [+1.00 blur lens test: 6/18] (R: right dominant eye)
L: -3.50/-1.25×160 (6/6) [+1.00 blur lens test: 6/12-] L>R
Adding +0.50 in left eye, R>L but she did not like it
Near: R>L {adding +0.50 in left eye, L>R but she did not like it}

Other assessments show:

Examination of Eye Alignment/Vergence (Cover Test, CT)
NMD @Distance
(alternating CT: upon covering left eye, patient reported the target goes to her right.. when covering right eye, the target goes to her left)
small EP, fast recovery @Near
(alternating CT: upon covering left eye, patient reported the target goes to her right.. when covering right eye, the target goes to her left)
(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: 1 – 3 – 5 EP (yellow part)
Near: 11 – 13 – 15 EP (yellow part)
+1.00 Near: 3 – 5 – 7 EP (yellow 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

Examination of Eye Alignment/Posture (Maddox Rod)
Distance: horizontal white line touches red spotlight but horizontal white line is slanting (patient left is higher, right is lower) & 5 Base-Out (touch then drift apart) [with head tilt to left, horizontal line becomes straight]
Near: same like Distance
(normal value: 0-1 EP (yellow part) or 0-3 XP (blue part) @Distance; and 0-6 XP (blue part) @Near)
Base Out/EP = Esophoria is misalignment of the eye, eye is deviated inwards
Base In/XP = Exophoria is misalignment of the eye, eye is deviated outwards

NRA (Accommodation analysis – ability to relax accommodation) by plus lens
+2.75
(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: +1.25 (vertical reflex seen is a slanting reflex at around 70°)?
L: +1.25 (vertical reflex seen is a slanting reflex at around 70°)?
(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: 6 YO, 6 YO, 6 YO 
L: 8 YO, 8 YO, 8 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
(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 minus lens(2nd lens)
R: 12 cycle per minit(cpm), difficult with minus lens(2nd lens) [both eyes see better than with right eye]
L: 12 cycle per minit(cpm), difficult with minus lens(2nd lens) [both eyes see better than with left eye]
– patient cannot clear -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-In/Divergent, NFV: x/6/2
Near, Base-Out/Convergent, PFV: x/12/10
Distance, Base-In/Divergent, NFV: 8/10/8
Distance, Base-Out/Convergent, PFV: 12/30/20
(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 – Adult Data]

Vergence Facility – ability to make rapid repetitive vergence changes (by Prism Flipper of 12Base Out & 3Base In)
Near: 6 cpm (double with Base-Out.. upon repeated testing, double with Base-In too)
Distance: 5 cpm (double with Base-Out then it becomes single & double with Base-In too – blink2 eyes then single)
(normal value: 1 cycle = 2 times clearing target
Distance: 12-18 cpm
Near: 12-18 cpm)

3D Vision (Random Dot 3S)
20″
16″ (with Add +1.00 BE)
(normal value: 12.5″)

Interpupillary Distance = 6.0cm

ZQing also told us that she sometimes sees double vision when eyes are tired. We refer her for cycloplegic refraction.

*UpdatedA

ZQing had cycloplegia last week. She came back for follow up.

Vision without glasses
R: 6/60+1
L: 6/45-

Vision with existing glasses
R: -3.50/-1.25×175 (6/9)
L: -3.25/-1.25×160 (6/7.5-)

Cycloplegic Refraction
R: -4.00/-1.00×170 (6/6)
L: -3.25/-1.50×160 (6/6)

Subjective Refraction (Delay Fogging +2.00 OU)
R: -4.25/-0.75×170 (6/6)
L: -3.75/-0.75×160 (6/6-)
Add: +1.50

Other assessments show:

Cover Test
Distance: small EP, fast recovery
Near: small EP, fast recovery

Howell Card
Distance: 3 – 5 EP
Near: 11 – 13 – 15 EP
+1.00 Near: 11 – 13 EP
-1.00 Near: 15 – 17 EP
+2.00 Near: 5 – 7 EP
-2.00 Near: >21 EP
(higher/lower than 075DC yields higher EP.. we tested @Near)
(2BO OU) Distance: 1 EP
(2BO OU) Near: 3 – 5 EP
(2BO OU + Add +1.00) Near: 1 – 3 EP (no blink: 7 – 9 EP)

NRA
+1.25

PRA
-0.25

AA
R: 16D, 16D (blur @end of RAF rule, clear @38cm)
L: 16D, 16D (blur @end of RAF rule, clear @34cm)

MEM
R: +1.25
L: +1.25

Accommodation Facility (+/- 1.50)
BE: 7cpm, difficult minus lens
R: 9cpm, difficult minus lens
Accommodation Facility (+/-1.00)
L: 12cpm, difficult plus lens
– BE see better than with RE/LE

Fusional Reserves
Near, NFV: x/8/6
Near, PFV: x/30/25
(Add +1.00) Near, NFV: x/8/6
(Add +1.00 + 2BO OU) Near, NFV: x/10/6
(Add +1.00 + 3BO OU) Near, NFV: x/12/6
(Add +2.00) Near, NFV: x/6/4

Interpupillary distance, IPD = 6.3cm

ZQing reported that far vision is clearer with 1BO OU.

We still notice that she will tilt up/chin up.. she said vision is clearer seeing far. She also reported vision is worse with head tilted to left.

+gradient AC/A : 3:1
-gradient AC/A : 5:1

B EP?

ZQing came at night, so we ask her to come earlier another day to confirm a few eye findings.

KIV
Maddox Rod slanting H line

We prescribe
Cycloplegic Refraction
R: -4.00/-1.00×170 1BO
L: -3.25/-1.50×160 1BO
Add: +0.50

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)

Random Dot 3S  – 3D Vision 
12.5″