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Vision Fluctuation?

Zara (F/9) came for follow up, first presented last year for eye examination, mother reported that she always copied wrongly & teacher asked to bring for eye check.

Vision without glasses
R: 6/15
L: 6/15
BE: 6/7.5-

Subjective Refraction (1st)
R: +1.50/-2.50×180 (6/7.5-)    
L: +1.50/-2.50×180 (6/7.5-)

Stereopsis (Random Dot 3S)

She came back for follow up, mother reported that she can copy from whiteboard now but she always blinks her eyes with her specs.

Subjective Refraction (2nd)
R: PL/-1.25×180 (6/7.5-) N5
L: PL/-1.25×180 (6/9-) N5

She came for follow up, mother reported that she blinks her eyes lesser now.

Other assessments show:

Subjective Refraction (3rd)
R: +1.00/-2.00×180 (6/7.5-) N5
L: +1.25/-2.25×180 (6/7.5-) N5

Cover Test
Distance: L Esotropia
Near: NMD

Hircshberg Test
L Hypertropia & L Esotropia

Maddox Rod
Distance: 3 Base Out, L 1 Base Down
Near: 1 Base In

Howell Card
Distance: 2-4 XP (with blink) – 3-5 EP (without blink)
Near: 0-2 XP

Worth 4 Dots
Distance: 3 dots
Near: 2 dots

There is vision fluctuation – sometimes Zara reported seeing better with 2nd subj Rx, at other times seeing better with 3rd subj Rx.. when we let her compare seeing far away.

We refer for cycloplegic refraction to co-manage with eye doctor/ophthalmologist and orthoptist

Zara’s auto ref


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 Posture
(Howell Card) by 6^ BD OD
– 0-3 XP (blue part) or
– 0-1 EP (yellow part)
– 0-6 XP (blue part)

Accommodation/Focusing analysis – ability to relax
+1.50 to +2.50

Accommodation/Focusing analysis – ability to focus
-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)
Children 7-12yo
Near, BO/PFV: x/15-31/10-22
Near, BI/NFV: x/7-17/3-11
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 

Worth 4 Dots – Binocular Perception 4 dots