Saturday, February 20, 2010

BV CLINIC 17/02/2010

HX ( AFI/7/M/M)


  • Diagnosed as having unilateral divergent squint when he was born

  • Unilateral LE squint change to intermittent with increasing in angle

  • At the age of 6 months went to the pediatric strabismus specialist

  • No intracranial pathology detected

  • No patching tx issued –as optometrist claimed wont benefit him

  • Paternal gf + paternal ucle has hx of fixed divergent squint

  • LE frequent diverge – When unattentive






6/9-2 (N6 @20 cm)

6/9, (N6 @20 cm)








+2.00DS/ -0.50x 180 (6/24)

+1.50Ds/ -0.50x 180


+1.00 DS/-0.50 x 170 (6/9)

+0.25DS/-0.50 x 180 (6/6-1)

CT (distance and near)

intermittent alternating XT (fixate more on LE)


29BI/24 BI

Stereofly Test

140’ arc

Phoria (distance)

Phoria (Near)

pt is unattentive

4 eso * unreliable sinc ept is unattentive


Came to the pediatric clinic today ( 17th of Feb 2010)








6/9 @28cm


6/9 @28 cm-1

AA (expected 16±2)






3cpm (hard on +)

8cpm (hard on +)


11 cpm



Alternating XT ( fixating more on LE)




30 BI

25 BI





cannot be measured


9cm, 9cm, 8cm ( RE deviates out)


Unable to perform since patient is attentive and uncoperative


  1. To grup 3, kindly state the dx n mx for this pt based on current visit's finding.. ^^

  2. can i join the group? hehe

  3. urmmm... before i diagnose the patient, i have few queries for you guys ..
    1. Is there any pCT data for near? do the patient's eye deviate more on distance or near?

    2. Furthermore, the Hx claimed that the patient's had unilateral LE strabismus, while the cover test results shows that the patient fixate more on LE ( RE deviation). Well, it seems like the deviated eye had change from LE to RE.. Is it so?

  4. azuwan, welcome to join us

  5. Since there were only 3 of us absent during the clinical session whilst the rest were all there, hope that we'll get the answer (for Ain's Q) as soon as possible.

    Azuwan, u can join our group (G3) to find the diagnosis and management for this case.... =)

  6. ain, on the second visit, PCT was measured at D & N. the result was there. D=30 BI and N=25 BI.. sorry =) sumer data terenjak ke atas sket..tak ikut row nyer. hehe

  7. for the deviation whether it has changed from LE to RE, i'm not pretty sure bout that, But during the clinic we noted, he focused with his LE most. after all, his condition is intermittent.
    could be when he is inattentive, the LE will deviate.

    -> may be other member have better explanation bout this.

  8. sure azuwan. welcome to this discussion. =) u can ask anything regarding this case, then try to diagnose and manage it. we will help u with all the info that we have.

    on this 2nd visit, i measured his PFV. for me, it is very difficult to measure PFV on children, might be because it involved prism and require respond from patient. i dun know whether he could understand or not my instruction. it is hard to explain to a 7 year old boy to report when the target appear two, or noticed when it become double.

    but he keep telling us the target appear two when 'it is on the line'. but become single when in the box.. we tried repeated the test a few times but the respond still same. -We will try again on the next visit.

  9. thank you, lovely sis..

    The boy prefers to fix more with LE because the vision is 'clearer' than RE. am I right?
    It may also be the reason why MFA is better in LE.

    I do believe he has no pathological problems.

    Sis, is the PCT done while patient wearing his best correction?

    My first prediction 'Basic XT'. can be intermittent... hehe..suka hati je

  10. @ wan, welcome~

    @ kak dil- sory, i havent visited this blog since my last post

    @ ain- the hx of LE squint was reported from his mother by observation, which was intermittent and increases in angle.. however, during both visits the boy came with RE deviated..

    During CT, the pattern was alternating and the fixating eye is more on LE..

    As for PCT, rara has answered..

    @ wan again- your idea about the MFA for LE is right.. since he fixates more with LE, thus the accommodation in this eye tends to be stable and better than the bad eye.. and yes, he is a healthy and active kid- d reason he cant wait to go to Gambang water park after this visit ^^

    basic XT? hmm, nice dx though still need the complete dx in terms of laterality n consistency (i need to putar2 ayat sket kt cni, hehe).. intermittent?.. it should be something that we noted in CT rite?..

    hope, it helps for now.. gambatte~

  11. azuwan, this child is not a spectacle wearer. =) so all the tests were conducted with his habitual vision.

  12. ni haw.

    welcome 2 azuwan.


    talak bole diagnose lg ma?

    here's a hint la...

    ujian tutup.

    jd mcm mane ujian tutup ni bole hint diagnosis, ha ini kite tak tau...

    jd lu pike la sendiri...

    skian, trimas

    may the peace be with you.

  13. hola..sory,this is radzi..stil cannot login aa,so gune sebi pnye account aa..

    mm,so what we have here..
    --> dx n mx for this pt based on current visit’s finding

    I would say,
    - based on PCT findings, it is approximately the same as
    previous visit

    - for MFA, the findings shows reduce FA in RE while normal
    in LE with hard on plus on BE.

    - other findings looks normal to me

    -but, how about suppression?..

    so, my possible dx = intermittent alternating exotropia

    for mx of exotropia,

    we need to monitor the deviation for the next 2-3 month to ensure that the deviation does not progress..

    i would say we can try prism-incorporated with specs for the time being..but for me it is illogical to put prism..>20 prism maa..

    If the magnitude of deviation become constant,i'm confident surgery would be the best option.

    for FA, i think we need to evaluate again the FA, maybe he was uncooperative..tq..

  14. Razy, the dx is almost betul.. but, as i mentioned earlier, the consistency is something that is noted in the CT.. however during the CT, we found out that the consistency wasnt 'intermittent'.. plus, he came to the clinic with the RE consistently deviated outward (XT)-- i should use 'that' word to avoid jwpn bocor ^^

    for suppression, 4BO test was conducted.. since it almost 12 (patient came at 10:20 am) the patient's eyes keep moving signalling his 'ketidaksabaran'.. so cannot b measured

    the MX-
    Since we need to monitor the angle of XT, d prism- incorporated glasses is d right solution for this patient (bravo razy!).. but do we need to wait in 3 months to prescribe him with prescription? as we could see here the magnitude of XT increases 1BI for both D and N in 1 month (though some would say negligible).. the magnitude would increase some more in months based on dis kind of fashion.. does dis mean monitor then?

    d prism- incorporated glasses is d right solution for this patient.. but u mentioned the irrationality to incorporate the 'larger' value prism in d spec.. hmm, i do think we have some modification to be made here.. anyone could help?

  15. wah! dah dpt final dx n mx la ni...

  16. according to lecture given to us by Miss Melanie, orthoptist form S'pore

    Indication for Surgery
    1) increasing tropic phase with diminished fusion control
    2) poor fusion recovery on cover uncover test
    3) XT is manifest >50% of waking hours
    4) XT > 20PD

  17. For Zul,

    In Malay, Cover Test= bukan ujian tutup..ujian katup

  18. Hurm as for Dx, i would like to quote some clues from sr Dd:

    'however during the CT, we found out that the consistency wasnt ‘intermittent’.. plus, he came to the clinic with the RE consistently deviated outward (XT)–'

    Mm... are you trying to say this the frequency of the 'deviation'(XT) is higher than the 'intermittent'(XP) in most of the time?? Meaning that the child had almost constant exotropia? If that is the case, i would say that this child is having RE constant (or almost constant) exotropia...

    AS for the Mx, Radzi said to monitor for 3 months... However, Dd argue with claiming that the magnitude could increase over time... Perhaps we could monitor but just in a month?

    Well, prism is a good choice and we could incorporate it using spectacle decentration. But as you said, the magnitude of deviation is large and it is almost impossible to prescribe then. We could consider spherical alteration ib this case. Thus, we need to calculate the AC/A ratio, but do you guys have the pt PD?

    The calculated AC/A ratio (assuming pt PD is 64mm) is bout 8.4. Not too high right, well it is because patient has basic exotropia. Thus, it shows that by overminusing the pt by -1.00D, the tropia should reduces from 30 to 22 at distance.. well we need at least -3.00D to reduce to approximately to 6 exo.. as i see the minus lens required to neutralize the tropia is too high.. So as the lens decentration required..

    Thus, from the AC/A and the minus lens required to reduce the deviation, i would say spherical alteration is not a good option. The issues are:
    1. we need too much minus lens( more than 2D) as AC/A
    ratio is normal..
    2. the deviation is too large. Even if we could minimize the deviation with the overminus lens, we still could consider the effect of the lens to pt's accommodation. In long run , pt's accommodation would not be enough to cater the demanded accommodation due to minus lens. what will happen if it occur? maybe the minus lens wont do its work to minimize the ocular deviation.

    After much consideration, i agree with Radzi. Surgery is still the best opt for this patient. After all, this patient fulfill the criterion for surgery as Wan mention:
    'Indication for Surgery
    1) increasing tropic phase with diminished fusion control
    2) poor fusion recovery on cover uncover test
    3) XT is manifest >50% of waking hours
    4) XT > 20PD

    Wallahu'alam... jgn malu2 nak baca...
    penulisnye pun da pening... LOL... ~_^

  19. i found out one good journal for managing intermittent exotropia, but still not done reading... here is the link

    maybe it could help us managing this patient?

  20. Congrats to my groupmates Ain and Radzi.
    Keep on giving ur opinions~

    I support U from behind (direct translation for "Saya sokong kamu dari belakang"... huhu)

  21. ain, tq for the journal. Radzi and Ain, both of u come out with a good management. it is true, the deviation is too large and surgery would be better for him.
    but then, while waiting for the surgery what are we suppose to do to this patient?
    -->may be ain and radzi want to support kak dil from behind lak? ekekeke...peace ya

  22. @ ain: lame btul tgu nk bukak journal tu (ke sbb aku tgh dw lupin at d same time?.. hihi).. so, sy reply dlu la ye..

    the dx- constant RE XT is almost correct ain.. but Im afraid its still not rite.. i think uve got d answer rite?.. so plz publish it here to make it official ^^

    again, u make a good point in managing this pt (seems like uve a pt kinda like this huh?)..

    u pointed out on how the minus lens would affect this kid in d long run.. but then since it is decided for this pt to have surgery as pt complies the indication for surgery (as listed by wan), so mayb the minus lens could help to monitor the XT for d time being?

    @ wan: tq for d indications.. it was a good one ^,~

    @ G3 n wan: mm, im curious whther the indications can b applied for alternating tropic cases?.. hmmm??

    @ ain n others: 1 month TCA is a good date for monitoring n prescribing.. he will b comin in 2 wiks time so good luck to all of u then ^^ (since i wont b there during the TCA)

  23. In coming visit, we have to determine RX that should be given on him..Please compromise with these findings

    1) VA
    2) Tropia

  24. sorry.. lama x buka blog ni... malas nak on9 kat bilik...
    here i go (hope this is the rite dagnosis)..

    Considering the result of cover test which i forgot to consider at the beginning, the diagnosis of this pt should be constant alternating exotropia preferably on RE... with normal AC/A ratio...

    regarding the option of giving minus lens for strabismus control before surgery, i could simply agree with u guys. But then, i'm afraid i have too little experience and knowledge regarding this.. perhaps i should seek some literatures on how the experts done this...

    i believe that there is a test to be performed before surgery as Prof. Faudziah taught us. However, i could not recall the name and procedures (nanti balik bilik baru cari notes, hehe)... should we be the one who perform this test?

    DD--> daa dapat download lupin belum? =)

  25. salam.

    2 aeyin: congrats 4 d dx - at least i thnkits correct. so serious smpe refer journal...

    bout d mx, i suppose most had already given deyr thought. so y don't sam1 summarise n conclude d mx.

    to lara: deviation above 20 prism is already an indication for surgery. like radzi said la kalo nk bg prism rx pn x logic.

    n gud question from lara. apo ekau nak buek somontagho nak nunggu bodah. ekau nak bia mato budak tu jadik cam arnab? atau ekau nak pakso dio buek therapy smpai jadik cam boyo? ha jawab kak dil.

    skian, trimas.

    may the peace be with you.

  26. salam~

    Sorry for not giving opinion regarding this case, just letting the discussion runs primarily among Ain and dD. The reason is as I said to Zul this evening, I'm trying to give opinion which is supported by literature and not merely based on my personal thought - as I know that I'm not perfect enough to give my own opinion without referring to any source. And to look for references needs an ample time, plus I have to divide my time to find sources for posts in my own blog as well.

    To zul:
    Biarlah ko kata "terlalu serius sampai kena buka jurnal" macam dalam komen di atas ataupun "ko tulis ikut apa yang ko tau jela" macam dalam kelas petang tadi... Yang penting menulis berdasarkan pembacaan lebih memberi kepuasan pada diri sendiri berbanding menulis ikut otak sendiri. Lagipun sekarang ni kan maklumat semua di hujung jari... Rugi la kalau kita tak guna kemudahan teknologi ni untuk menambah pengetahuan. Takkan guna teknologi untuk download movie dan games je kot (no offense ya~ peace...)

    Straight to the point... (sorry, panjang pulak kata2 aluan tadi. Bersedia untuk baca ayat2 seterusnya yang jauh lebih panjang... Be ready to vomit out ya~):

    Up to now, our discussion has reached the diagnosis (basic, constant alternating exotropia, RE>LE) and some of the management part, so I'm going to talk about the management.

    As we all know, this patient has fulfilled the criteria to be indicated for surgery, and thus surgery is the best option for him. Have you guys told anything about surgery to his mother? If yes, what was her response?

    In case of constant exotropia, non-surgical treatment is believed to be less effective. In fact, it's also not working very well for intermittent cases. From what I read, non-surgical treatment is only preferable in these following cases:
    1) convergence insufficiency
    2) small angle exophoria
    3) exotropia with high hyperopia
    4) interim treatment prior to surgery
    For our case, the 4th point (interim treatment prior to surgery) could be applied if we still want to give non-surgical treatment to this patient.
    Concerning non-surgical treatment for this patient, I know already that you've planned to prescribe glasses with overminus and base-in prism prescription (by PD decentration).

    Overminus works by stimulating accommodative convergence but a study reported the probability that the patient will discontinue the use of the overminus is very small. Seems that it gives little hope, but yeah... we can try first with strong belief that Allah has power over everything (innallaha 'ala kulli syai-in qadir, al-Baqarah 2:20). Let me try calculating the amount of overminus to be given, but of course we need the figure of patient's PD.

    Prism prescription is OK if patient is not adapted to prism. Have u guys done a prism adaption test on this patient? Or u planned to do it on the next visit?
    One more question, is there any suppression on either eye?

    p/s: Though there's quite a number of questions, hope u'll miss to answer none of them (ayat berbolak-balik, harap faham)



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