Thursday, December 30, 2010

Pediatric Optometry Case 2 : 3 yr old/F/C

Came to IIUM optometry clinic as a referral from IIUM eye clinic. They suspect Convergence Insufficiency on RE. 

History Taking:
Mother complain that her RE sometimes deviate out 3 to 4 times a day. 
She notice since 1 ½ years ago. 
There is no specific time of deviation.
Patient has the ability to control the deviation. 
She is the eldest of two siblings, younger brother doesn’t have condition. 
Patient also have Pelvic bone problem in the Left leg and is on going therapy with pediatrician. 
Her mother also claim that she often bump on stationary object but is not sure either due to leg or eye condition.
Her birth history is normal but she starts walking only when 2 yrs old. 
There are no history of strabismus in family. 


1) What is her specific diagnosis?
2) The probability of having this condition among young children is it high or low?Justify.
3) What is the management for this case?

prepared by: Group 1 :)


  1. hi everyone..happy new year..may this new year bring us success!

    okay..i'll try answer the question:

    1) diagnosis: intermittent accommodative exotropia as with +3.00DS the degree of XT reduced.

    2) probability of having this condition ehh? i'll answer that question later..ill google that first! hehehee

    3) management:
    - give RX as with +3.00DS, degree of XT reduced.
    TCA: 3/12 to recheck the degree of XT

    okay kawan2...hurry! lets discuss! i want the right answer!

  2. This is a case of unilateral intermittent (latent) exotropia at both distance & near. However XT is greater at near.

    I'm not sure whether it can be classified as convergence insuffiecy since the definition of CI says eyes which are orthophoric at distance fixation and exophoric/exo tropic at near fixation.

    According to a book Pediatric Ophthalmology by Birgit Lorenz & Michael Brodsky, they said that exodivation are common among population in the East as compaerd to the west. In US, intermittent XT is the 2nd most common strabismus diagnosis with 17% of cases. A recent study also reported that twice of the cases often occurs among girls.

    As for the management, i dont think pt have any problem with the accommodation. I think further examination should be done such as vergence measurement, accommodative measurement, stereopsis.

    For the management;
    1)VA= good
    2)Accommodation= is it good? (not stated here)
    3)Vergence= can do over minus spectacle Rx (-1.50D to -2.00D) or BO prism therapy.

    I've read that in order to know the exact amount of deviation, it is wise to occlude deviated eye for 30mins to 1 hr than do prism cover test.

    Let say a prism prescription or over corrected Rx is to be given, how much do we prescribe?

  3. please take no the rule in prescribing correction to preschool children.


    first the diagnosis.
    *RE intermittent exotropia with low ac/a ratio.

    the suitable management for this patient is undercorrect wet ret correction. Subjectively try to reduce the plus power and maintain the best VA. Undercorrection plus power is helpful to aid convergence. Perhaps +1.00Ds under correct may be enough. But we have to reassess the visual performance at both near and distance.

    Make sure the aided vision is better of same with unaided vision if we wish to undercorrect.

    in short ---- undercorrect wet ret, full time wear.

    TCA a month later to look at the improvement on vision and tropia. Do give patient a log book as well during the spectacle delivery visit.

    Just a gross idea. Let us discuss more.

  4. guys, almost forget.

    look at the dry and wet retinoscopy.

    it is almost the same---------indicates no accommodation is associated.

  5. that's right, azuwan...comparing dry and wet refraction, the finding is almost the same..thus the accommodation component is not likely contribute to her deviation.

    this is the case of RE intermittent exotropia with low AC/A ratio.

    undercorrect her wet refraction, but still need to take into account her best VA with less plus power.
    -TCA 1/12 to monitor her VA and deviation.

    thanks for the information regarding the prevalence of intermittent exotropia. it is interesting to reveal that exodeviation is more common in Eastern population and the intermittent exotropia is the 2nd most common in strabismus cases.

  6. i have question, the PCT above done without correction or with correction?

  7. @che nur for ur information PCT was done w/o correction

  8. @nurlizz : nice try noli...lets discuss more on diagnosis n management... :D

    @atikah : i also not agreed wif the statement of suspected Convergence Insufficiency for this pt..n u work hard on the 2nd question...gud job... :)

    @azuwan : managing this case, we need to take consideration all these factors...

    @hidayah : the wet & dry ret findings is almost the same might be bcoz of her pupil not fully dilated (strong accommodation)...

  9. her mother complaint the pt's RE sometimes deviate out...

    but during the clinic session, we noticed that not only her RE deviate out, but also her LE (deviate out)...PLEZ TAKE NOTE ya... :D

  10. Knape x bole delete comment atas tu?.... yg atas tu cancel ye...silap sket...

    @nurlizz : nice try noli...lets discuss more on diagnosis n management... :D

    @atikah : i also not agreed wif the statement of suspected Convergence insufficiency for this pt...n u work hard on question no 2...gud job... :)

    @azuwan : managing this case, all of these factors need to take into consideration...

    @hidayah n azuwan : for the reason wet n dry ret findings is almost same; maybe...

  11. @azuwan n hidayah: please take note in managing strabismus we must also consider about AC/A ratio either low/normal or high AC/A ratio

  12. salam ;;)

    hmm..i think this patient has basic intermittent exotropia..based on not much different in distance deviation and near deviation..

    i agree that, this case has no related to accommodation,as said by azuwan and also by PCT with +3.00D that used to exclude the accommodation..

    for 2nd question, thanks atikah for the good information :)

    for the managament...
    hmm..the overminus therapy can be given to stimulate the convergence..but as stated above, the AC/A ratio is low and not suitable for that..
    the VA is normal for children with 3 year old..
    futhermore, the NPC is, should we give exercise to improve the convergence, but how about the AA? you did not mention it..

    then, monitor 1 month to remeasure the deviation and monitor control..

    surgery will always be the last choice..

  13. from:

    Prevalence - Exodeviations are much more common in latent or intermittent form than are esodeviations. Exodeviations occur more commonly in the Middle East, subequatorial Africa and the Orient than in the United States (as state by atikah)..

  14. i have few question to ask to group bahjah,nisah n jaher.

    1)did u take only one measurement for NPC? i'm expecting several mesurements that show receeded npc.

    2)other than those tests given, are there any relevent test performed during that visit, such as NRA/PRA, FA, and others (stereopsis)

    3)did the patient's eyes deviate during the visit? Before tests were performed on her.

    4)Any c/o headache upon near task?

    5)did patient go to school/nursery or etc?

    6) do you have anything else to add before we go into conclusion for the diagnosis n management?

  15. @che nur

    why do you think low ac/a ration is not a suitablr candidate for undercorrect plus or overminus?

    Upon reading,i believe that undercorrection of plus power is helpful in low ac/a ratio cases.

  16. what i can recall bout clinical signs of patient with CI are:

    orthophoric at D with exhophoria at near, or

    low exophoria at distance and moderate to high exophoria at near.

    (this patient has EXOTROPIA)------can this be considered as CI? CI is just for non strabismus cases only.

    So, the dignosis is 'intermittent RE XT with low ac/a ratio'

    Anyone please clarify this.

    perhaps someone can list down the common clinical signs that patient with CI might have, so that we can have better understanding.

  17. VA : tally with pt's age.
    Wet Rx : NI in VA.
    PCT : Near > Distance, ~10 PD.
    +3.00 D : reduce in deviation.
    Ac/A ratio : low.
    NCT : receded only on the RE.(should be accommodation problem???)

    Diagnosis : Basic XT (no significance near and distance disparity).

    Exodeviations occur less frequently than esodeviations. This ratio of approximately 1:3 in the prevalence of exotropia and esotropia.

    Since the patient is XT with hyperopia, has involved allignment problem,
    thus we should prescribe full rx to avoid disturbing emmetropization process..

    TCA of 3/12 can be given to monitor the acuity,accommodation, alignment, and degree of deviation.

  18. @HANNAN

    what do you mean by 'NCT : receed only on the RE'. You mean NPC?

    from the data given by group 1, the NPC is reduced, not receded because it has only one measurement.

    eg: 12cm, 14cm, 15 cm <------this is receded NPC.

  19. @nurlizzz

    are sure it is accomm XT? does accomm XT has low ac/a ratio?

  20. @Kak Long (HaNiSaH)

    thanks for the info. Which eye deviate more frequent?

  21. @che nur : some idea there...nice... :)

    @azuwan :
    1] we took some measurement...the readings are the same...13cm (RE deviate out)...sorry for miss it out...

    2] we tried randot stereofly test...but she didn't respond well...the frisby, not in our clinic on that day (might be)...perform frisby test on the next visit on her...

    3] yeah...i noticed her LE deviate out when she at waiting area in our clinic...n in paed clinic sometimes her RE deviate out n sometimes her LE deviate out...

    4] no HA reported

    5] nursery or stay wif her grandmother...

    6] not now...lets discuss... :D

  22. HUHU..tenet problem~ :((

    1)DX: intermittent alternating XT as the VA between each eye similar and as mentioned by hanisah, sometimes the LE also deviates out.

    2)still searching~PENDING~

    3) it seems like her VA quite good as with RX or without RX the VA is similar 6/9.

    SO, to align her eyes, prism prescription can be given since the AC/A ratio low but for her age it might not works very well.

    Thus, over-minus can be prescribed for her. but, HOW MUCH? use Sheard Criterion to calculate the over-minus power.

  23. Sori for the late entry...

    Looks like we have quiet a heated discussion here..

    @azuwan: regarding the question for c.nur, overminus or u/correcting the +ve will not help those with low ac/a ratio since with o/minus, it involves the help of ac/a ratio to improve the convergence

    @hannan: yes, it is basic XT but the diagnosis is too general. Yes, exodeviation rarely happens in those of young age such as this one. Like we've learn in class, in infant or young children, we usually see esodeviation cases..

    @ my frenz:
    1) Does accommodation really involve in this case since in Exo classification, there are no acc exodeviation as one of em

    2) It is intermittant since the patient can control the deviation. But the vision is good in BE even though the patient has XT? Why?

    3) In terms of management, most of you got half of it correct. It is good that the rule of A3DS for prescription of hyperopia is noted, pay closer attention to the rule of 'stability'. So what is the management for this visit?

    4)Most mention prescribing Rx, and tikah mention BO prism therapy... what other option can be done to the patient if the deviation is still present when both optical and vision therapy has been done?

  24. @ rohaila: good.. it is alternating since the VA in BE is good

  25. thanx zahirah for answering azuwan question :)
    for azuwan..remember back, the overminus theraphy is only useful for high AC/A ratio but not for low AC/A ratio..

    i think, the diagnosis is basic intermittent alternating XT.. as KAK LONG said, it also deviate on LE..hehe

  26. @che nur


    is this the case of CI? it is XT case. CI is for non strabismus..

    group 1, please clarify this.

    so, when the next visit will be?

  27. @azuwanYEAH..WELCOME..

    betul2..plz clarify this..KAK LONG & the gang :D

  28. Tropia= strabismus Orthoptics)

    phoria= non-strabismus (BV)

  29. @azuwan : yeah...this is XT case...the ORC suspected her as having CI...but i think we should not too rely on it right... :D when the next visit? is the answer for management question...

    @rohaila : as u said...intermittent alternating mentioned by che nur & hannan, it is Basic XT, it is "Basic Intermittent AXT" case actually... :) gud job...


    *hint : management for this visit, we asked the pt for follow up...1/52??... 2/52??... 1/12??... or 3/12??... and why?....

    Intermittent basic alternating XT.

    NPC not NCT.
    Reduce not recede.

    actually referred on the hyperopia notes by sir, we should consider age, acuity, accommodation, alignment and degree for hyperopic case.
    if alignment does not involve, plus the refraction is +3.00 DS, the prescription of spectacles for this age is not necessary as the working distance is only up to her arm length.
    so, since the patient is hyperopic and XT (alignment involved), so full correction is needed to avoid disturbing the emmetropization process.

    am i correct??? please correct me if i'm wrong....
    thanx :)

  31. answer for question zhrh

    1)Does the AA involve? as we answered it, NO according to PCT with +3.00DS.

    2)the VA is good in BE because it is alternating XT, like Rohaila said..

    3)so, the managament is monitor closely 1month, to look for the stability..

    4) last option might be surgery if all optical theraphy or visual theraphy does not help..

    correct me if i;m wrong :)

  32. sorry guys for missing the train yet again.
    A very happy new year to all.

    So conclusively the patient has basic intermittent alternatiing XT.

    Regarding issues mentioned by jaherah:
    1. Yes accommodation component wasn't involved as mentioned and explained by nabilah. Furthermore patient is exo, and accommodation usually involved in eso cases (as in accommodative esotropia).

    2. VA is good since BE were well stimulated due to alternating nature of her exo. If the tropia is unilateral, than we anticipate a unilateral reduction in VA, the deviating eye have the worse VA. And this is not the case for this patient.

    3. Yes we shouldn't overlook the stability part. TCA 3/12 to re-perform refraction and assess stability. But sorry I cannot justify why, I just recalled that during paediatric class last time, Br Muzziman gave TCA 3/12 for stability monitoring. Correct me if I'm wrong will ya?

    4. Yes last option would be surgery.

    Crap I feel just like re-typing everyone's answer.

  33. fuyyo...basic intermittent atnernate longgg..

    thanks azuwan...we should not ignore the stability of the RX...thanks for reminding me :)

    accommodation not involve zahirah...saya pon tersilap..urghhh!

    thanks guyss!! i learned alot!

  34. tenet prob lg....huhuhu

    For this case, we should consider age, acuity, accommodation, alignment and degree...
    For 3 yo with power ~3 DS, usually we do not give prescription because the working distance is up to her arm length only...
    Since the patient has alignment problem, (hyperopia and XT), full prescription should be given to avoid disturbing the emmetropization process...
    So, for this case, instead of undercorrect the power, we should give full prescription power....
    Am I correct????any other opinion????

    3/12 TCA is to monitor the acuity, alignment (deviation)and degree (refractive power)...
    But, i've question for this group...How about the accommodation for this patient???...Is it normal for both eyes or it juz abnormal for RE only????

  35. so as many of you already stated, the final answer would be basic intermittent alternating exotropia.??
    i think i need to read more regarding this diagnosis..

    lastly the management would be??
    to answer hanisah's question, the TCA for 3 years old patient would be 1/12 in order to monitor her stability & improvement of VA with current rx...then after there is some progression with the rx, we will monitor her again for the next 3 months..correct me if i wrong...

    is there any other home therapy for this patient other than prescribing rx???

  36. :-O
    - i think case hyperopia in paed, the refractive error should be confirmed stable after 3 visits, then we can prescribe if the vision improved with the RX given.

  37. from the results above,the answer for no 1 Question is:
    -intermittent alternating exotropia basic type

  38. yup..monitor for 3 visit, every 1 month..if every 3 visit, the stability of deviation is good, then the patient can be discharge..

  39. yes, i think we should confirm the stability of her deviation after 3 visits. then, if the deviation stable at more than 20 prism diopter consider for surgery but if i'm not mistaken the surgery could only be done for the age 5 years old or more...

    group 1 pls correct me... :D

  40. wahhh...i can see some points there...

    okke we giv some more time to those who do not try to answer yet...

    xnk comment...nk main dlu la... :D

    ;) :X =(( :-/ 8-} :)] ~x( :-t b-( :-L
    x( =))

  41. Gud job everybody..;;)

    For Q1: i agree with the answer: intermittent alternating exotropia basic type bcoz
    -involve BE, n different deviation ~ 10PD

    For Q2:as mention by jaher, in our lectures stated that most of the infant case is esodeviation, rarely of exodeviation..eventhough, it is possible je sbnrnya..myb this pt is in that category.

    For Q3: management:
    b4 prescribe, take consideration of 2ADS + M formula
    estimated VA for 3yo is 6/9 -6/6
    so, b4 we prescribe, should monitor 1st at least 3 times visit (agree with rohaila)..
    so next TCA should be 3/12.

  42. for 2nd question,

    AOA stated that more than 30% of children with hyperopia exceeds 4D develop Esotropia by the age of 3 yr old. thus, it shows mostly in paediatric there is Esotropia case rather than Exotropia.

    So, this is very uncommon among peadiatrics.

  43. discussion..I'm just come back from Hoya Visit..

    Basic= distance & near deviation are almost same
    and of course basic XT fall under intermittent

  44. 1. basic intermittent alternating XT? it can be meh? because for me i would answer basic XT but more XT at near with low AC/A ratio. it is because the different of deviation is not more then 10pd. i miss a lot here and confused already..

    2. @ atikah interesting prevalence u got.adding my knowledge.

    3.since this child is 3 y.o and based on VA, we should monitor at least 3 months to check the VA and stability and if there is no improvement,we can give her vision therapy. if the vision therapy failed we would suggest her to do surgery because the value of tropia is more than 20pd.

  45. that's a warp.

    now we already have the diagnosis n management for the patient. no need to explain more.

    ---tomorrow ur group will have one more patient having the same problem. referred from ORC as well. intermittent strabismus. plus, having vertical deviation----

    very interesting. 'Need to read on vetical deviation management'

    see you!

  46. please conclude the Mx...for basic exotropia, what is the best treatment option?

    please answer this question class

  47. @azuwan

    what warp? haha..warped laa..aiyoh nak laugh on me tp salah.

    i know i just stated my answer because im a late comers. n cofused too.

  48. If on the first visit the patient already showed 25-30 PD deviation, do we still need to hold the prescription???

  49. If I'm not mistaken, stability should be considered if only involve the refractive error...But, in this case, it involves alignment problem...
    HMMMMMM.....still curious about the management :-/

  50. @eli aimi

    aiyo sebut pandai la, aku sekolah kat nigeria wei..

    warp = kuih koci

    hoho....'that's a warped'

    Eli, i'm not referring to you lah... tak da @Eli aimi pomm.

  51. @HANNAN

    rilek la hannan,

    we'll discuss the actual Dx and Mx tomolow!



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