Thursday, January 21, 2010

clinical BV 20/1/2010 (week 7) by Group 1


:: bismillahirrahmanirrahim ::


File no: 6084


SND/22/F/M/STUDENT/READING


The patient came to the clinic (29/12/2009)complaining of blurring of vision after prolonged near wear (no specific time). She complained of pareital HA & pulling sensation to focus at far (more frequent since 3 weeks ago), usually after prolonged near work. No vision problem at near & no reported diplopia. She never wears spectacle before and her last eye check-up was 6 month ago at retail shop but no spectacle was prescribe to her. She does take spirulina for supplement and have no unknown allergies. She has gastric problem and often take medication for it. She also has myopic sister and has hypertensive dad.




Diagnosis:


1. Accommodation infacility & weakness


2. Mild myopia


Management: refer to BV clinic (20/01/2010)


Comment & action (by the examiner):


1. According to clinical findings, the patient have accommodation infacility & weakness and her Rx might help to stimulate her accommodation


2. However, Rx are not given due to the very low degree of myopia and further evaluation and management of her condition would be done at BV clinic (perform MEM, NRA+PRA which wasn’t done today)



Week 7 (20/1/2010)

BV & ORTHOPTIC CLINIC


History & symptoms: She complains of having bluring of vision at distance after near work frequently and had no problem when looking back at near. This occurs since last semester. She also have parietal HA (throbbing pain) after prolonged distant vision & eye strain and resolved it by taking a short break. She reported no problem when looking at near & no diplopia experinced. She has gastritis and on painkiller under doctor prescription (take only when needed or necessary).


RE                                      LE


VA Unaided: (D)    6/12 ph: 6/6-2                        6/6-2 pH: 6/24



(N)    N4.5 @ 40cm               N4.5@ 40cm


Sub. Rx:     -0.50/ -0.25 X 165 (6/6+3)   -0.25/ -0.25 X 180 (6/6+3)


AA (expected 11±2 D):


11/9, 10/9, 10/9                     9.5/8.5, 9.5/8.5, 9.5/8.5 (before correction)


12/9, 12/9, 12/9 11/8, 11/8, 11/7 (after correction)


MEM:        +1.00 DS +0.75 DS


Facility:       9 cpm 8 cpm


BE: 8cpm


Hirschberg: center & symmetry


CT:


(D):No movement detacted  small XP


(N): moderate recovery


Vergence function:


Phoria (∞): orthophoria (Howell card)


Phoria (N): 2XP (Howell card)


NRA: +2.00 DS


PRA: -2.00 DS




Could anyone state the possible diagnosis and proper management for this case?


Let's discuss together-gether~



12 comments:

  1. is there any difficulties observed with either + or - lens during facility testing?

    ReplyDelete
  2. one more thing, i'm confused, whther she's having blurring of vision after prolonged near work or prolonged distance vision?

    according to the data above:
    -visit on 29/12/2009: complaining of blurring of vision after prolonged near wear (no specific time)

    -visit on 20/1/2010): parietal HA (throbbing pain) after prolonged distant vision & eye strain which resolved after a short break

    ReplyDelete
  3. bismillahirahamanirahim...

    G1, may i answer sab's question? ( actually i'm from G4,hurmmm :).....eventhough this case was fully attended and managed by gRoup 1(Dd, Asma, Sha n hasbi),G4 was also here before attending Colour Vision clinic (^_^) (sempat perform some test jer, tak sempat part management)...

    1st :
    is there any difficulties observed with either + or - lens during facility testing?

    ANSWER: patient has no difficulty on any lens; + or -. :)

    2nd:
    ANSWER:
    this patient has blurring vision and headache when focusing at FAR after prolong focusing at NEAR. below i quote back some of her complaint
    1st visit: "She complained of pareital HA & pulling sensation to focus at far (more frequent since 3 weeks ago), usually after prolonged near work."
    2nd visit: "She complains of having bluring of vision at distance after near work frequently..."


    Sab,is it clear?
    G1, correct me if the fact is wrong...;)

    ReplyDelete
  4. if based on patient's symptoms....having difficulty to see at distance after prolonged near task sort of indication for accommodation infacility

    ReplyDelete
  5. Could you provide a diagnosis for me?

    ReplyDelete
  6. salam..
    i dont think the diagnosis is accommodation infacility...
    it does not meet the criteria of accommodation infacility.
    accommodation infacility:

    ReplyDelete
  7. salam, sorry, just ignore previous post, cannot delete huh?

    From my point of view, the diagnosis is not accommodation infacility. the findings does not meet the criteria for accommodation infacility.
    if the patient is having accommodative infacility,
    -patient may report blurry vision at far after prolonged near focusing and/or after prolonged distance viewing,reading material is blurred.
    - Facility test: patient invariably fail the +/- 2.00 D accommodative facility test monocularly and binocularly or has difficulty on any lens
    -PRA/NRA : abnormal relative accommodative finding
    -AA : normal finding according to age

    i think for this case the diagnosis is:
    Low compound myopic astigmatism BE

    the reason:
    -all the findings are normal
    -AA for LE is slightly reduced compared to RE. but it still within normal range. Expected AA for her age is 11.5D (sd:+/- 2D). However,there is marked improvement of VA on LE after wearing correction.
    -thus, for management purpose:
    1)advice her for visual hygiene includes having frequent break after prolong focusing at near task, proper eye-to-activity distance,good lighting condition, and good body posture as well. patient must avoid study in both supine or prone position.
    2) Correction might be given to patient if patient notice there is a marked difference of vision with/without lens.

    Do correct me if the final diagnosis is not achieved...heee~~~

    Kamsahamnida (^_~)

    ReplyDelete
  8. i do think correction should be given to this patient....one of da reason....da accommodation did improve by having it...its true dat before prescription pon da accommodation is within normal range...tp de sket perbezaan on RE and LE....leh kate imbalance ke???tp by prescribing da spectacles....accommodation on RE and LE cam lebey kurang je...

    ReplyDelete
  9. salam

    just to make a CORRECTION...
    my statement regarding AA..
    ''-AA for LE is slightly reduced compared to RE. but it still within normal range. Expected AA for her age is 11.5D (sd:+/- 2D). However,there is marked improvement of VA on LE after wearing correction.''-->

    Actually, the exact statement is "....However,there is marked improvement of AA on LE after wearing correction''.

    tq ;)

    ReplyDelete
  10. Since all the BV findings are all normal, I would say that the problems reported by the patient may be due to uncorrected refractive error - nothing to do with BV (ceh, konfem je.. hehe)

    Previous visit (PCO clinic):-

    It's true that the refractive error seems to be very small but it's not necessarily insignificant. A small refractive error can be very distracting for some people especially people with type A personality. For this person, I don't really know what type of personality she is of but we can say the refractive error was significant because it did improve her RE vision by 1 line!

    For the LE, even though she could still see 6/6 without correction, but upon +1.00 test, she could only see up to 6/36 (not 6/18) which may suggest a presence of at least small myopia. These, for me, may indicate that the refractive error was significant and might need to be corrected.

    One more thing, referral to BV clinic is only indicated if the problems still exist even after a full RX correction has been given, because refractive error can also give rise to those problems (headache & eyestrain at distance viewing). We have to rule out the refractive error first before proceeding with BV assessment.


    This visit (BV clinic):-

    It seems that the refractive error has become a bit worse than before. Unaided vision has been reduced from 6/9 (last visit) to 6/12 for RE, and from 6/6 to 6/6-2 for LE. This may be due to development of -0.25 DC of WTR astig on each eye.

    In this case, there's no doubt that the management is to prescribe a refractive correction because the correction may improve her vision up to 6/6 and even improve her AA as well.

    After delivering the correction, a follow up after 1-2 months is required to see whether the symptoms have resolved. If otherwise, then only further assessment on BV and ocular health status should be done in detail.

    :: Memberi diagnosis dan management dengan penuh yakin, sorry kalau salah ::

    ReplyDelete
  11. good one munirah, shazana and adilah..

    in this case, findings does not fit the diagnosis for accomodation insufficiency. Her results afterall are normal. Like munirah had explain. Pt is having low compound myopic astigmatism BE.

    Adilah said " prescribe a refractive correction because the correction may improve her vision up to 6/6 and even improve her AA as well".

    Her AA is within normal limit as said before. But, it is slightly better with the correction on. Both are considered in normal range.

    So, the correction is prescribed because patient did complaint of DISTANT VISION BLUR and the subjective finding DOES correct her ametropia.

    Apart from that, the correction balance her state of accomodation..(trying to put my toughts into words, tp mcm tak jadi).


    correct me if i'm wrong

    ReplyDelete
  12. Congrats...correct diagnosis & Mx...Sometimes, the case that be referred to BV clinic is not involves BV interaction. For this case per say, the previous examiner was suspected his pt had BV problem...For this type of case, after second follow-up, you can discharge this case from BV clinic

    ReplyDelete

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