Sunday, February 20, 2011

Binocular Vision: 9yo/M/M

Binocular Vision clinic: 9yo/M/M


He is referred from IIUM eye clinic for binocular vision assessment.
·         Parents complaint he always bumps on many things (table,wall)
·         Has history of ROP as he born premature through C-section at 7 months of pregnancy
·         Has history of laser treatment both eyes for ROP case
·         Has history of wearing spectacle since last year, but complaint uncomfortable
·         Parents report he always watching TV at about  1m

Previous Tests
Cycloplegic Refraction
-2.50DS/-2.00DCX10  (6/18)
-10.50DS/-2.75DCX165  (1/60)
PCT with the RX

Tests performed
The only management given was full spectacles RX to preserve the vision on RE.

Please think of..
1)      The exact diagnosis.
2)      The prognosis for Binocular vision.
3)      The complications of ROP.

prepared by Group 2 =)


  1. 1.anisometropia with bilateral amblyopia. amblyopia is an organic type.

    2.the prognosis for BV is poor since the deviation is large. maybe surgery can be done for cosmetic purposes because the deviation is more than 20 pd.

    3. a. The retina may become stretched and pulled by the contraction of the scars in the eye. This may physically pull the macula, the most sensitive part of the retina, causing abnormal vision.

    b. It may also cause folds in the retina and lead to retinal detachment.

    c. Strabismus is another complication and it is the crossing in or turning out of an eye. This may occur from the loss of vision in one eye or be related to the large refractive differences between the eyes.

    d. Both cataract and corneal problems can develop. Severe damage may lead to Phthisis bulbi, a shrinking of the severely damaged eyes. Glaucoma may develop either early or as a later in life complication of ROP.

    e. Nystagmus is common in all patients whose vision loss occurs at an early age.

  2. besides, i would like to suggest to prescribe this patient with polycarbonate lenses. why?? because protection of the remaining functional eye is important. Patients who have only one functional eye should wear adequate protective eyewear fulltime. polycarbonate lenses are preferred due to their high impact resistance. Additionally, physical education in school and other recreational activities must be limited to safe, non-traumatic activities due to increased risks for retinal detachment.

  3. aslmkm..
    for this case, he is probably having anisometropic amblyopia secondary to ROP.

    the prognosis is poor since the binocularity is poor - finding from W4D test and stereopsis.

    among the complications of ROP are retinal detachment, higher risk of developing strabismus and myopia (Kanski, 2007)

  4. good from eli and dayah~

    ok, i have a question. can we perform anti-suppression therapy for him?

  5. a) diagnosis: Bilateral anisometropic amblyopia

    according to W4D test, LE is supress at distance. LE supressed due to the high anisometropic which produce aniseikonia.

    b)prognosis is bad since he has no streopsis. He has no binocular vision as his LE supressed.

    c)Complication of ROP: As known, retinal detachment in stage 4 and 5. What stage is he?

    Since he has history of laser, for case of ROP, ophthal usually laser the blood vessels right? Can someone explain? i forgot oledy..hee

  6. @rohaila

    should we normalize the vision first? using CL perhaps?

  7. @nurlizzz

    gud responds guys..:)

    the stage of ROP is not mention. but according to his mother, the patient had undergone laser therapy..

    recent studies suggest that argon laser and diode laser photocoagulation for treatment ROP with stage 3+..with diode laser therapy, 81% successful.

    on 22nd Feb, ophthalmic delivery and fundus photo assessment done on him.
    VA: RE:6/9+2
    it improves a lot..:)

    fundus: laser scar presents on posterior pole of LE. others finding normals.

    actually, before we normalize VA, should eliminate any abnormalities first. for this case, we should eliminate amblyopia first. eventhough the LE suppress, we should try on anti-suppression therapy.

    so, can u guys explain how to do anti-suppression therapy for this patient?

  8. @eli aimi

    eli: I think for this case, though the deviation is > 20PD surgery is not indicated as it may leads to intractable diplopia (horror fusionis)...

    thus, for this case, since the pt has peripheral suppression, before anything, we should first treat the peripheral suppression....

  9. @eli aimi
    p/s to sir...please correct me if I'm wrong....

  10. anti suppression therapy:

    1) physiological diplopia- exercise involved: aperture rule, brock string, dot card

    2) after patient is able to see diplopia, whats's next?? hurryyy!! tell me hee

  11. @aiDaMaDiHa
    tq for such an informative discussion guys..
    but before performing anti-suppression therapy, dont we think we should follow step by step guide in orthoptics training?
    1.normalize n equalize VA (patching)
    2.normalize accomodation training (antisupression, overminus etc)
    maybe we can discuss further on this, specifically for this pt
    -should we proceed with amblyopia therapy
    -or just give in since he is already 9 y.o

  12. Hurm,as you all can see the deviation is very large >20PD. Therefore vision therapy will not be one of the treatment in option. Surgery is actually the best method to correct the XT. I think the prognosis for the surgery would be good since pt have LE suppression and no stereopsis.

  13. sorry sir, the anonymous person is actually me...hehehe...tersilap tekan tadi... :)

  14. there are two diagnosis i can give here.
    1) high anisometropic amblyopia secondary to ROP.
    2) Large LE secondary XT.

    the prgnosis is very poor. the conservative therapy may not be helpful for this kind of case. Other reasn is due t patient age. Too late for any therapy.

    my suggestion for this patient is strabismus you still remember bout the indication of surgery?
    a)increasing tropic with diminish fusion control.
    b) poor fusion recovery on cover / uncover test.
    XT is manifest >50% of waking hours.
    c) XT >20PD.

    If we wish to preserve the sereopsis, i would recommend this patient for surgery first. the undergo anti-suppression therapy. For anisometropic patient, cntact lens is the best option for visin correction. it will also improve the stereopsis since the effect of aniseikonia is reduced.

  15. btw, did patient complain on glaring? It is common in XT patient.

    Conservative treatment such as tinted glasses may be helpful.



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