Amblyopia with Eccentric Fixation

New Case-5/C/F

A female Chinese girl age 5 years old was came to Paediatrics clinic for fully eye check-up. She has no complaint of blurring of vision at distance and near and has no headache. But her mother claimed that she unable to get the most Visual Acuity according to her age during Eye test in her kindergarten school. Her mother had bring her to optical shop for refraction but had been refuse since she is very young girl. This patient had never wear glasses before, she was full term delivery baby and generally healthy, undergone ear operation before. Below are the full report of her eye examination.

Objective

VA	RE		LE
	Distance Unaided: 6/9¯³ Ph: 6/9¯³		Distance Unaided: 6/18⁺¹ Ph: 6/9
	Near: N6@25cm		Near: N6@25cm
PD Distance: Near:	27.0 mm		27.0 mm
	25.5 mm		25.0 mm
Hirrschberg	Central & symmetry
NPC	TTN, TTN, TTN
OMT	SAFE
Retinoscopy	-0.50 DS/ -0.75DC x180	6/9⁺¹	-0.50 DS/ -0.50 DC x 180	6/9
Subjective Refraction	-0.25 DS/-0.50 DC x140	6/9⁺³ N5	-0.50 DS/ -0.50 DC x 180	6/9 N5
Post Refraction (CT) Distance: Near:	Orthophoria Orthophoria
Stereopsis	50” of arc, Stereofly test
Ophthalmoscope (visuoscope)	0.5˚ superior nasal unsteady EF		Central fixation
Neutral Density Filter VA        ∞:	0.6 log;     6/9¯³		0.9 log;     6/9¯³

Asessment / Diagnosis

1.      Bilateral low compound myopic astig

2.      BE amblyopia , RE with Eccentric Fixation (EF)

Plan / Management

1.    Prescribe full correction for full time wearing

2.    TCA 2/52 to ask level of comfort with RX and to check on EF, do visuoscope one more time
Group 1 

Infantile esotropia

1year 1month/malay/female (Follow up case)

Date:12/10/2011

History :

-          mother noticed her daughter left eye squinting  1 year ago constantly

-          full term delivery

-          no medical illness or eye disease (check at IIUM specialist)

important test:

VA (LEA grating paddle):    BE; 2cpm (6/18)

Refraction (mohindra):       RE; -0.50DS                 LE; -1.50DS

Hirschberg: 30⁰ to the temporal (LE)) fixing eye is RE

Prism cover test:  ∞; unobtainable         N; 30Δ

                           

                                                                              

 Stereoacuity (frisby) ;unobtainable

Diagnosis: Infantile esotropia

Management: refer to ophthalmologist for eye surgery

(group 1)

Esotropia - nystagmus blockage syndrome

5/M/M came to the IIUM Optometry Clinic for follow up visit.

• Prescription from last visit: 
• RE: -6.00DS/-1.00DCX174      (6/15)
• LE: -6.00DS/-1.00DCX15        (6/15)
• mother complained that his performance is better after wearing the glasses

 

Test	RE	LE
VA with LEA Symbols (aided)	6/15	6/15
Hirschberg	Center and symmetrical
Cover test	Dist: cannot be obtained Near: moderate esotropia with fast recovery
OMT	Nystagmus intensity increase upon abduction
Worth Four Dot	Dist: seen 5 light Near: seen 4 light (2R,2G)
Stereopsis (Frisby)	300”
PCT	Dist: cannot be obtained Near: 25∆ BO

from the examination, we found that he is;

• BE amblyopia
• Nystagmus intensity increase upon abduction
• Nystagmus obvious at distance than near
• Cover test at near reveal esotropia

Diagnosis

• Esotropia nystagmus blockage syndrome

Management

•  Alternate patching at least 2 hours/ day with near task
• wear correction full time

TCA: 3/52 to review VA

By: Group 1

CASE 2 (GROUP 4)

GROUP 3: INFANTILE ESOTROPIA

GROUP 2 (CASE 2) : LEFT EYE BASIC EXOTROPIA

5yo/Male/Malay

1. Come to IIUM Optometry Clinic as referred from IIUM Eye Specialist Clinic (ORC) and have been diagnosed to has left eye exotropia.

2. He has no complaint of blurry vision or headache. However, recently, his teachers complain of his decreasing performance in class. The parents realized that their son has left eye deviated out since birth. 

3. He had born full term birth and generally healthy. Has sinusitis but not on any medication. He has no ocular trauma, injury or surgery. 

4. Besides that, there are two of his sisters wearing spectacle and the parents reveal that there is history of tropia in the big family in the mother’s side

 

DIAGNOSIS

LE Basic Exotropia associated with refractive ambyopia

PLAN AND MANAGEMENT

1. Prescribe spectacle correction

2. TCA 1/12 (for follow up of improvement in VA and comfortness of patient with prescribed spectacle)

GROUP 2: CASE 1 (New case)

SUBJECTIVE

• 5/M/M 
• Patient was referred from Eye Specialist Clinic IIUM 
• Pt wear spectacle since 2 years old 
• Parent had noticed his eyes nystagmus since he is 2 years old 
• No hx of ocular trauma 
• Allergy to dust 
• Born as healthy and full term baby 
• Pt like to watch TV closely 
• No c/o headache

EXAMINATION RESULT

	RE	LE
VA aided @3m (Lea symbol) @40cm (Lea symbol)	6/30 6/24	6/30 6/24
Current Rx	-4.00DS/-1.00DCX180	-4.00DS/-1.00DCX10
Refraction	-6.00DS/-0.75DCX180 (6/15-2)	-6.00DS/-1.00DCX10 (6/15-2)
PCT without glasses : Distance Near PCT with glasses :  Distance Near	10˚pd BO 35˚pd BO 8˚pd BO 12˚pd BO
Stereopsis	Patient cannot appreciate
Hirschsberg	LE 15˚ temporally reflex at pupil margin

TENTATIVE DIAGNOSIS:

1.   Myopic amblyopia

     2.      Infantile ET 

     3.      Nystagmus blockage syndrome
 

MANAGEMENT:

•   Prescribe new glasses with full prescription

           RE: -6.00DS/-0.75DCX180 (6/15^-2)

           LE: -6.00DS/-1.00DCX10 (6/15^-2)

     # The glasses is prescribed to improve his vision since the finding reveal that new Rx can achieve 6/15^-2 which is better than his VA with current spectacle

      # This is also as a step to treat amblyopia

• TCA 1/12 to review his VA with prescribed glassses