CASE DISCUSSION and Prescribing aspects Anshika Shah TS012 1

Case 1 A 40 year old man presented for a routine eye examination. No specific complaints for distance or near vision. 2

Clinical findings UNAIDED VA: OD: 6/5, 40 cm OS: 6/5, 40 cm (habitual reading distance) Cover test: Distance : Ortho Near : 4 prisms Exophoria 3

Clinical findings Retinoscopy: OD: +0.75DS OS: DS Acc: OD: DS (6/5) OS: DS (6/5) ADD: OU: Plano 40 cm NRA/PRA: +1.75/ DS 4

 Diagnosis  Management 5

Treatment plan Patient was asked to compare vision for distance and near, with and without glasses. No significant difference in vision observed subjectively. Diagnosis: OU: Hyperopia Management: No intervention required Reasons: Exophoria for near and good accommodative amplitudes for age 6

CASE 2 2 yr old child with the c/o suspicious less vision (parents version ) Vision (PLT): OD: 6/18 OS:6/18 Cycloplegic Flash: OD: DS OS: DS Cover Test : Ortho Distance / Near Management : ? Full cycloplegic correction 7

Case 3 A 6 year old school girl was referred since she failed in the school screening. No visual complaints noticed so far. 8

Clinical findings Vn (OU) 6/60, 40 cm Retinoscopy: OD: DS/ x 90 OS: DS/ x 90 Acc: OD: DS/ x 90 (6/7.5) OS: DS/ x 90 (6/7.5) ADD: OU: Plano 40 cm NRA/PRA: +1.75/ DS 9

Clinical findings Cycloplegic Refraction: OD: DS/ x 90 (6/7.5) OS: DS/ x 90 (6/7.5) Keratometry: OD: 43.37/ 90 0 OS: 43.87/ 90 0 Post Mydriatic Test: Acc: OD: DS/ x 90 (6/7.5), N6 OS: DS/ x 90 (6/7.5), N6 10

 Diagnosis  Management 11

Treatment plan Diagnosis: OU: Compound Hyperopic astigmatism Management: PMT value can be given as glasses to ensure compliance. Plastic lenses Follow-up 3/12 Follow-up examination at 3 months with glasses: OU: 6/7.5, N6 CT- Ortho for distance and near Stereo: 70 arc seconds 12

Case 4 A 38 year old software professional came for a routine eye examination. He had no complaints regarding vision for distance or near. He also reported that his left eye vision is always poorer than the right eye since childhood. He was prescribed glasses thrice between 10 and 25 years and he never felt comfortable with glasses and it did not improve his vision also. He wants to know the further management that can be done to improve his vision in the left eye. 13

Clinical findings UNAIDED VA: OD: 6/6, 30 cm OS: 3/60 with ph NI, 40 cm Cover test: Ortho for Distance and near Stereo acuity at near: 100 arc seconds Retinoscopy: OD: DS OS: DS/ x 30 Acc: OD: DS (6/5, N6) OS: DS/ x 30 (6/60, N12 at 20 cm) with ph NI 14

 Diagnosis  Management 15

Treatment plan Diagnosis: OD: Hyperopia OS: Compound hyperopic astigmatism Anisometropia OS: Refractive amblyopia Management: Polycarbonate protective glasses in a safety frame Prescribe: OD: DS; OS: DS (Balance lens) Patient explained about the condition and the need to protect his spare eye. 16

Case 5 A 39 year old school teacher reported for an annual eye examination and expressed an interest for contact lenses. She was comfortable with her old glasses. 17

Clinical findings Visual acuity with glasses: OD: 6/6-4, 35 cm OS: 6/6-3, 35 cm OU: 6/6, 30 cm. Glass prescription: OD: DS OS:-6.50 DS Cover test (With glasses): Ortho for distance and 4 prisms Exophoria for near. 18

Clinical findings Retinoscopy: OD: DS OS:-7.00 DS Acceptance: OD:-6.50 DS (6/5), 40 cm OS:-7.00 DS(6/5), 40 cm NFV: D: X/8/4 N: 16/24/18 PFV: D: 12/24/15 N: 28/32/14 NRA/PRA: +2.25/

 Diagnosis  Management 20

Treatment Plan Diagnosis: High myopia Approaching presbyopia Discussion: Low PRA can be attributed to approaching presbyopia. The new correction for distance can cause near vision difficulties. Binocularly patient does not have any complaints for distance or reading with old glasses. 21

The patient’s fusional ranges are normal and the blur values for PFV are more than twice the Phoria. Hence the need for increasing the minus for distance is not necessitated. Near PFV is according to Morgan’s normal values. Contact lenses might increase the accommodative demand of the visual system for reading. Patient has to be educated about this and add for reading can be prescribed over the CL if required. 22

Case 6 A 9 year old school going girl had been wearing glasses since past 3 years. No complaints regarding vision with glasses for distance and near. But she complained of discomfort while reading for more than 20 minutes. Mother had noticed occasional deviation of the eye inwards while concentrating at near. 23

Clinical findings UNAIDED VA: OD: 6/12, 40 cm OS: 6/15, 40 cm Cover test: Distance- 10 prisms Esophoria Near - 4 prisms Esophoria Stereo acuity at near: 100 arc seconds 24

Clinical findings Visual acuity (with glasses): OU: 6/6, 30 cm Glass prescription: OU: DS Cover test with glasses: Dist: Ortho. Near: 15 prisms Esotropia Stereo: 140 arc seconds Retinoscopy: OD: DS OS: DS Acc: Same as old glasses (OU) (6/6, N6) Cycloplegic Refraction: 0U:+5.00 DS 25

 Diagnosis  Management 26

Treatment Plan Diagnosis: OU: Hyperopia with Accommodative Esotropia Management: Cover test for near repeated with DS: Ortho for near: With DS: Exophoria Impression: Accommodative Esotropia with high AC/A Ratio 27

Advice: Plastic lenses/ Polycarbonate executive bifocal lenses with the segment line at mid – pupil to ensure that the patient sees through the addition for near works. Need for bifocals and full time wear of the glasses explained to the parents. Follow-up 3/12 Follow-up examination at 3 months with glasses: OU: 6/6, N6 CT- Ortho for distance and near Stereo: 70 arc seconds A review with the bifocal glasses should always be advised to avoid any overcorrection in the addition leading to consecutive deviations. 28

Case 7 12 year old with aversion for doing reading but love to watch TV with unaided Vision of 6/6; N6 in both eyes Flash : OU : DS (6/6) N6 Ortho – Distance and Near Vergence : Normal Management : ? Prescribe only for reading and near work. 29

Case 8 A 28 year old woman came with complaints of driving difficulty at night. No other specific complaints. 30

Clinical findings UNAIDED VA: OD: 6/7.5, 30 cm OS: 6/60 with ph NI, 30 cm Cover test: 3 prisms Exophoria for Distance and 4 prisms Exophoria for near Stereo acuity at near: 60 arc seconds 31

Clinical findings Retinoscopy: OD: DS/ x 175 OS: DS/-1.00 X 180 Acc: OD: DS/-0.50 X 180 (6/5, N6) OS: DS/ x 180 (6/5, N6) Even though visual acuity ahs improved with correction, patient does not want glasses. 32

 Diagnosis  Management 33

Treatment Plan Diagnosis: Anisometropia with mixed astigmatism (OD) Compound myopic astigmatism (OS) Antimetropia Management: Contact lenses to reduce anisekonia 34

Case 9 A 10 year old boy was brought with the complaint of left eye drifting outwards. Mother felt that the problem is getting worse. There were no other specific complaints. 35

Clinical findings UNAIDED VA: OD: 6/9, 30 cm OS: 6/9, 30 cm Cover test: 20 prisms intermittent left Exotropia for Distance and 5 prisms Exophoria for near Stereo acuity at near: 60 arc seconds Calculated AC/A Ratio: 12/1 NPC: 7 cm 36

Clinical findings For near: NFV: 10/16/12 PFV: X/15/10 Retinoscopy: OD: DS/ x 180 OS: DS/-0.50 X 180 Acc: OD: DS/ x 180 (6/5, N6) OS: DS/-0.50 X 180 (6/5, N6) 37

 Diagnosis  Management 38

Treatment Plan Diagnosis: Low myopia (OS) with Astigmatism (OU) Divergence Excess Management: Full correction of myopia and astigmatism Review with glasses Vision therapy 39

Case 10 A 9 year old school girl complained of distance blur with the present glasses. She has been wearing glasses for the past 1 year. She reads extensively. 40

Clinical findings Visual acuity (with glasses): OD: 6/9, 40 cm OS: 6/12, 40 cm. Glass Prescription: OD: -2.25/ X 80 OS: -2.00/-0.25 X 95 Phoria measurements: Ortho for Distance and 5 prisms Esophoria for near 41

Clinical findings Stereo acuity at near: 100 arc seconds Retinoscopy: OD: DS/-0.25 x 90 OS: DS/-0.25 x 90 Acc: OD: DS/-0.25 x 80 (6/5, N6) OS: DS/-0.25 x 100 (6/5, N6) 42

Clinical findings Gradient AC / A Ratio: 6/1 PFV: D: 10/20/10 N: 24/32/15 NFV: D: X/8/3 N: 6/18/4 NPC: 3 cm Amplitude of accommodation: D 43

 Diagnosis  Management 44

Treatment Plan Patient felt that the distance vision is better with the new glasses but felt that the near vision is better with the old glasses. DIAGNOSIS: Increase in myopia Convergence Excess Low Base-in fusional vergence and low PRA at near 45

Management: Add of DS can be prescribed to shift the near Phoria range into the normal range. Explained the need for bifocals and increasing myopia. Option of Contact lenses for Distance and reading glasses over the lenses suggested. Review with bifocal glasses after 2 weeks: Patient felt very comfortable for reading. Cover test: Ortho for distance and near with bifocals. A plus add is the treatment of choice for convergence excess. Any latent Hyperopia should be identified using cycloplegic refraction and should be prescribed. 46

Thank you 47

Hyperopia Guidelines Upto 6 yrs yrs No compensation (2 -3D) Except Strabismus, suppression or poor school performance No compensation Except near asthenopia or ↓ Vn Liberal cut Plus Cx

Hyperopia Guidelines 20 yrs and aboveCompensation for complaints + Moderate Plus cut distance + full compensation for near

Hyperopia Guidelines Low Hyperopia + Symptom +/- eso: Full to Partial correction – age dependent High Hyperopia + ↓ Vn - Cx Initial Mx for Hyperopia + eso – full cyclo. Cx Reduction of Cx – School going children and adults

Myopia Guidelines Cycloplegic refractions are mandatory- infants,esotropic children, high Myopes Prescribe full amount of refractive error including cylinder. Young will tolerate well Intentional undercx of a myopia esotropic to decrease angle of deviation is rarely tolerated 30 yrs go in steps

Astigmatism Low with the rule + asymptomatic: No Cx Low with the rule + symptomatic : Cx Low against the rule : Cx High with the Rule : Cx Oblique astigmatism + symptomatic: Cx High Spherical + low astigmatism : Based on Vision clarity > 2.50 D : Amblyopia

Presbyopia Guidelines ▫Based on Amplitude of Accommodation ▫½ or 1/3rd AA reserve ▫Exophoria with add : plan for prism if less PFV

Prism Prescribing Guidelines Morgan’s Criterion : Based on Morgan’s Normative Values Clinical Wisdom : 1/3 rd of measured angle of deviation Sheard’s Criteria: 2/3(Phoria) – 1/3(Fusional vergence) - eso look BI ; exo look BO eg : 6 prism exo, BO to blur 6 prism Amount of prism will be 2 prism BI ( 1 prism each eye) Percival Criteria : 1/3( greater limit of BI or BO range) – 2/3(lesser limit of BI or BO range)