Sunday, January 30, 2011

Pediatric Optometry Case 8: 10yo/M/F

Hx:      patient is generally healthy.
            Good vision at near and distance with current spectacle.
            The current spectacle was worn for 2 years.
            Was undergone amblyopia treatment for 1 year, loss of follow up for 1 year. 

Last Visit ( Jan 2009)
Final Rx
+6.50DS/-2.00DC x 180   (6/18)
+4.50DS/-2.00DC x 170   (6/12-2)
Stereopsis (Stereofly)
Small XP with moderate recovery at N and D
Other test
(funduscopy, tonometry, OMT, pupil reaction, Hirshberg)
All findings are within normal limit
Treatment / management
Home therapy : Alternate patching

Office therapy: CAM simulator
                             Eye Relax

Lattest Visit (26th Jan 2011)
(PH + aided)
Single letter snellen


+5.00DS/-1.75Dc x 180   (6/9)
+5.00DS/-2.00DC x 180   (6/9)
Final Rx
+5.50DS/-1.75DC x 180   (6/9)
+5.50DS/-1.75DC x 170   (6/9)

orthophoric at N and D
Other test
(funduscopy, tonometry, OMT, pupil reaction, Hirshberg)
All findings are within normal limit
Treatment / management

No questions will be posted here    =)   . Start asking questions guys!

Prepared by Group 4
Azuwan, Nazaryna, Atikah, Eli Shakira


  1. nice! thanks ela.

    *spelling error for the word 'latest'

  2. salam..
    woowww..congrats for all lecturer n student involved in managing this case..Alhamdulillah,,her vision was improved..a lot of improvement!!!

    i want to ask about the Mx given before..
    1.How many hours the patching Tx for home and office therapy? Did the patient give full cooperation?
    ..looks like very effective because the vision and stereopsis improved a lot.

    2. How about the diagnosis? she has bilateral amblyopia..but how to classified whether it is meridional or refractive because this patient is high hyperopia with moderate astigmatism..

    3. Last visit, Rx power is reduced. we prescribe another Rx for her kan..So, when this patient need TCA? how about further Mx for amblyopia. Do we need to discontinued or continue until VA and Rx are optimum and consistent?

    --Sorry for asking s0 s0 many thing--hehehe

  3. yezaa..the deadline for discussion is 6th of Feb. 2011..

    for 3rd year, you must involve in this case and also Pediatric case 7

  4. @Nur Syazriena Bt Ghazali

    the patching therapy was prescribed to pt on 2009. We don't know how effective the therapy was due to loss of follow up for a year. luckily, the vision was improved!

    2 hours alternate patching per day with intense near activities is enough in this kind of case. TCA 3/12 to look for any improvement and to review the therapy prescribed.

    The diagnosis? Try give yours first. the we discuss later here.

    Next TCA? Em....3/12. that one will be given once the new spectacle is ready. What do you think, do we need to proceed with amblyopia treatment? Why we have to do so?

  5. @azuwan

    hmm good for her to achieve 6/9....

    hmm i dont think she need to undergo further amblyopic treatment coz she had achieve 6/9 BE and no result in eye deviation with Rx (woo00 impressed u guys can work out until this little girl happy with her vision).....

    lets say if in next 3month after f/up... is it possible if her VA will be reduced again?? since no amblyopic therapy was given??

  6. Patient started the amblyopia therapy when she was 8 years old if i'm not mistaken. Even though she was at the end of the emmetropization stage and prognosis would have been slim, it seems that her VA and BV functions had improved much.

    According to the mother, patient comply well to the threrapy given during the first one year. However due to the loss of follow up we didn't manage to keep track on the pt's development. Pt had stopped the therapy on her own last year since she reported that she could see well.

    Patient was previously diagnosed with bilateral refractive amblyopia. Would it be right to say that it was due to both high hyperopia and significant WTR astigmatism. In this case it would also mean meridonial amblyopia.

    It would have been interesting if we have the axial length measured. what will be the expected axial length findings?

  7. Salam :)

    hmm..i think the patient has bilateral refractive amblyopia because the astigmatism power is not significant high enough compare to her hyperopia..what do u think guys?

    I'm curious about office theraphy..How many hour done on each eye? how its significant enough for amblyopia treatment?

    The patient had achieve the main target, which is, VA is equalize..But, why not just continue the treatment because the patient is very good and comply well with amblyopia that she can achieve 6/6. It will be good enough for her although her age is already 10..then, follow up to check the VA..

    hmm..i like farahiyah question.. if patient stop the it possible that VA would drop or maybe it will maintain 6/9? I think it will not drop unless if there is some factor that cause to her vision to drop. for example if there is inaccurate or change in refractive correction, it also can drop the vision. The correction also lead to effective treatment..What u guys think?

    correct me if i'm wrong..

  8. @farahiyah zainir

    farahiyah, this pt is not solely pt. She came for follow up visit after 1 yr not having f/u visit. The first therapy was prescribed by last 2 batch (batch br. aleng). Yes it was a success.

    Why do you think she doesnt need to do amblyopia treatment anymore? It is not merely on improved VA, what else do you think? other than VA.

    For ur information, one of the management given during last visit was prescribing new spectacle. New Rx. She needs to come again. for sure. Why the next TCA is necessary for her? Others can try to give your opinion as well.

  9. @Nurul Atikah

    thanks atikah!

    Hey everyone! did you realize that we hv put 3 smiley icons on diagnosis and treatment columns.

    Perhaps, you can guess what was the diagnosis given on 2009. As well as our 'new diagnosis' during previous visit (Jan 2011).

    Do come out with proper managment plan. =) hehe

    Atikah, nana, eli and me will help you to ease your uncertainty.

  10. @che nur

    Che nur, you meant if there any possibility for the 'VA to improve or maintain with the new spectacle' right?

    InsyaAllah. =) what do you have in mind guys?

    Che nur,Is it possible to do amblyopia therapy on 10yo children? prognosis? =) So, do we still need to continue the therapy?

  11. mohd faiz mohd haseriJanuary 31, 2011 at 9:01 PM

    salam n happy chines new year.
    after go thru the case data, i bravely + confident want to diagnose this cute patient to has bilateral refractive amblyopia compound bilateral meridional amblyopia...
    my evident is based on her high hyperopia and also degree of astigmatism...why not we put on two causes that lead to amblyopia..

    if we compare from previous visit and latest one, the VA is's good news to hear.. and i suggest to discontinue the therapy since the pt age over the plastic range.. the best VA of 6/9 should be accepted since we have miss contact with the pt before...
    p/s:moral of the story..dun miss contact with patient especially paed's cases..he2

    furthermore, the level of streopsis also shown big improvement that indicates the pt already appreciate the usage of two eyes.. perhaps need to re-asses with her new Rx on 3months later.. i do believe she will has extra improvement by 20 degree of arc..hopefully

    last, why don't we perform AA test and NPC to see the level of focusing and convergence... at this ages, patient should has optimum AA and NPC to be able her see clear + comfortable..that all i think..

  12. @mohd faiz mohd haseri

    Great idea faiz!

    20' improvement. hehe..insyaallah. 50' is normal already maa...

    Yes, we should measure the AA and NPC. Perhaps on next ophthalmic delivery visit.

    Emm....I don't agree with your diagnosis. Can 6/9 VA be considered as amblyopia? Hint: That's why i put 2 smiley icons in the diagnosis columns. Meaning to say, there eare 2 diagnosis, previous and latest one.

  13. looking at pt's photo, why do her eyes look 'bigger' than other spectacle wearer?

  14. mohd faiz mohd haseriFebruary 1, 2011 at 1:33 PM

    @The Traveler

    since the patient wear convex lenses that contribute to magnification effect, the people will notice the bigger appearance compared w/out the lenses before both eyes...

    hmm..from my observation, this little gurl generally has a big eyes also..a little bulging perhaps..=)

  15. Yes you were right. One of the contributing factor to the large appearance of the eyes are due to the convex shape of the lens. However in this case pt did also have a large ocular structure because when she took off her spectacle her eyes did appear to be slightly larger. Possibly due to physiological factor.

    Define amblyopia?

  16. According to Millodot (1997), AMBLYOPIA is:

    A condition characterized by reduced VA without any apparent lesion of the eye or proven disorder in the visual pathway.
    Not correctable by spectacles or CL.

    The usual clinical criterion is 6/9or less in one eye or;
    2 line difference or more on the acuity chart between the two eyes.

    VA 6/9 is will be considered as amblopic if pt was presented with such VA during her 1st visit. Pt's VA when she was diagnosed with amblyopia were 6/18 and 6/12 in each eye. What do you think? Is this pt still categorized as amblyopic?

  17. hi everyone..happy holiday :)

    sorry for the late response... the vision of BE are 6/9.. that vision is not considered amblyopic eye anymore as the ambyopic eyes is worse than 6/12..

    am i right?? however, i still think that she still need the alternate patching treatment as the vision does not achieve 6/6 yet (6/6 the guideline for normal)

    i think the right Dx for her is BE refractive amblyopia...

    do u guys change the RX with the new power? the changes of vision with the new RX is not much..

    should we change it??

    the eyes look bigger because the wear plus lens. it magnifies the eyes

  18. where are rest of you?a few only join this discussion...

  19. @Nurul Atikah
    in respond to atikah's latest question, can we diagnose her to have reduce vision after a successful amblyopic therapy.

    it might be due to the emmetropization has already stopped (age:10yo) and with the therapy, she only manage to get VA:6/9 which is equal between both eyes.
    In fact, her stereopsis also improves a lot.

    But, regarding TNO result, it is true she got 180?if, i'm not mistaken there's no 180'arc in TNO. Here's the order:15,30,60, 120, 240, 480,1000.

  20. @Nurul Atikah

    in 2009 the diagnosis might be patient to has bilateral refractive amblyopia with compound bilateral meridional amblyopia.

    can this patient be diagnose with bilateral visual deprivation amblyopia???? because this patient was uncorrected high bilateral hypermetropia and makes no effort to accommodate and grows up with chronically blurred retinal images.

    as the latest diagnosis might be coumpound hyperopic WTR astigmatism. (huhu adakah btoi?)
    i do say this girl not amblyopic anymore after correction because there is no difference line in VA for BE (achieve 6/9 on BE).

    the Mx should be 1st, must prescribe her with new Rx, and why not we give her intense near task home therapy, perhaps in next follow up, by sake of god her VA will achieved 6/6.. we should try eventhough her age is above the plstic age.

    since all others finding within normal limit, so i agreed with FAIZ to do assessment on vergence, accomodation, and NPC test in next TCA as to maintain her eye in good condition.

  21. nurulhidayah mohamad nordinFebruary 5, 2011 at 7:43 PM

    salam guys,
    i would like to ask regarding the final Rx.
    is there any modification hv done on the final Rx?
    did the patient feel any slanting surface?

  22. NOR ARIFAH BT ZAKARIAFebruary 6, 2011 at 6:03 PM

    @The Traveler

    Yeah...i did notice the patient’s eye appear larger. I think we can recommend for contact lens.

    • because she is high hyperopia—to prevent accommodative esotropia.

    • To have realistic view and sight -there is spectacle magnification for retinal images.

    • Cosmetic appearances- avoid larger appearance of the eye & self confidence, hence increase compliance wearing Rx.

    • No prismatic effect

    Also the patient is already 10 years that supposedly she could able to manage and handle the CL regime and hygiene herself with some observation from her parent....

    however, it still based on patient compliance and preference to use spectacle or CL...

  23. NOR ARIFAH BT ZAKARIAFebruary 6, 2011 at 6:04 PM

    @The Traveler

    Yeah...i did notice the patient’s eye appear larger. I think we can recommend for contact lens.

    • because she is high hyperopia—to prevent accommodative esotropia.

    • To have realistic view and sight -there is spectacle magnification for retinal images.

    • Cosmetic appearances- avoid larger appearance of the eye & self confidence, hence increase compliance wearing Rx.

    • No prismatic effect

    Also the patient is already 10 years that supposedly she could able to manage and handle the CL regime and hygiene herself with some observation from her parent....

    however, it still based on patient compliance and preference to use spectacle or CL...

  24. NOR ARIFAH BT ZAKARIAFebruary 6, 2011 at 6:05 PM

    Based on last visit on Jan 2009, my diagnosis is the patient suffered from bilateral refractive amblyopia secondary to uncorrected hyperopia with WTR astigmatism, however the amblyopic show an improvement on the latest visit.

    The previous management conducted really shows an improvement of her amblyopia. By comparing, the STEREOTEST from 200’ to 50’, CT from small XP with mod recovery toward ortho at near & distance, equal VA b/n 2 eyes.

    I would like to add Farahiyah and kak Che Nur’s discussion and answered for azuwan’s Q : about “IF PATIENT STOP THE TREATMENT...IS IT POSSIBLE THAT VA WOULD DROP OR MAYBE IT WILL MAINTAIN 6/9?”

    Guys, as we know the stereopsis performance influence by important factors like equal VA in each eye and on eye alignment.

    The stereopsis also determines the pronogsis for the amblyopia theraphy. Since the patient VA improved and equalized, also stereopsis (binocularity) present— I think that the VA will maintain after the VT being stop.

    Moreover, the single letter chart show the VA is 6/9—the aim/ end goal of VT to be and have been achieved.

    However, I think the previous VT should be proceed for 2-3 visit, if VA stabilize (or maybe improvement to 6/6) , then stop occlusion. But don’t discharge patient, still do the f/up 3/12 to monitor regression of VA.

    And also I did agree to faiz, for the next TCA, do assess her BV function like AA & NPC, AR, FA, etc to evaluated her vision so patient will have comfortable sight and happy vision =) .

  25. good conversation we have here.. but what i learn in BV. we will give bifocal for this kind of children.. why 4th year only give single vision for the patient?

  26. NURULHUDA ABD LATIFFebruary 6, 2011 at 11:11 PM


    for the monitoring progress...we should monitor once every 6 month until at least 12 years old...

    but if degree WTR astig is change let say 170 but we give 180, will it effect the vision vigorously?

  27. nurulhuda abd latifFebruary 6, 2011 at 11:14 PM

    correction ---> will it effect the vision swiftly...?

  28. @muhamad zulhusni
    (ye,ye je zul ni) it right?..for what reason we should give her bifocal?..what is her VA for near?

  29. @nurulhuda abd latif

    huda, for sure we must give the optimum correction for this patient...

    optimum correction meaning here is meaning that correct and power , axis, and even the optical center..

    but referring to your question..i think i absolutely will affect her patient vision..since hav quiet significant & high astigmatism...

    if the wrong axis given, her has one meridian blurred while the other meridian is in other word, there is a residual blur on the retina...besides, she is already in the end of plastic we learn, any astigmatism after age 2 years old will impair her vision..

    so my answer is it may not detereriorate pt drastically vision but clearly it will be an obstacle to successful treatment for amblyopia.

    which supposely must be avoided, since the time is very value due to his age in end of crtitical age..

  30. nor arifah bt zakariaFebruary 7, 2011 at 12:12 AM


    haha...shahril, i'm in doubt in zul statemnet too...

    zul,we are in amblyopia case here..bifocal should be given in some case like if there is esotropia component the over plus power / add given to decrease the convergence by reduce the accommodation component...

    since the CT show is ortho at near and distance. i guess nothing wrong with her BV part...

  31. nurulhuda abd latifFebruary 7, 2011 at 12:17 AM

    @shahril arifah & shahril..i wonder too...zul, u should state your reasons for choosen the bifocal as this patient treatment..why??i wonder..mmm.

    zul, if u read athers comment regarding faiz comment, he wrote that we should assess her AA and NPC for next TCA...

    but not simply give the bifocal...i wonder..

  32. @nor arifah bt zakaria

    yeap u are right. this patient BV component was considered normal but we need to assess the NPC and AA during the delivery

    sorry for the late response. i just came back from a vacation in a very nice internet access.

  33. @farahiyah zainir

    can this patient be diagnose with bilateral visual deprivation amblyopia????

    the answer is NOT. deprivation is cause by any ocular pathology such as ptosis

    Mx..yes we can prescribe the new Rx with intense near work..but at this age, her home work from school teacher is rally enough to stimulate her visual cortex

  34. @muhamad zulhusni

    4th year, please answer this Question. Zul is asking U..

    This case needs to be discussed more and, I extend the deadline until this Friday..

    Hope, for those who not join in this discussion take this chance to involve in.

  35. salam
    sorry for the late response...
    Patients of any age are unlikely to wear lenses that blur their vision.
    Bifocal lens is only be considered in a case when patient needs more plus at near than that found at distance vision.
    Since near vision is good plus her BV is normal, there is no reason to prescribe bifocals to her...
    (for example bifocals is considered in the case of accom ET ).

    I agree with others. AA n NPC should be measured to rule out if there is any abnormality in those components.

    * extra info about bifocals.
    From Brookmann, it stated that pt who have worn bifocals for a long period of time often manifest more hyperopic at distance. Thus, distance prescription can then be increased and at the same time bifocals is eliminated.

  36. @nurulhidayah mohamad nordin's patient comfortable with her vision with new power?ade repot ape2 x?

    i think no need for any modification if there is no any symptoms arise...since her not 1st time wearer kn?


  37. @nurulhidayah mohamad nordin's patient comfortable with her vision with new power?ade repot ape2 x?

    i think no need for any modification if there is no any symptoms arise...since her not 1st time wearer kn?


  38. slm..sory..sory..sory..4 my late involvment..huhu..nk tnye anyone, is it compulsory to get VA 6/6? bley x treatment to improve VA lasts until vision is normal, or until vision stops getting better je? what if the best vision for this pt is only up to 6/9?wondering ~x(

  39. slm.. regarding this case, i still wonder and curious bout her vision. she juz got the best VA 6/9 for BE eye aftr the last visit.

    In my opinion, i think she's still consider amblyope since her age now is 10yrs. she supposedly to have vision of 6/6.. is it true?? ;))

    for the treatment, is there any alternatives that is suitable to make her vision get 6/6?? or 6/9 is the last and better one for her??

  40. salam everybody..nice discussion here :D..sory sgt3 for the late comer..baru hbs rase 'bercuti'..hehe ;)

    answer for the Diagnosis question:
    Diagnosis for 1st visit (2009)
    1. bilateral high hyperopia with moderate astigmatism WTR
    2. bilateral refractive amblyopia

    Diagnosis for latest visit (2011)
    1. bilateral high hyperopia with moderate astigmatism WTR

    For the question, it is pt is still considered amblype after improve VA from 6/18-6/9??answer is not ambyope anymore. coz the VA can be improved from 6/18 -6/ is true???? :-/

    for the question, it is need to con't the therapy?
    i think no need. cz already equalize the VA on BE and also due to social aspects. In addition, pt is already in school age.. so the load homework (as mention by br.Syah) also alternatively can be considered as task/exercise for her to stimulate the VA.. moreover, pt already achieved plastic age which means poor prognosis due to slower recovery vision.

    NEXT TCA, do BV assessment as mention by others and need close monitoring and make sure no reversible amblyope occur (amblyopia recur)

    nak respond soalan zul.. 8-}
    i think bifocal not suitable to prescribe for dis pt. bifocal considered for treatment of nonrefractive accommodative esotropia in a patient with a high AC/A ratio (convergence excess).As hannan said, hyperopia will become worse if we give bifocal..

    enlighthen if i'm wrong..
    saya budak masih belajar, if salah tolong ajarkan..

    xie xie, thank you, jazakallah, syukran..:)

  41. norhafizah abdul nasirFebruary 10, 2011 at 11:45 AM

    @Zanariah Muda

    sorry everybody becauce i'm late joining u all in discussion because my laptop has broke down since 2 weeks ago..

    zana, this patient is amblyopic so that she will not achieve 6/6 with correction. according to Grosvenor, amblyopia is considered to exist when VA is poor which is less than 6/6 with corrective lenses. so that, even this patient is given any correction, she will not achieve 6/6..

    to all of u, please do correct me if i'm wrong..hikhik.. :p

  42. Nurfadzillah Bt. ArifinFebruary 11, 2011 at 10:02 AM

    salam, sorry for joining this discussion late
    according to kak aida, the patient is not consider amblyopic anymore because her VA has improve from 6/18 to 6/9.. so meaning we cannot consider her as amblyopic pt dahla??? but can her VA become better than that despite her age is already 10years old, or is it impossible...heee please correct me if im wrong. btw can I ask, is amblyopia is consider ask low vision patient???

  43. NurfadzillahBt. ArifinFebruary 11, 2011 at 10:04 AM

    sorry typo error i was going to write "as" instead of "ask"

  44. @Nurfadzillah: hehehe are u already forget what Dr mohmoh said??? amblyopia is one of the causes for visual impairment in children....

  45. @Nurfadzillah Bt. Arifin

    hmmm..your question about ambylopia is consider as low vision is totally wrong. The amblyopia and low vision have their own meaning and charateristics...

    for amblyopia based on Millidot (2002:
    -condition reduced VA
    -without any disease of the eye
    -which not corrected by spec and CL
    -6/9 or less in one eye, or two line difference or more

    for low vision based on Millidot (2002):
    -vision below normal even after corrected
    -resulting fron either congenital anomalies/ocular disease
    -best VA after correction is 6/18 on better eye

    thus, clearly stated that the amblyopia and low vision are totally different item which must be understand by heart..=)

  46. @Ahmad Izzul Azfar

    yup3...i did agree with izzul lor bout fazilah's Question..this adik can tbe said as low vision as she can be corrected until 6/9...

    kak aida, i read ur comment..i think we must at least TCA until patient VA is comfirm stable.. but how actually we decided to proceed/ stop the amblopia theraphy? what the aspect we look..?

  47. above "can' --> cant...typing error...



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