Monday, January 17, 2011

Pediatric Optometry Case 6: 5yo/M/I


-Referred from PCO clinic. Based on PCO, vision is fluatuate, required cycloplegic refraction. 
-Parent report, patient like to watch TV very close, squinting and make pinhole effect to see small letters, like to rub, tend to have face turn (not confrm either right or left) in order to focus. Generally healthy.


Vision unaided
pH: 6/18+²
N: N6 @ 33cm
pH: 6/12ˉ²
N: N6 @ 33cm
Central @ symmetry
Cover test
∞ = no movement detected
N = small XP with fast recovery
V pattern
Nystagmus on lateral gaze
Stereopsis (TNO test) (without correction)
Cycloplegic refraction
- retinoscopy refraction
- subjective refraction

+0.75/-3.00x180 (6/12)

pl/ -0.75x180 (6/18+²)
+0.75/-3.00x180 (6/12)
+0.50/-1.00x180 (6/12ˉ²)
BE: 6/12+²

- corneal topographer

- pentacam

46.45(7.27) @ 82 [e=0.94]
43.11(7.83) @ 172 [e=0.70]
dK=3.34 (0.56)

H: 7.86/42.9 @ 175
V: 7.27/46.4 @ 85
CA= 3.50D x 175

46.27(7.29) @ 97 [e=0.96]
43.31(7.79) @ 7 [e=0.71]
dK=2.96 (0.50)

H: 7.88/42.8 @ 7.1
V: 7.50/45.0 @ 97.1
CA= 2.20D x 7,1

                                                                    OMT with wet-Rx 
1) What is the best diagnosis?Justify your answer.
2) Since the patient has V pattern at upper gaze and nystagmus at extreme gaze, could you think of the possible causes?
-->Specially prepared by Group 2 & 3. :D


  1. Am I the first here?

    Very interesting case...
    1) From the VA and refraction, I can say that this is a case of BE meridional amblyopia. But Im just wondering, why is it that the degree of ablyopia is the same even though RE has higher astigmatism compared with LE? IS it from the corneal astig?

    2) From my reading, doesnt V pattern usually associate with presence of exotropia or esotropia. And it is usually due to cyclorotation muscles. But since it involve nystygmus, I'm not sure.

  2. lately, we got lot of interesting cases. GREAT!

    Ok group 2 and 3, before we can jump to any DX and Mx. i need to have more info about the clinical finding.

    1) did the prescription improve the deviation?

    2) how long/since when this patient was having this problems?

    3) You gave us only photo on upgaze. What bout the other gazes? is it normal?

    ('brown's syndrome'. that is what i have in mind)

    need to explore more.


  3. salam..hye guys..let discuss..
    i know u all familiar with catchy word "tanushhhhh....".my b it relate..hehehe:p

  4. Tanuusshh...i love that sound..hehe

    1) Actually this is my PCO patient.From the findings,it can be said that he has bilateral meridional amblyopia..since a 5 y.o boy should get 6/6 already..

    2) Yes, V pattern usually associate with cyclorotation muscles like zahirah said, and usually involve vertical deviation.

    Question: Why pentacam and corneal topography is done on this patient?Is he suspected to have keratoconus?

  5. @azuwan

    1)with the wet RX, it did improve the deviation as the v-pattern reduced.

    2)if i'm not mistaken,his father noticed it since a few years ago.

    3)there's no deviation observed at the other gaze.

  6. @azuwan

    1) sorry, as far i remember we didn't perform CT after the prescription is given as we plan to do it during post-cyclo..
    **group 1&4 please take note..

    2) his father notice his problem since 3 months ago

    3) other gaze is consider normal. as for upgaze, the v-pattern is obvious without rx and it reduce after prescription is give..

    p/s: anyone from group 2&3 please correct me if i give wrong info...

  7. salam...Tanushhhh (tiru gaya mulut ela dlm pic. sir,he3)

    1)this pt. has meridonial amblyopia on BE since the vision is just 6/12 on each eye. at the age of 5 years old the VA should be 6/6 or better.besides,meridonial amblyopia develop at the age of 2 years old if the high astigmatism is not corrected.

    for the 2nd question I'm not sure yet.

  8. hmm..sob, pentacam and corneal topography is not only done to check for keratoconus.. we can estimate from corneal astigmatism result..

  9. okey guys..gud job..
    let's discuss more..

    @ chenur: agree wif che nur..pentacam and corneal topo can estimate the degree of CA..and also gud to screen keratoconus as he is indian..

    my Question is what possible test can we do during post-cyclo other than common tests (VA,AA,CT,STEREOPSIS,RX,OMT)..?

  10. Tanushhhhhhhhh~ i loike :P

    1)based on the Rx, it is bilateral meridonial case...n also amblyopia, the vision at this age should be 6/6...

    2) i agreed with zahirah, some said V pattern always associated with exo or eso diviation. but his hishberg is central n symmetry during the clinic rite?. maybe he has intermittent eso/exo deviation. his parent reported he sometimes squinting, inward or outward deviation?..

  11. yep, from pentacam n corneal topography we can detrmine the corneal astigmatism...

    if we look at the finding from pentacam, the corneal astig is -3.50 which is almost the same with finding in wet RX. so, it can be said that corneal astig gives major contribution in his total astig. to refresh, our total astigmatism consist of corneal astig and lenticular astig.

  12. Patient will come for the next TCA on the 19th(wednesday) for postcyclo. rx...

    anything regarding the managemnet will be decided on the TCA..

  13. Hello everyone...

    I see so the diagnosis was bilateral meridonial amblyopia.

    I can see that there wasn't much finding on the pt's vergence facility.

    I would suggest further test using meddox rod or howell card since V pattern was said to have much association with XT and ET as mentioned by zahirah.

    The OMT findings only shows nystagmus upon lateral gaze does this mean he has weak muscle control especially MR and LR muscles? Pt is orthophoric at primary gaze i think tropia is unlikely. Other than nystagmus you didn't mention any presence of O/A or U/A muscles.

    I think the 1st management would be to prescribe Rx and to start on amblyopia Tx. Do you think pt with nystagmus has any contraindication for patching?

  14. yes..i agree with everyone.. these is bilateral meriodional amblyoia.

    thus to equalize the vision, RX needed and of course alternate patching is a must.

    the presence of V pattern and nystagmus at extereme gaze, could be caused by o/a of IO??

  15. 1.For the diagnosis i would agree with everyone ; bilateral meridional amblyopia.

    2.But then, i think examinations done werent complete. I should suggest for u guys to do Hess chart to confirm the cause of V pattern. either exo or eso or any cyclorotation muscle affected. As we discuss in class this patient most probably has IOOA. Concrete evidences before any diagnosis, perhaps.

  16. @nurlizzz
    V-pattern is obviously a characteristic IOOA.
    Regrading the nystagmus, i think it is ok for patching to b done since hte nystagmus is at lateral gaze only.
    Association between nystagmus and IOOA: unclear.
    But i read that one type of nystagmus, the torsional nystagmus is accentuated at lateral gaze.
    So it might be worthy to note the type of the orientation&type and nystagmus to rule out what is the actual cause of it.It can be a serious cause like lesion in midbrain or something.
    Further reading:

  17. yes, we can say this patient has bil. meridional amblyopia. The VA is not much improved with the correction.

    treating amblypia will follow the same rules as before. Atikah, patching may be helpful for this patient. but then, It'll be challenging for 5yo child.

    my concern is how we can treat or manage the vertical deviation.

    I can say that patient is 'orthophoric' primary gaze. The deviation and nystagmus only present on the upper gaze.
    V-pattern is a sign of IOOA. We need to have a full OMT test showing not only the upwarg gaze.

    As far as im concerned, the vertical deviation is not disturbing, so, no need worry on the suitable management for the time being.

    did you know that brown's syndrome has the V-pattern characteristics as well? Pt may have diplopia at certain gaze especially upgaze and eyes move up when adducted. It is somehow idiophatic. Emmm....



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