Thursday, December 24, 2009

Paed Clinic.23/12/2009-LJS-Hasbi Group


(member: hasbi, amalina, ain, shafiah)
SNM 9/F/M (file no: 5964)
-Previous visit
• Mother reported that patient needs to squint her eyes to see clearly leading to symptoms of headache
• She has high WTR astigmatism OU + meridional amblyopia
• Full prescription prescribed and vision improvement noted 2 months afterward
• Her last visit was 16th May 2008
-Today’s visit (December 23, 2009)
• Pt sits in front of the class-no problem with copying notes from blackboard. However, headache reported occasionally during writing + reading+ looking at blackboard + sometime at home; location: top of the head
• Father reported: headache in the morning and evening (1-2 times a month)
Current Rx
RE: +0.50/-4.00 X 8 (6/6-2 ; N5@ 30cm)
LE: +0.50/-4.00 X 8 (6/6-2 ; N5@ 30cm)
Subjective refraction
RE: +0.50/-4.00 X 5 (6/9 ; N5@ 30cm)
LE: +0.50/-4.00 X 5 (6/9+3 ; N5@ 30cm)
AA
RE: 10/9 11/9, 12/10D
LE: 12/9,12/9,12/9D ; BE: 11/8, 12/9,11.5/8D
NPC: TTN
Phoria assessment
Maddox rod: 2ep @distance, 2xp @near
Howell card: orthophoria @ distance and near
Acc facility
RE: 7cpm ,LE: 9cpm ,BE:8cpm
Acc response (MEM)
BE: +1.50DS
K reading (Pentacam)
RE: 7.87mm/42.90D@H ; 7.22mm/46.70D@V
LE: 7.90mm/42.70D@H ; 7.13mm/47.30D@V
Other findings
-how do I put it? Mild to severe scratches was inspected on her current lenses…hehehe
To the rest of the class (excluding me, amalina, shafiah & hasbi), what is the possible assessment of this patient? To be more specific: what is the probable causes of her headache? Selamat menjawab \(^_^)/

46 comments:

  1. but look at her AA as well. is it normal?

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  2. poorly dispensed correction, the decentration of OC is significant, hence, headache.. i quess

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  3. I'm quite curious, why is that your subjective refraction gives slightly poorer vision than her current glasses?

    Seems that the Rx for both are exactly the same except for a very slight difference in axes: is the difference in axis by just 3 degrees really significant for -4.00 cylindrical power?

    ---> but it's still ok kot, because the visual acuities (for your Rx and her recent Rx) only differ by few letters je kan...

    ReplyDelete
  4. mmm... who is visitor x anyway?
    ohh... regarding your question Adilah, for her current Rx , we did push her to read till threshold.. For our subjective refraction, patient seem a bit tired and we did not push her to read.. That's the reason i guess... However, with our subjective refraction, pt manage to achieve 6/6-1 binocularly... pretty good right?

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  5. For visitor X, assuming there is no significant decentration and the correction is not poorly dispensed, what else would u think of?
    another hint, patient does not report any headache soon after her spectacle delivered...

    ReplyDelete
  6. Ain, komen yang I hantar guna nickname Adilah (note the capitalized A) dah hilang pulak sebab sistem blog ni kata I kena flag pasal hantar komen banyak sangat - dia ingat I spam.

    "Adilah" tu nickname yang I guna tanpa log in dalam blog ni.
    "adilah" ni pulak nickname yang I guna untuk log in sebagai author.

    I malas la nak login kalau setakat nak hantar komen~

    ReplyDelete
  7. btw ain, silalah ajak grup U memeningkan kepala dengan kes kitorang pulak.

    Kes korang I dah jawab tadi, cuma dah hilang je jawapan I tu. Uhuh, malas nak taip balik.

    ReplyDelete
  8. kepada Br Muziman:

    Nanti Sir bukak kat Dashboard, kat situ ada 8 spam.
    Saya tak boleh bukak tapi saya yakin ada post saya dalam spam tu,
    (yang guna username Adilah). Nanti Sir tolong restorekan ye.

    TQ

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  9. Who is visitor-X..please introduce yourself to join discussion

    Admin

    To Adilah..I will check and solve that prob..tQ

    ReplyDelete
  10. Ain wrote:
    another hint, patient does not report any headache soon after her spectacle delivered…

    My comment:
    OIC, I thought the headache appeared after the patient has been wearing the glasses (as written in my previous post).
    If that's the case, then the most probable cause of the headache is of course the high amount of uncorrected astigmatism la kan?

    In another words:
    It is a refractive headache due to uncorrected astigmatism.


    p/s: If a term "astigmatic headache" really exists, then that is the more specific assessment for this patient =D~~

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  11. haha... the discussion become more confusing ever... may be i did not elaborate it precisely....
    my dearly kak 'Adilah, it is not astigmatic headache... because patient is now wearing her full prescribed correction constantly..
    what i was trying to mention before is 'patient to x sakit kepala bila mula2 pakai spec (indicating the spectacle delivered is not badly dispensed and patient is adapting well with the presription)'...
    and there is no case of high amount of uncorrected astigmatism because we did prescribe full cylindrical power to her...
    One more, patient does not do anything when headache appear, she reported that removing her spectacle will cause her headache as well...

    hopefully u guys do not get headache trying to solve this case...
    gambate !! :)

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  12. Oh no~ I'm on headache now... Can't think so properly.

    Hope other friends may help me~

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  13. Assalamualaikum,

    To 'Adilah,

    I can't restore the 8 spasms.

    ReplyDelete
  14. Since this patient is 12 yrs & having high astigmatism, 6/6- VA is considered as good. No amblyopia.

    In my view, to achieve 6/6 we have to prescribe her with CL.

    The headache is not due to full astigmatic correction given as Ain said. This point was elaborated by AIN..please read her comment.

    Now, our concern is her complaint of headache. The factors that contribute to this situation are;

    1.) this factor is seems like to Visitor-X point..related to her current spectacle or correction. please think of it?

    2.) for 2nd factor..please look back at the clinical findings,..there are some abnormal findings

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  15. It's ok Sir. Thanks btw.

    One of my post in the spams (macam spasm pun ye jugak) is mentioning about the possible causes of the headache and I've given 3 points there. But after looking back at the case more deeply, I've excluded one of the points. Seems like I have to re-type the points la ni? adeii...

    The 2 points of Possible Causes to the Headache are:

    1) Disorder of accommodation giving rise to a symptom of headache
    - Reduced AA (AA should be 15 D for her age). But we can't diagnosed this as accommodative insufficiency (AI) because amblyopia is often associated with reduced AA.
    - Laggy response to accommodation (MEM should be between +0.25 to +0.75)

    2) Scratchy lenses
    - From my own experience, scratches on the lenses in front of my eyes really compromise my visual comfort so much and consequently lead to headache.

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  16. Yup, i agreed with adilah's points. headache could be due to her insufficient AA. after all, she had lag of accommodation.

    To group 3,
    How about patient's NRA and PRA? those are not stated in the case. Are both reduced?
    for facility testing, are you guys noted if patient is having difficulties in plus or minus lenses?

    if the patient is having headache when trying to change fixation from writing or reading on the table (near) and look at the blackboard in the class at the same time?
    then i guess, she might has a problem with accommodative response. difficult to relax and stimulate her accommodation. because headache also can e caused by accommodative infacility.

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  17. hehehe....sowie. not to group 3 (just noticed that abu, hasbi and sha are involved in this case), so..'to ain, amalina, hasbi and sha'...

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  18. in order to properly diagnose this pt, we need more information from the clinicians (aboo,ain,hasbi n sha)..

    -NRA/PRA,difficulty observed during facility testing?

    but yet,from the informtn given above, we can have the idea that the prob is most probably related to accommodatn anomalies (accom insufficiency or accom spasm i guess?) due to:
    -high lag of accomm (>+0.75DS)
    -mono FA of RE < than bino FA even the value of mono FA (RE) is normal(it should be higher coz no vergence componnt involve in mono FA)
    -unstable AA of RE (the value is keep increasing,looks like acc spasm huh..?)

    *bino AA is less than AA of LE?hm....bino AA should be slightly higher than mono AA due to the presence of convergnce accomm, lower bino AA may signify the presence of vergence anomaly.but in this case,bino AA< AA of LE might be due to the problem with accom fnctn of RE (specfclly AA)..wallahu a'lam..

    #da mkin cun la blog sir nampaknya..congrat..!^_~

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  19. Who is Aboo? Please use your ordinary name.

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  20. aboo is amelina. hehe. they still not respomd to us sabrina. -->still waiting the result for NRA and PRA.

    If that the only findngs that were given to us. I will say the same thing as sabrina and adilah did. That the only thing I could think of rite now.

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  21. salam to all,
    fuh, bley gak log in n comment, hehe!.. am i lucky that this post hasnt reached to the actual diagnosis yet?.. im feeling impatient to have d itd bro updated my wifi access asap- huhu!

    before proceeding, i hope this H2AS (hasby, amalina, ain n shafiah) could give the requested items mentioned by aznira n sabrina above, n ones added by me:
    1) NRA/PRA finding
    2) any hard on lens during facility
    3) the wearing mode of glasses
    4) the age of her current glasses
    5) mild to severe scratches? it is a mixed scratches coz i couldnt tell d difference..
    6) the onset of HA and scratches?

    as for d diagnosis (after considering the stated clinical findings0 are:
    1)Scratchy lens
    2)AI

    Scratchy lens- at first i thought it was a refractive HA case, but the prescribed Rx was exactly the same with the subj Rx done during the clinic except merely 3 degree out of astigmastic axis- which i do fould that it is trivial.. scratchy lens as kakak Adilah has described is really bothersome. even a mild scratches could cause visual discomfort (esp for highly sensitive wearers) since they look thru the lenses to see things ahead 24-7, plus when FOCUSING -- 'writing + reading+ looking at blackboard'-- like mentioned by SNM..

    "SNM, its time for a NEW lens ok? we'll educate you on proper handling and mantainance later =D"

    2) AI - as pt shows reduced AA (as her expected AA by Donders should be 15, Hofstetter is 13), it should be either AI or AS.. then, patient shows lag MEM which could narrow it down to AI, as AS should show lead right?

    Looking deeper, the RE shows a trend of AS huh? did H2AS repeat this test to confirm? clinically, i do think certain tests which yield significant value, should it be repeated to confirm the tentative dx.. As for MFA, the RE also shows reduced cpm. was it hard on +, - or both? i do think that this test should be repeated too..

    i'd like to see a response from H2AS regarding the 'holes'-- ceh, cam master je kan, hehe!

    tq, wallahu a'lam ^^

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  22. i totally agreed with adilah's and sabrina's previous comment..Yet..appropriate ke untk give patients's contact lens??is it true that her vision will improve to 6/6 because based on her keratometry findigs it does not shows that her high astigmatism due to the corneal surface rite...

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  23. * 5) is it a mixed..
    * which i do found it is trivial
    * like experienced by SNM

    sory for d typo, since it isnt something like u can delete after u posted- type here..and i juz rush on posting, hehe ^^

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  24. opsss..tersilap la calculate corneal astig...so...rasenye....sesuai la..klu bg CL...heheheh=P

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  25. bagus zane, i br nak betulkan..

    i do think that cl doesnt benefit patient much since ain said that patient can achieved 6/6-1 binocularly..

    as for why this patient cannot achieve 6/6?.. this patient has meridional amblyopia. wikipedia stated that:

    "Meridional amblyopia is a mild condition in which lines are seen less clearly at some orientations than others after full refractive correction"

    for H2AS, the 6/9 achieved vision-- does it actually patient can read till 6/6 but still minus in lines at certain orientation which comes to the va of 6/9?

    meridional amblyopies as amalina said (as she read); the best vision is 6/9 and 6/6 is considered as bonus-- which i can conclude 6/9 vision shouldnt be a problem for this type of patient likewise SNM.

    *FREE FOR CRITIQUE* ^^

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  26. j_phurcane@yahoo.comDecember 29, 2009 at 6:36 AM

    salam.

    waa.. name pt ni SNM... Symphony N Metal...

    AA - nmpk cm pelik. tp ma b pt was getting 2 understand d task. dats y RE makin naek, LE maintain je.

    haha - k dil spam

    "kalu high astig, laghi 1 degree pn depa bole peghasan" - a pivate optometrist.

    MEM lag, distance phoria eso, pt hyperopic- x rase cm spek 2 undercorrect? AC/A n NRA/PRA die brape? k dil is probably correct bout amblyopia cosing MEM lag n reduced VA, bt s Br Syah said, u cant expect nuch from a high astig.

    i'm x sure y "visitor x" prefers 2 kip his/her identity close 2 d chest. bt i would like 2 take note of her 1st comment. if that be true, dat's probably d killing point 4 dis case. but then, scratchy lens is also possible s a cos.

    I disagree with rara bout facility - hx said no problem copying from blackboard. dats when facility is put 2 d test.

    sekian, trimas.

    may the peace be with you.

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  27. j_phurcane@yahoo.comDecember 29, 2009 at 6:40 AM

    Salam.

    sory.
    kate dulang paku serpih.

    j_phurcane was registered 2 jpn s Zulhimie Azari.

    sekian, trimas.

    may the peace be with you.

    ReplyDelete
  28. Salam guys..our discussion becoming hot like a boiling water, ha..which is gud for us..hemm..so, back to the question above,what is the probable causes of her headache?
    So,in this case i agree with a few of u guys..

    1.) It might related to her current spectacle or correction which is presented with mild to severe scratches.It is well-known that,scracthes onto the lens may result to multicoated layer to be peeled off.MC formerly play an important role as anti reflective coating n also to prevent glaring, so since this pt has high power of astigmatism,thus for sure she can' tolerate with glaring caused by poor MC layer.Therefore, this condition may bring such an irritating problem like headache.


    2)That headache probably came from AI problem as AA achieved is lower than expected value which is 15 D.In fact,MEM result also showed in accommodative lag which is +1.50..And acccording to Elliot(2003), lag in MEM may shows of accommodation insufficiency,accommodative infacility,uncorrected presbyopia and hyperopia.So,since not enough AA achieved , no wonder she was presented with HA especially during reading,writing and so on.
    And 1 more thing,,result of NRA and PRA should be provided as low PRA may assuming pt has AI too.

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  29. from group LJS

    haha... seem like u guys are waiting for our answer huh? sorry, we couldn't make enough time for prompt response...
    To answer ur question, please refer for Dd sequence of questions

    1.NRA/PRA: we did not measure it during that visit. why?? because we dont think it is necessary at that time by looking at the synmptoms and signs... after all she is a paediatric right?
    2. any hard on facility: there was equal response on both plus and minus...(no difficulty on either lens)
    3.wearing mode of the glass: she wears the glass for all the time... remember, she reported headache if the spectacle removed?
    4.age of the glass: bout a year
    5.mild to severe scratches... urm, i was trying to say that the scratches was graded in between mild to severe...
    6. onset of headache and scrathes: camne nak jawab ek? agak2 budak tu perasan x bila scratches tu ada? hehe..

    To repeat, the headache is located at the top of the head, not at the forehead, eyeglobe,or occipital part... Plus, we never mention on difficulty on changing fixation. We just mention that the headache only occur sometimes when looking at blackboard, sometimes when writing or reading... It looks like there is no specific pattern on her headache occurrence...

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  30. ow, ic.thanx amalina (even feels weird call her by that name) so clearly she is not having facility problem.
    well, i do not think this patient is having meridional amblyopia. because she able to achieved 6/6- (quite good what)

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  31. hello... radzi here...

    1.well, i personally think that her AA is not that reduced for her age... not too high or low... it is because her facility and VA quite normal...
    Thus, my conclusion is that her Acc is not the main problem in her case.. But, we cannot exclude it totally, only that her headace might be combination in cause?
    2. It is true when there are lot of scratches on the lens, there will be very significant discomfort glare... ( i'm talking base on my own experience).. Thus, my suggestion is we need to compare her visual performance with her cuirrent glasses and our trial lens in performing near task or etc.. If there is significant performance difference, it highly suggested that the scratches cause her problems..
    3. Bout the headache, because we are not sure the exact cause, why dont we measure diurnal variation of IOP just to rule out other factor...

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  32. Erm..for this case, since patient is having accommodative insufficiency, i do not think fit her with contact lens is a good idea. If she is wearing contact lens, she needs to accommodate more. may be we need to normalize he AA first, could be by doing that, her headache also will be resolved..hehe.

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  33. "the headache is located at the top of the head, not at the forehead, eyeglobe,or occipital part…"-amalina-
    -from this explanation,i think we can exclude Accom,vergnce, and hyperope as the causes of the HA.

    "Plus, we never mention on difficulty on changing fixation. We just mention that the headache only occur SOMETIMES when looking at blackboard, SOMETIMES when writing or reading… It looks like there is no specific pattern on her headache occurrence…"
    -from this explanation, facility is not the problem now.

    -i agree wit zul,displcmnt of axis even a small degree in moderate to high astig may cause headache as well + dizzy.
    -second option, agree wit radzi bout the iop.coz it seems that the HA may be caused by other factors rather than Acc n refrctve error if dsplcmnt of axis is not the answer.
    -plus,there is a word "Sometimes" there, and since she has no spcfc pattern on HA occurnce, i think malingering is probably the cause as well.hehe..=P

    p/s: HA is when she is wearing the previous spectacle or without the spectacle?

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  34. so mostly agreed on headache due to poorly dispensed Rx ? axis faulty ?
    but patient had been waring Rx for more than one year and is it quite recently that she complaint of headache. it does not look like problem to adapt.
    Like amalina said, the headache occured when she is writing and even looking at the blackboard, to point out distance has mere correlation with the headache. Headache does not resolve if she remove her glasses.
    so guys ..?

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  35. @amalina, thanks for d tidbits!

    @zul- "undercorrect?" i dont think co.. the EP is juz 2- merely 1 out of normal range. mem lag?.. ya, it maybe symbolizes undercorrect but then wasnt the subj Rx similar with d prescribed one?.. which i could condclude no 'undercorrect' issue here..

    @j-purchane - "axis out by 1 degree can make pt aware esp for high astig".. as her gls was measured by our special foci in the clinic, the foci somehow somewhat can be 2 or 3 degree out of the exact Rx axis. plus our trial frame doesnt have the 1-to-1 degree scale.. it is 5-to-5 degree right?.. so 5 and 8 huh?.. again, i do find that it is trivial

    @razy and sabrina- the iop can also be the matter of contention.. but why this LJS/SNM hasnt been registered to our PCO clinic yet ye =D

    @amalina- "there is no specific pattern of the HA and the location is at the top of the head".. then likewise sab- i dont think it is due to ocular reason.. there is no exaggerating factors of her HA- not migraine then

    @razy- i really think the idea of comparing vision comfort when pt wearing the gls and our trial lens is a good one.. if the HA springs only when wearing her gls- then the ultimate cause of the HA is due to the SCRATCHES

    @shafiah- "after removing gls, pt still experienced HA".. the recovery period of the HA is not something sudden, it takes time to recoup.. the pt must translate the Q as if " after bukak gls, HA terus hilang ke?"-- i'd like to believe this =D

    my diagnosis again like mentioned before:
    1) HA due to the scratchy lens
    2) AI

    can we proceed to MX now? ^^

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  36. good idea from razi on comparing patien's visual comfort with her current 'scratchy lens' and our trial lens set....

    totally agreed with dd luke on da recovery period of HA which will not resolved abruptly...once it happenned...it needs time to resolve gak kan...tp...scratchy lens mmg akn lead to HA..BADLY (based on my own xperienced=P)...tambah plak patient is having high astig......so...if the HA is due to the scratchy lens... a new pair of lenses is needed then....=)

    ReplyDelete
  37. from group LJS (not amalina only.same with previous post under my name--> important for the marks.hehe)

    so..we've been seeing n hearing lots of theories and differential diagnosis about the HA. we would like to congratulate all for giving out great ideas. so in this case, we came to this decision, at that time, where the HA is most probably due to scratchy lenses. however, due to reduced AA, deficiency of accommodation performance cannot be totally ruled out.

    if this is the case,what shoud we do about it then? :)

    shazana suggest we change the glasses-good idea

    next?

    ReplyDelete
  38. wow, better contrast. baru senang nak nampak. i like this one, sir.ehe

    erm, bout the headache. few members claimed scratches even mild can cause headache. (i'm not wearing spectacle, so i don't know how disturbing it would be sampai leh cause headache. )But logically, of course it could be the cause of headache for this case.

    so the management, i think we prescribed her new glasses with same prescription like her previous glasses.
    -->OC and axis need to be precise.

    Once the spectacles is ready, asked patient to do monocular push up to increase her AA.

    ReplyDelete
  39. Good point from Rara and clear explanation about correction that must be prescribed to pt.

    On pt
    -same Rx
    -correct PD

    Dispensing
    Make sure the OC is correct= PD monocular
    the axis

    Follow-up= next? (from amalina)

    - Rara suggested to do push-up..

    So, class what else should be done and focus on next visit?

    ReplyDelete
  40. j_phurcane@yahoo.comDecember 30, 2009 at 11:09 PM

    salam.

    in my opinion, during the next visit, we should first make a thorough inspection of her glasses.

    second, we should compare pt's vision using trial lenses n using her present glasses to rule out her glasses s d sos of problems. 2 power should be exactly the same, especially axis of astig.

    if its the same, try to alter the axis to see if it helps.

    then, may be we should perform a lil PCO kind of stuffs such as tonometry and phasing, etc to rule out pathological causes. it is called paed clinic becoz irt handles small animals. not becoz d cases r related to rx@accom@bv. small animals get sick too, if u must know. savvy?

    perform some test to see i its malingering. just becoz d complaints sounded random, it doesnt mean dat it doesnt have a pattern. its possible dat d pattern is yet to be found. eg:

    "adek saket kat maner?"

    "kat ats kepale, makchik..."

    betol ke die saket kat ats kepale atau die die sndiri on x sure die saket kt mane sbb yg die tau die saket kepale n die x kesah saket kt mane sbb kepale die saket. die bukan nye adult n far bfrom being a medical doctor yg probably akn complaint camni:

    "saye saket kepale yg berasal dari frontal lobe dan kemudiannye merebak ke occipital lobe. sakit ini berdenyut senada dengan denyutan nadi saye dan saye berpendapat yang kalau saye prescribe panadol actifast, simptomnye akan berkurang sedikit."

    p/s: my bad. undercorrect not possible.

    skian, trimas.

    ma the peace be with you.

    ReplyDelete
  41. this one is good sir .. layout y chantek dr segi contrast, readable font size (kalo x before nie nk kne zoom taknak ks strain) n profesionally looks ergonomic =D

    next visit:

    after new Rx prescription with precise OC and axis- should educate patient on proper handling n mantainance since we thought the scratches were the possible cos of the HA.. avoid using her baju to wipe the lens (memori lama ^,^)..

    1) recall d history of HA - any trigger factor, the exact location of the HA, the laterality- coz sometimes the same spot of HA with intense pain can be attributed by brain tumour (clinically saying), the duration n severity of the HA and self- treatment.. --- this should be done to exclude it from being minor

    if the HA still presents, then maybe due to accommodation prob or pathological factor, to boot zul n razy- IOP n phasing should be conductd

    2) reassessment on accommodation analysis TRO the reduced AA.. if patient having AI- may start with mono push up as the VA has been maximised.. if AS- maybe we can proceed with cycloplegic or i would prefer delayed fogging/ cyclodamia to determine the highest plus power possible for her..


    tq, wallahua'lam ^^

    ReplyDelete
  42. From what I understand, patient got HA both with and without glasses. From my opinion, the reasons of HA could be:-

    HA without glasses: because of uncorrected refractive error (refractive HA)

    HA with glasses: because of the scratches in her field of view or because of the accommodation problem, or may be the combination of both (scratches and accommodation).

    As some of us said, we have to rule out diseases that may lead to the HA by a comprehensive exam on ocular health status. Yep, I agree with this, every possible cause of headache must be ruled out first before coming into a confirmed diagnosis.

    For this particular case, they've been sure that the diagnosis is really due to scratches on the lenses, then the primary management is to change the lenses to the new ones.

    If the HA still exists even after wearing the new lenses, then the residual HA may be due to problems in accommodative system (reduced AA & laggy accommodative response), so the next management should be focusing on her accommodative system.

    ReplyDelete
  43. For this case; HA w/out glasses is not related at all.

    But, I love the 2 nd answer. good..

    From my point of view, Adilah gave us a clear and complete explanation and Mx should be given.

    Anything must be added? Hasbi n gengs, pls give ur comment

    ReplyDelete
  44. j_phurcane@yahoo.comJanuary 4, 2010 at 9:47 PM

    salam.

    i think k dil got a point there.

    it's just that, according to House, MD:

    "either 1 of both condition is possible. both condition at once is plausible, but not likely. it takes a third to connect the two, which is even more unlikely. so the fourth should the one that explains all."

    skian, trimas.

    may the peace be with you.

    ReplyDelete
  45. ...Diagnosis is very important in optom mx...so, maybe the fourth will be our diagnosis and explain all of the problems

    ReplyDelete

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