Thursday, December 10, 2009

BV Clinic X- Files 9 Dec 2009 -- specially dedicated to Group 4 members



SNM 21/ F/ M (880416-06-5050)

This young lady came for PCO Clinic on 22 Oct 2009 with this symptom:

- Double vision after prolonged reading which is then resolved with blinking

Today morning (9 Dec 2009), she came again for BV clinic assessment. Here are
the reported symptoms:

1) Double vision seen horizontally after 5 minutes of reading (resolved with
blinking)
2) No blurring of vision at both D and N
Unaided Vision
RE: 6/6+3 (+1.00: 6/9)
LE: 6/6+1 (+1.00: 6/18+2)

Refractive error found during PCO visit
(all the tests during this visit were done using this correction)
RE: +0.50/-0.25X10 (6/6)
LE:  pl /-0.75X180 (6/6)

Refractive error found during this visit
RE: +0.50 (6/6)
LE: +0.25/-0.50X180 (6/6)

AA
RE: 13/11, 13/11, 13/11
LE: 12/10, 12/10, 12/10

MEM
RE: +0.50 D
LE: +1.00 D

NPC: 12/14, 14/16, 17/20

Phoria: 2 XP @ D, 16 XP @ N (vertical orthophoria)

NFV: 5/4 @ D, 18/17 @ N
PFV: 4/3 @ D, 5/4 @ N

AC/A ratio: kindly calculate by urself~
Zul, Muni and Amalina,
Can you state the TENTATIVE DIAGNOSES for this patient based on the symptoms?

(PLEASE post first before u take a look at the FILE ye ^^)

43 comments:

  1. testing... testing...

    bagus jugak sir dah buat blog ni.
    saya dah nak buat blog jugak semalam tapi tak tau nak letak nama apa.

    Zul, Aboo n Muni ----> dipersilakan dengan segala hormatnya~

    (ops, tertaip in Malay pulak. Sori2)

    Btw, the tentative diagnoses based on symptoms have been given by Amalina in our YG, so now the 3 of you can start making diagnosis from the above clinical findings. Good Luck~~

    remember (again), don't look at the patient's file yet =D

    ReplyDelete
  2. guys (special referring to group 4), do you think we need to give correction to this patient? why u said so?

    ReplyDelete
  3. guys (special referring to group 4), for this case, should we prescribed correction for her? what do u think and explained the reason for your answer.

    ReplyDelete
  4. testing… testing…

    bagus jugak sir dah buat blog ni.
    saya dah nak buat blog jugak semalam tapi tak tau nak letak nama apa.

    Zul, Aboo n Muni —-> dipersilakan dengan segala hormatnya~

    (ops, tertaip in Malay pulak. Sori2)

    It's ok....semua Melayu kat sini..saya dah lama buat blog ni, masa pegi kursus pasal iium website, web blog,..etc ngan ITD for all lecturer. Tapi ni first time nak di manfaatkan.

    So, because of that, don't laugh and comment about appearance of this blog..tunggu Adilah buat..."dah nak buat"-bukan dah buat cuma tak tahu nak bagi nama apa je.

    Anyway, go back to our discussion...Group 4..Hurry up...What is the diagnosis...please state an accurate diagnosis. If wrong, Class and I will lead you to it...

    ReplyDelete
  5. hmm... nampaknye bloggers2 dari group 4 masih belum respons.... xpelah, tengah kumpul idea kut...
    going back to our discussion, there is no data regarding accommodation facility recorded... perhaps u guys can take a look at patient's file because i dont remember the exact findings. one thing that i'm sure is the accommodation facility come out normal monocularly for RE & LE.. So as the findings for for binocular facility EXCEPT that the patient had some difficulty on +ve lens binocularly....
    so my question for our dearly group 4 IS
    what does the findings on accommodation facility telling u??

    GOOD LUCK... :)

    ReplyDelete
  6. As the vision at distance and near is good, i assummed that she has no refractive error or the error is already corrected.
    Reporting that the symptom arises not long after reading, there might be problems on the pt's accommodation or vergence mechanism. some of the differential dx that i can give are:

    1- decompensated heterophoria: either vertical or horizontal phoria, high demand with inadequate reserve can give rise to diplopia as the eyes cannot maintain fixating at the object of regard (prints) for prolong time.

    2- pseudo-CI: CI that is secondary to accommodation problem. accommodation weakness or infacility for example, can cause the BV component 2b disrupted. disability to maintain clear vision for longer time (due to accommodation prob),causing the eyes to go to their resting position when the image received is not good.

    * do correct me if i'm wrong :)

    ReplyDelete
  7. sorry~ there are some other important findings left. Here they're:

    PD: 65mm

    Facility of accommodation
    RE: 14 cpm
    LE: 13 cpm
    BE: 12 cpm (hard on plus)

    ReplyDelete
  8. the comment i juz posted is the copy-paste from YH.hehe.xprasan da de accommodationnye info.

    by looking at the given data, the pt might having CI. this is due to the decreasing NPC along with high and decompensated exophoria especially at N.as the AA and MEM value is within normal limit,this might be a case of true-CI. but the BFA with difficulty in clearing plus is a bit out of ordinary.(i'll think about this part later..hehe)

    ReplyDelete
  9. congrats amalina! you hit the correct diagnosis...
    as for acccommodation faciloity, why not leave it to muni or zul?
    hehehe... jgnla conquer semua plak...:p

    ReplyDelete
  10. So now, we've got the diagnosis of the case (as given by Amalina).

    But Rara's and Ain's questions above haven't been answered yet.

    kindly give your answer, along with the reasons ya~

    ---> Now you can refer to the patient's file if you want to.

    ReplyDelete
  11. Adilah
    December 11th, 2009 at 4:42 pm e

    sorry~ there are some other important findings left. Here they’re:

    PD: 65mm

    Facility of accommodation
    RE: 14 cpm
    LE: 13 cpm
    BE: 12 cpm (hard on plus)

    Aiyoo!!!! This group should be penalized.

    MFA & BFA are important findings for this discussion even the values are normal.


    (but the BFA with difficulty in clearing plus is a bit out of ordinary)= From Amalina

    Zul or Muni,referring to Amalina statement above,could please explain it?

    ReplyDelete
  12. Actually I've already created a "Wordpress" blog 2 days ago but I haven't announced it because the blog is very-very ugly and simple. Even simpler than this blog, without even any decoration or

    But since Br Muziman has offered his blog, I think better we just proceed here until the end of the semester. Kalau nak pindah lagi ke blog yang saya buat tu macam leceh la pulak asyik pindah randah je. Lagipun functions blog ni dengan blog tu sama je.

    Tapi kalau ada sesiapa yang boleh buatkan online forum, best jugak =D. Kalau takde siapa boleh buatkan forum, kita teruskan diskusi kat sini je la eh.

    Boleh kan, sir?

    ReplyDelete
  13. To Alls,

    In giving differential diagnosis, as a clinician, you must give a specific term of diagnosis; not giving general term such as decompensated heterophoria....It could be CI, DE, CE, etc...

    Congrats to AMALINA! You reached the correct diagnosis. CI.

    1. What are the findings that support your diagnosis?

    2. Referring back to the whole story of this patient and your diagnosis, please justify a proper treatment plan for this patient.

    Please discuss among your group..Amalina, Zul, Muni...

    ReplyDelete
  14. sorry sebab lambat reply,nampaknye semue orang tertunggu2 respon from group 4, personally bukan taknak reply, tapi internet is not accessible all the time;;-D...

    Tentative Diagnosis:
    True Convergence Insufficiency(agree with amalina) due to:
    - N exo larger than D exo
    - reduced NPC (normal NPC should be 5cm-10cm)
    - Reduced PFV at N. even at distance just cukup2 jer, still can be alleviated eventhough dah mematuhi percival's criteria.

    - low AC/A ratio
    (calculated AC/A ratio: 6.5cm + [-16 - (-2)]/2.5D
    = 0.9D

    - Double vision (diplopia) reported by the patient is one of the major symptom in CI. patient did reported " Double vision seen horizontally after 5 minutes of reading (resolved with
    blinking)"---> HORIZONTALLY suggests that patient having problem either eso or exo (findings has revealed pt has exo). and diplopia happen due to inability of the eye to maintain proper binocular alignment. In this case, highly might be due to very low PFV (5∆) which did not compesate the demand(16∆ BI).

    i want to ask something, did patient report double vision at near only or both at distance and near?

    that is some explanation regarding tentative diagnosis, sekiranye ade percanggahan info boleh la kiranye sahabat2 memberi input yg lg btul dan tepat (skema btul ayat kn ;-D )

    ReplyDelete
  15. CORRECTION!!!
    my statement above "Reduced PFV at N. even at distance just cukup2 jer, still can be alleviated eventhough dah mematuhi percival’s criteria."it is not percival but sheard's criteria.sheard states that the the reserve should be twice the demand...kamsahamnida (^_~)

    ReplyDelete
  16. to answer Murni's question:
    The symptom of diplopia is only at near.

    to repeat again all the questions for Group 4:
    - proper management for this patient.
    - significance of the accommodative facility findings to the case.

    ----> jawab... jangan tak jawab~~

    ReplyDelete
  17. salam,group 4 here to answer the Q regarding "significance of the accommodative facility findings to the case."

    PFV can be measured directly or indirectly. the DIRECT test includes step vergences, that has been performed during your clinical session with this patient.meanwhile, some of INDIRECT test includes measuring
    1) NEGATIVE RELATIVE ACCOMMODATION (NRA/ B+) (
    2) BINOCULAR ACCOMMODATIVE FACILITY
    3) MEM

    ReplyDelete
  18. cont. from above post (tibe2 dah terpost even tak click submit lg)

    ok, back to Q.

    Tests that are performed binocularly with plus lenses (NRA & BFA)evaluate the patient's ability to relax the accommodation and control binocular alignment using PFV.

    Did u perform NRA test?if yes, can i have the finding.


    as we know, testing accommodation facility binocularly involve both convergence and accommodation ability. in contrast, MFA only involves accommodation. that is the reason why the finding of MFA is normal with no difficulty on any lens. in BFA test which involve binocular system, patient has difficulty on plus lenses due to receded NPC finding and reduced PFV.

    According to Scheiman & wick, patient with high exo, reduced NPC, and reduced PFV will tend to overaaccommodate and use accommodative convergence to assist her deficient PFV system. this is the reason why the patient having difficulty on plus lens.(((correct me if i'm wrong)))

    ReplyDelete
  19. wow muni... u sure read a lot.... :) u give the correct answer for our clinical findings of accommodative facility regarding this patient.... now, one question is solved, should we move to the proper MANAGEMENT for this patient... I'll repeat rara question, SHOULD WE PRESCRIBE SPECTACLE FOR THIS PATIENT? give your reason.... perhaps we could have zulhimie to answer this question.... zul?? where are u??

    ReplyDelete
  20. Only few of students are really participate in this forum. The deadline for this post is 16/12 before 4p.m..

    Please remember, i will rate you based on your participation and the content of your post.

    Thank you.

    ReplyDelete
  21. Salud. El condicion es insuficiencia de la convergencia. Mi argumento es do acuerdo con la comparicion de la phoria proximo et la PFV proximo.

    P/S:

    X yah bg correction. Condition is not refractive n she's x complain bout blurred vision. Even if its refractive, d AC/A ratio is low. Xde fx pn. kalo AC/A ratio tggi, wajib x bg.

    Bout accom facility: patient is hyperopic. assuming d pt never wear glasses, she is a latent hyperopic. she probably got used to accommodating to facultatively overcome her refractive error, which probably explains y its rather difficult 4 her 2 relax her accommodation. N we observe dis as a hard-on-minus character during facility test. regardless, I thnk its benign s she still got 2 score enuf cpms.

    ReplyDelete
  22. 'X yah bg correction. Condition is not refractive n she’s x complain bout blurred vision'. FROM ZUL

    Please give proper and clear justification to say that this patient is need no correction.

    Please list three reason in point form.

    "Even if its refractive, d AC/A ratio is low. Xde fx pn. kalo AC/A ratio tggi, wajib x bg". FROM ZUL

    Could you re explain about this statement to class and me also?

    "Bout accom facility: patient is hyperopic. assuming d pt never wear glasses, she is a latent hyperopic. she probably got used to accommodating to facultatively overcome her refractive error, which probably explains y its rather difficult 4 her 2 relax her accommodation. N we observe dis as a hard-on-minus character during facility test. regardless, I thnk its benign s she still got 2 score enuf cpms".

    I can't understand this. Anyone can re explain to me or Zul should rephrase your sentences.

    ReplyDelete
  23. Salam.
    Haiya.. manyak mau rephrase aaa...

    x yah bg spec:
    1. she has only low latent hyperopia and she did not complain bout it
    2. patient's bv problem is not refractive. correction would not help.
    3. even if her problem is refractive, the AC/A ratio is low. large accommodative stimulus would result in only small accommodative convergence response.

    if AC/A ratio is high: dont prescribe. patient will accommodate to falcutatively overcome her latent hyperopia. such accommodation will induce accommodative convergence, thus reducing her large exophoria at near.

    hard on plus: patient is a latent hyperope. she got used to accommodating to falcutatively overcome her hyperopia. if the situation is long-standing, she may have some degree of spasm and will have difficulty to relax her accommodation. this causes her to have HARD-ON-PLUS during facility test.

    sekian, trimas.
    wabillahi taufiq wal-hidayah.
    wassalamu 'alaikum warahmatullahi wabarakatuh.
    may the force be with you.

    ReplyDelete
  24. response to zul...hard on minus??i do believe that based on the data given...patient's facility testing is hard on plus...

    ReplyDelete
  25. salam.

    the most preferred management is VT. correction is an option if patient had significant refractive error component that affect the condition. in this case, refractive error is not a component of the problem. glasses is only prescribe to correct her hyperopia, not her bv problem. prism is priscribed as the last resort if VT fails. this is because it is better to have her own system to be strengthened than to have its burden relieved by prism. this will remove her of dependency onto prism to maintain comfortable single vision.

    VT comprises of 4 components:
    1. appreciation of physiological diplopia
    2. jump vergence excercise
    3. smooth vergence excercise
    4. free fusion excercise

    the first 2 components can be directly and indirectly met with Brock's string. patient will be assessed after 2 weeks to see any improvements on his bv system. if succesful, training will proceed using tranaglyph for smooth vergence and bv system will be re-assessed after another 2 weeks. free fusion component can be achieved using 3 cats card if training with tranaglyph is successful. this planning is made, assuming that patient would be motivated and compliant.

    sekian, wassalam. hepi managing.

    truely, madly, deeply,

    -group 4-

    ReplyDelete
  26. yep, BFA finding is of normal value but there is a difficulty on clearing 'PLUS' lens.

    ok, teruskan perbincangan~

    ReplyDelete
  27. This week has no case for BV and paed. Therefore, i would to extend the deadline for this discussion until next wednesday.

    So, teruskan diskusi ini.

    For Zul;

    Nape perlu ada Haiya2x..

    ReplyDelete
  28. salam to all,
    i havent visited this blog for like a week and it has reached the management part. sorry for my poor participation since i cannot get wifi acces and doesnt have mini laptop like double A ^^

    CONGRATZ to group 4!!.. u've managed to complete this first x-files!!

    1. Rara asked whether we should prescribe this patient with Rx- Zul answered it as SHOULDNT just like he described above and that is true.Moreover, the Rx value is insignificant plus patient can still achieve 6/6 unaidedly which then warrant no prescription.

    2. One of double A- Kak Dill asked about the importance of facility testing- munirah had answered it in her superb elaboration which was then supported by another A- Ain.

    3. Our kakak also asked about the proper treatment- Group 4 dengan penuh rase 'kegroupan' answered it in a very ordered manner.. tahniah!

    4. Dd also wanna asked Qs-
    a. why do u choose brock string (BS) exercise instead of other therapy for physiological diplopia?.. i think u know other treatment which is usually prescribed for patients having CI - pen to nose or 2 pen..isnt the latter stated easier to be carried out compared to BS?..Scheiman n Wick also agreed that PTN/ 2P was the most common exercise precribed for patient having CI.. brock string huh?.. do u really think it is a good start for VT instead of PTN/2P?

    b. u said that if the brock string exercise is succesful, u wanna proceed to tranaglyph for smooth vergence xcise.. ehmm, wut if patient doesnt show marked improvement with your BS xcise? do u wanna opt for PTN/ 2P then?.. or u wanna proceed with other alternatives? ehm?? or ape2 aje, any idea?..

    c. if patient shows improvement (insyaAllah) with your BS xcise, do u really wanno go DIRECTLY to tranaglyph?.. i mean 'TERUS'?.. wut bout jump vergence xcise? does trana applied for smooth vergence xcise only?..

    sekian, happy answering!.. gambatte to group 4!^^

    ReplyDelete
  29. salam 'alaik...

    Despite dd's question, i want to ask some more..perhaps group 4 can think of it,n u can answer either one,xkesahla y mana dl..but, MUST answer both questions ya..=)

    "x yah bg spec:
    1. she has only low latent hyperopia and she did not complain bout it
    2. patient’s bv problem is not refractive. correction would not help.
    3. even if her problem is refractive, the AC/A ratio is low. large accommodative stimulus would result in only small accommodative convergence response." -Zul-

    the first point is correct,Bravo Zul..!when we try to manage a ptient, pay attention to the symptoms reported.da info from hx taking will help us in deciding whether to prescribe or not.since this pt didnt report blurry of vision, yet diplopia at near only,thus no RX required.

    my question here,what happen if in such case, a practitioner does prescribe RX for the ptient, would the condition be worsened,or not?or better?wut do u think grup4?state ur reason pleaz..=D

    happy answering..^_~

    ReplyDelete
  30. TQ to our beloved sir because extend the discussion date for this case (CI)..-->boleh creates more questions to group 4. hahaha.
    after u answer dd's qs, let proceed answering my qs (below)lak eh. huhu.

    So group 4, you did answered that the first VT treatment for this case is 'create awareness of physiological diplopia' and you agreed to prescribed her with Brock String. could you please tell us how u gonna teach your patient for this therapy? you could imagine as if u are giving instruction to your patient regarding Brock string therapy. ehe. tq and happy answering..

    ReplyDelete
  31. Please tell class how you teach patient to use the string effectively. Describe in detail. I would like to appoint Radzi and Hasbi to describe it.

    ReplyDelete
  32. Salam alaik..asma' is coming :).oh..by the way..there are such a lots of question that would like to dedicate to grup 4 yek..soklan dd,sab n rara pon xtjawab lg nih.kecian plak nak asking another question..nak bg ke x ni yek.but b4 that,congratulation to grup 4 four best answers given untuk soklan yg sbelum2 ni!!
    ok lah..i will give grup 4 only one simple question .hope ur grup will like it..

    q: For the case management, what is the final target using Brock String theraphy?


    k,gud luck!

    ReplyDelete
  33. salam shafiah here...
    congratulations to grup 4 on your active participation..uhuh tak tau nak tanye ape lagik ni..question from didi ira n asma is yet to be answered. And here is another workload to you guys..

    Asma did ask about final goal for Brock String exercise. So if there is reported success with Brock string, we would resume with jump vergence exercise. Would you give the example of such exercise and eloborate on how to perform the test..

    if the brock string exercise does not achieve its target during the second visit, what would be the suitable action for consideration?

    ok.cuti da abes..back to work

    ReplyDelete
  34. the exact term is end point....not final goal or final target

    ReplyDelete
  35. wow...keep it guys!
    At least your junior can learn something.

    ReplyDelete
  36. i'm looking the answer from grup 4 actually..yet still no respond. never mind, they still discussing (hopefully). After this, my group (group 2)lak will be tortured by other members. Oh noooo!

    ReplyDelete
  37. Bismillahirahmanirrahim...

    nampaknye group 4 bertubi2 dihujani soalan..baiklah, kami dengan sehati sejiwa akan menjawab segala persoalan...tapi ade baiknya jugak kalo kita kongsi2 menjawab..

    regarding Dd's Question, why using BROCK STRING (BS)... Y not PTN?... Why? Tell me why? Ain't nothing but a heartache... Well, indeed PTN is simpler n easier 2 understand. and having said that, it is simplicity that compromises it's efficiency in allowing patient to appreciate diplopia. according 2 Scheimann n Wick (pp.234), n i quote "there is no clinical studies suppoprting its efficacy".

    "The first goal of the therapy itself is to teach the concept and feeling of convergence. The patient should be able to voluntarily converge and diverge to any distance... This objective can be achieved by using Brock String... " (Scheimann & Wick, pp. 236)

    the first sentence covers the appreciation of diplopia component, and the second sentence covers the jump vergence part (if the beads are removed, even the third component). the third sentence said that BS can achieve all that. which is why in our previous post, we mentioned the phrase "directly and indirectly" cover the first two components.

    Once the goals of this objective is achieved, other therapy can be achieved easily.

    SAB's question:
    what happen if in such case, a practitioner does prescribe RX for the ptient, would the condition be worsened,or not?or better?wut do u think grup4?

    ANSWER: sile bace balek post kami yang lalu.


    ASMA's Q: For the case management, what is the final target using Brock String theraphy?

    ANSWER: y not other group members answer this question. this whole discussion is becoming more like a royal inquiry where we are the accused.


    wassalam.. :)

    ReplyDelete
  38. in case sab wants direct answer:

    the answer is wallahu'alam :)hehe

    at this stage, i think the condition may be static as her accommodation is strong plus her hard-on-plus BFA results even though she wears the correction.these clinical signs indicate her tend-to-over-accommodate to 'cover-up' her hyperopia and some of the decompensated exo during binocular viewing. the correction is also not that high in amount

    however, in a long run, wearing the correction may worsen the diplopia especially if she wears them all the time including during intense near work like studying, or when the hyperopia is towards manifestation.this is because the accommodative mechanism can no longer support her binocular viewing with intense near work and the diplopia may develop in less than 5 minutes reading. blinking hard may also cannot recover the diplopia.

    in short, the outcome is multifactorial- hyperopia stage, near workload, visual hygiene; all these can influence the progression of the condition with the correction on. but improving the condition, i think its unlikely

    but again, wallahua'lam :)

    ReplyDelete
  39. Salam.

    To members of group 4, do forgive me for breaking the code of unity, should any of such exist. for to differ, i beg, in the matter pertaining to amalinaisa's answer.

    while i do agree in the "wallahu'alam" part, i could not help but to disagree with the "in a long run" part. with both the hyporopia and the ac/a ratio being low, i personally opine that it it is of little harm to the bv system, even in the long run. assuming that procedures were followed, the phoria was measured while the patient was fully corrected. without the correction, the phoria may be slightly reduced, but probably of no measurable difference.

    should the patient wear full correction all the time, in the long run, the phoria would most probably be just as measured during this visit. and this applies even when she performs demanding near tasks. such is because, as said, with both the hyporopia and the ac/a ratio being low, accommodative convergence holds very little sway over her bv system.

    skian, trimas.

    may the peace be with you.

    ReplyDelete
  40. HOW TO TEACH YOUR PATIENT TO USE THE BROCK STRING EFFECTIVELY

    1. Approximately 1 meter of string strung with two beads is used for this task.

    2. The patient is instructed to hold the string taut and against the bridge of the nose while trying the other hand to a fixed object such as a door knob.

    3. Set one bead (red bead) at the far end of the string and the other bead (green bead) at 40 cm.

    4. Ask the patient to look at the closer bead and to describe what is seen. because of physiological diplopia, the patient should report 1 green bead and two red beads. in addition, 2 string should be perceive crossing at the green bead, with one string extending from the right eye and the other appearing to extend from the left eye.

    5. Ask the patient to fixate on the far bead red and he or she should now report one bead with the string crossing at the red bead. two green beads will be seen.

    6. Explain the following observation to the patient by saying:
    "This is a procedure that is design to teach you how to improve your ability to cross your eyes.
    The technique is design to provide you with feedback about what your eyes are doing at all times.
    The way the visual system works is such that wherever your eyes are pointing, you perceive single vision.
    All other objects in front or behind the object you are looking will be seen as double.
    Look at the green bead and you will see one green bead, two red beads behind it and a string that crosses right at the green bead and forms the letter X or Y.
    The strings should look as though they are extensions of your right and left eyes.
    Where you perceive two strings cross is actually a point at which your eyes are aimed.
    Thus, if you are trying to look at green bead but the string appear to cross farther away from the bead, this is an indication that you are looking too far away.
    Use this information to correct your eye to position and to look closer".

    7. If the patient experiences difficulty in accomplishing any of the goals listed above, use the following suggestion:

    -suggest that the patient try to get the 'feeling' of looking close and of crossing his or her eyes.

    -have the patient touch the bead that he or she is trying to fuse. this kinesthetic feedback is sometime enough to help the patient achieve single vision

    -use binocular minus lenses to stimulate accommodative convergence

    8. Once the patient is able to fused the near and far beads, fixation on the near beads should be maintained for 5 seconds and then switch to far bead and should be maintained for 5 seconds. (This is considered as one cycle).

    9. Have the patient perform 10 cycles, move the near bead 5 cm closer, and repeat.

    10. Continue moving the near bead closer until the patient can successfully converge to a distance of 5 cm from the nose.

    Thank you for reading this procedure. Hopefully we can gain some knowledge from this post.

    ReplyDelete
  41. simple words from me 'Do not rock the boat'.

    For this pt..if there is no BV problem and pt showed improvement of VA with correction, we can consider the correction.

    In this case, pt had no complaint blurring vision and had CI with low AC/A, the correction must not be prescribed.

    Hasbi and Radzi explained B.String procedures, now please discuss how to conduct step vergence for CI case using Tranaglyph.

    1. Slides Target (eg BC 515)

    2. Exercise Distance

    3. How to calculate prism demand

    4. RG google- eg..RED on RE Green on LE...

    5. procedures

    ReplyDelete
  42. opsss... forgot to mention.
    opia2612@yahoo.com also known as ain... :)

    ReplyDelete
  43. well, i agree with br.muziman as well as zul's opinion:

    i personally think that wearing the correction even in long run will not sway pt's BV as her AC/A ratio is low.
    However, provided that this patient only has low hyperopia and her unaided vision is already 6/6, prescribing correction is still not a best option.
    Why?
    1. compliance problem.
    2. even in low AC/A ratio, the plus lens still took effect to relax the eye. Not too strong to sway her BV but enough to delay the her recovery from CI.
    3. Why spend money for nothing??

    ReplyDelete

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