GROUP 4 (CASE4) ANISOMETROPIC AMBLYOPIA WITH MILD PTOSIS ON BE

SUBJECTIVE

1.      12/M/M

2.      Last visit almost 2 years ago

3.      Medical history : - had done ptosis surgery on RE when 4 years old at HUSM, has been prescribed with contact lens for correction

4.      Previous therapy : - eye patching   - Eye Relax

5.      At beginning, patient compliances with therapy given and VA on RE can achieve 6/9. Later, he stopped the therapy given

OBJECTIVE

	RE	LE
VA (unaided) ·         Distance ·         Near	6/60 (PH : 6/36-1) N14 @ 40cm	6/36 (PH : 6/18) N5 @40cm
	BE : 6/36
Retinoscopy	-8.00DS/-0.50DC X 180 (6/36)	-4.50DS/-0.50DC X 180 (6/12)
Subjective refraction	-8.00DS (6/24)	-4.50DS (6/9)

ASSESSMENT

Anisometropic amblyopia with mild ptosis on BE

PLAN

1.      No new prescription is given yet

2.      Refer patient to the ophthalmologist for further investigation/treatment and for LASIK treatment

Best Regards,

GROUP 4 (Norhafizah, Nur Syazriena, Nur Hanani, Muhd Zulhusni)