Monday, August 16, 2010


9 years old/Male/Malay


- He came with LE XT.

- He keeps rubbing his eyes during the eye examination.

- He has skin problem


- He was referred from PCO clinic.

- No c/o blurred vision at Distance & Near.

- No c/o headache.

- No c/o double vision.

- No history of allergy, other eye disease & systemic disease reported b his guardian.


Let's Discuss!

1) What is the exact diagnosis for this case?

2) How would you manage it?



  1. i think there's some technical error going on here... :( what to do?

  2. sorry..for the error.
    i've already edit, now it should be ok.

  3. salam
    we've confirmed that the patient has alternating XT for distance and near.
    so, what other abnormalities you can detect???
    how to manage the patient and what is the profnosis???

    *p/s: everyone please get involve in the discussion... :(

  4. Base on this case we can diagnose the pt with basic alternating XT.

    For the management part, i think we should perform cycloplegic refraction because NPA indicate pt have accommodation problem. After the cyloplegic we may be able to identify the type of accommodation problem.

    The first thing is to correct pt refractive error.
    After proper correction is given, we can than manage pt accommodation problem.

    After accommodation problem is resolved, we can start on the vergence therapy.

  5. differential diagnosis:
    1) accommodation weakness as expected AA=15.5 D but his AA only 3D

    2) alternate XT with RE as a fixating eye

    3) Basic XT

    1)accommodation weakness
    2)basic alternating XT with RE as a fixating eye

  6. that is right atikah..

    but what is your suggestion for accommodation therapy that we can do to him as 9 years old child..
    then, what is ur planning?eg. by giving TCA,but how long should we give?

  7. differential DX:

    1. alternating XT with RE as a fixating eye

    2. type of XT is divergence excess since the deviation is larger at distance and the difference between near and dist is more than 10pd.

    3. accommodation weakness


    1. correct refractive, prescribed RX to him
    2. accommodation therapy ( we can try to give pen-to-nose therapy) about 3weeks
    3. TCA after 3 to 4 weeks to monitor the improvement of AA then we can proceed to vergence therapy.

  8. should we give him optical therapy by overminus RX to treat the vergence component


    should we treat the accommodation first by home therapy monocular pen to nose to increase the amplitude of accom?

    or just prescribe w/o overminus?

    can someone teach me? i got confuse..heheeee :P

  9. Salam.. :)

    - Diagnosis: Pt has alternating XT with RE fixating and worst @ distance

    - The patient also has accommodation weakness.

    my question, why doing PCT with overminuses of -1.00?


    1. Correct d refractive error..but the power is too little.. how about the PCT with his correction? Why u guys not doing cycloplegic to this pt?

    2. treat the AA. pen to nose should be as home therapy. But as 9 yo, he might not be compliance. So, juz opinion, patching one eye and give a near work stimulation. ask to do 15 minutes for each eye. Is it right?

    3.Treat the vergence

    for TCA after 3 weeks


  10. 1) Actually he has alternating XT (divergence excess type) with RE fixating eye as well as accom weekness.

    2) PCT with overminused 1.00D is to know how much the deviation left if over minus optical therapy is given to him later on.

    3) no cycloplegic done because it was exodeviation.

    4) for mx, ciknor, you got some point..

  11. norli..
    for this case, as the refractive component very low and with the correction given the AA still not improve..
    the best is give monocular pen push-up therapy as to normalize AA first before procede with vergence therapy..

  12. in response to che nur:
    1. cycloplegic is beneficial for active accommodation (to relax acc), but this pt has weak acc. therefore cyclo was not performed.

    As for management, dont get mixed up. Step by step guys =)

    Remember the BV protocol....

  13. haha..ok2
    I got that.. for exotropia, no need to do cycloplegic because, exo mean eye move outward and at this time there will be no accommodation no need to do cycloplegic to relax the well as convergence will also affected..thanx ela :)

    So, for M(x), patch the eye monocularly when doing pen push up therapy..then, tca for checking his AA as well as the convergence..

  14. ok thanks ela..

    from my understanding, RX is not prescribe yet isnt it?

    accommodation component is treated with monocular pen to nose...

    so now i can i see the flow..good job group 2!

  15. noely: yes totally right, treat accommodation 1st...when acc is normal, proceed with vergence component...

    but how do we manage the vergence problem? (answer's actually in the trigger)

  16. oh, all of you had discussed it a lot!

    No need to prescribe any Rx since it is useless, -1.00Ds is too much guys. VA may drop as well.

    i'm agreed with the therapy part.

    but then, we cannot easily jump into conclusion of this patient having alt XT.

    Did the examiner look externally how this patient come in with. Head tilt? Partial ptosis? Photo?

    what about the ocular motility? HESS chart some more. Who know it may be related to any ocular syndrome.

    regarding the near acuity, is it normal for children at age of 9 yo to achieve N7 for near?

    Examiner, please clarify this.

  17. back to nazaryna's question: how to manage vergence prob?

    urrrmmmm.....since PCT with -1.00 DS show reduce of exo at distance, can we prescribe optical therapy of over minus to this patient when the accom component back to normal?

  18. hi..
    in respond to azuan questions,

    through our observation, he came with normal posture and gait, no ptosis. (p/s: sorry, we cant provide the photos as there's some problem with the photos.

    the OMT result revealed V-pattern at uppergaze while the HESS test shows no deviation at each gaze for each eye.

    regarding near acuity, since he has accommodation problem, thus he cant achieve better near visual acuity.

    lastly, for the mx, actually azuan..we didnt prescribe the lens yet, we just giving him home therapy monocular pen-push-up to normalize his AA first.

  19. Adding to rohaila's point: we already ordered the lens for the patient, overcorrection of -1.00D since the exo at distance is reduced. It is useful, and vision did not drop. We r sure bout that rite Ela?

    And while waiting for the Rx to be ready, he was instructed to do therapy like Ela mentioned.

    TCA during lens delivery would also include the evaluation of accomodation status after the therapy.

  20. What was the spectacle power prescribe for this patient?
    I think since this patient AA is very low he will need ADD power, exudative bifocal would be the best.

    Remember that pt is 9 years old so the prognosis of the therapy will not be as successful as compared to younger children.

    Even if patient is to perform monocular pen-push-up to normalize his AA i think he would need some ADD while doing the therapy. Not a full ADD power but partial. Sir Muziman is there such technique? because since his AA is only 3D, wouldn't the therapy be too difficult for him?

  21. Good day everybody.....'so long no see' (eyestrain from reading too many comment, feels bad from not participating for so long)

    After reading.....
    I agree with most of you that
    1) this patient exhibit clear Alternating XT with RE as fixating eye associated with divergence excess

    2) The patient also shows signs of AW but how is the MEM result.. just to be sure.. does puting +0.50 during AA helps? or it effects the XT condition at near?

    3) I agree that cyclo wouldn't do much help since pt has XT and -ve power will help especially at distance. Just curious. The overminus -1.00 is added after Ret power is it? so for LE PCT was done with -1.50? What is the PCT with his correction only?

    4) I agree that first is give full Rx. But we should deal with the accommodation problem first. I hope the monocular pen-to-nose 10 cycles/day for 1 month will do. Set target of end-point 15D for his age. But for the first month try to increase to 7D only is enough i suppose. Increase target for each visit. Full cooperation from parents is needed to ensure success. But as tikah has said, we can try bifocals but hopefull it will not disrupt the XT condition.

    5) after this has been normalize, then takcle the BV problem. But how is his BV function. Does he have any stereopsis? Or fusion the least?

  22. salam...

    i) alternate XT with RE as fixating eye
    ii) divergence excess since the deviation is larger at distance compared to near and the difference is more than 10pd
    iii) Accomodation weakness since his AA is only 3D which is below than expected AA

    How is the AA with the overminus (-1.00DS)? Is it affect the AA?

    I think we should handle accommodation problem first by giving monocular push-up exercise at least 3X/day with 10 cycle each session with full correction for a month. I agree with zahirah, to set the target 7D for the 1st month and increase it for each visit until reach the end point; 15D.

    Vergence theraphy can be done after the accommodation part has been normalize. Overcorrection can be prescribed for this patient as long as it not distrupt the vision and the exodeviation reduced.

  23. wahhh think i was soo left behind...(sorry sir)
    it seem that everyone has already point out all the details..
    yeah i'm soo agree with all of you this patient has alternating XT with RE as fixating eye...
    another one is, this patient also has accommodation weakness with NPA is only 3D as we already know the expected AA for 9 years old is 15D..

    one thing i'm curious about is why they use RX with over minus one to perform the PCT??

    for mx i think we should give this patient full rx with monocular push up exercise...

    p/s: thank you sir for teach me on how to teach & demo the right way to perform mono push up test to the patient yesterday...kihkih

  24. assalamualaikum...

    based on data shown, this pt has
    i) alternating XT with RE as fixating eye

    ii) since the diff between distance and near PCT reading is > 10 pd, so he also was diagnose as having divergence excess. dont look at the reading of PCT with Rx overminused -1.00 bcoz it is to know how much the deviation left if over minus optical therapy is given to him later on

    iii)his AA is lower than expected normal AA. Accommodation weakness

    for this case we need:
    i) we have to normalize his AA by giving monocular pen-to-nose 10 cycles/day for 1 month. the aim : 15D of AA
    but i think if hi AA can be increased up to 6D should be ok for the first follow up.

    ii) after accommodation problem solved proceed with vergence therapy

  25. EDIT: oops as i read all the comment once again, it seem ela is already point out (comment no.10) why they use oveminus -1.00 to perform PCT...thank you...

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