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 

Clinic LogBook and Clinic Report Submission

Attention to All IIUM Optometry Students,

Kindly, please submit your all clinical logbooks and clinical reports for any clinics (OC, Jaya Gading, Ophthal Posting, Special Clinic) include two previous semester by this Monday to your respective Class Representative.  Please separate them by type of report (logbook or written report) Semester (Sem 1 & Sem 2), Batch, and Subjects (course).

After gathering all the logbooks and reports, please put in  'your basket' in front of Optometry Notice Board at IMC, Level 5. I'll collect them at 5.00 p.m on this Monday.

For those who have been submitted the logbooks and reports, please write "submitted" in comment section.

Your cooperation are highly appreciated.

Any inquiry, please call my hp.

Tq

Ptosis Evaluation

:: bismillahirrahmanirrahim ::

Mind you, the term "ptosis" which means "droopy" does not merely refer to "droopy eyelid" as we can have something else droopy as well, not just our eyelid. As you know, the exact term for "droopy eyelid" is actually "blepharoptosis" (blepharo=eyelid, ptosis=droopy). But in our field of optometry, we are just comfortable to use "ptosis" rather than "blepharoptosis" in referring to "droopy eyelid"... and so will I do in this article as I'm lacking of time to type the whole lengthy word again and again.

Straight to the point requested by Br Muziman (my PBL group instructor), here are some of the popularly used ways in evaluating ptosis, and you can add them up if you have known another way that is not mentioned here. For any of the pictures below, you can get a clearer view simply by clicking it.

1) Levator Function

- Levator function is measured as the extent of eyelid movement on maximum down and up gaze. Method:

i. The thumb of one hand is placed at the eyebrow (don't press, just gently place) - this is to block the effect of forehead on the elevation of the eyelid.

ii. With another hand, hold a ruler near the patient's upper eyelid (with zero-point at the central upper lid margin) while the patient is looking downward (Pic. A & C)

iii. Then have the patient look upward as high as possible without any head movement, and take the measurement on the ruler at which the upper lid margin is now positioned (Pic. B & D).

- Classification of levator function: Good (≥8 mm), Fair (5-7 mm), Poor (≤4 mm)
- An accurate measurement of levator function may be used to determine the type of ptosis and also the best surgical approach to repair it. For instance in cases of involutional ptosis, the patient has a quite normal levator function despite the droopy eyelid.

2) Palpebral Fissure (labelled as PF in Pic. XYZ)

- a.k.a PAS (Palpebral Aperture Size) in our CL clinic

- Measured as distance between upper lid margin to lower lid margin passing through the center of pupil in primary gaze.

- Normal measurement: 9-10 mm

3) Crease Height (labelled as VCD in Pic. XYZ)

- a.k.a Margin Crease Distance (MCD) / Vertical Crease Distance (VCD)

- Crease height is the distance from the upper eyelid margin to the upper eyelid crease in downward gaze.

- Normal measurement: 5-10 mm

4) Marginal Reflex Distance #1 (labelled as MRD1 in Pic. XYZ)

- MRD is the distance from the upper eyelid margin to the corneal reflex in primary gaze.

- Normal measurement: 4-5 mm

- MRD 1 +ve: if upper lid margin is higher than the level of corneal reflex.

- MRD 1 -ve: if upper lid margin is lower than the level of corneal reflex.

5) Margin Reflex Distance #2 (labelled as MRD2 in Pic. XYZ)

- MRD 2 is a distance between corneal reflex and lower lid margin in primary gaze.

- Measurement greater than 5 mm is considered normal.

Picture XYZ:

SEVERITY of PTOSIS

- Bilateral ptosis: the amount of ptosis is measured as difference from the normal value (as given above), with larger difference indicates more severe ptosis.

- Unilateral ptosis: the amount of ptosis is taken as difference in PF / VCD / MRD 1 between RE and LE. Classification of ptosis based on difference between the 2 eyes: mild (2 mm), moderate (3 mm), severe (4 mm)

References:

http://www.eophtha.com/ejo13.html

http://emedicine.medscape.com/article/1213228-overview

:: wallahu a'lam ::

BV CLINIC 17/02/2010

HX ( AFI/7/M/M)

FIRST VISIT

• Diagnosed as having unilateral divergent squint when he was born


• Unilateral LE squint change to intermittent with increasing in angle


• At the age of 6 months went to the pediatric strabismus specialist


• No intracranial pathology detected


• No patching tx issued –as optometrist claimed wont benefit him


• Paternal gf + paternal ucle has hx of fixed divergent squint


• LE frequent diverge – When unattentive

FIRST VISIT

TEST	RE	LE
VA	6/9-2 (N6 @20 cm)	6/9, (N6 @20 cm)
Pinhole +1.00DS	6/9 6/18-2	6/9-1 6/24
Ret	+2.00DS/ -0.50x 180 (6/24)	+1.50Ds/ -0.50x 180
Subjective	+1.00 DS/-0.50 x 170 (6/9)	+0.25DS/-0.50 x 180 (6/6-1)
CT (distance and near)	intermittent alternating XT (fixate more on LE)
PCT	29BI/24 BI
Stereofly Test	140’ arc
Phoria (distance) Phoria (Near)	pt is unattentive 4 eso * unreliable sinc ept is unattentive

SECOND VISIT

Came to the pediatric clinic today ( 17^th of Feb 2010)

TEST	RE	LE
VA Distance Near	6/9+1 6/9 @28cm	6/6 6/9 @28 cm-1
AA (expected 16±2) BE	15/13,15/13,15/13 15/8,15/8,15/8	13/10,15/10,15/10
MFA	3cpm (hard on +)	8cpm (hard on +)
BFA	11 cpm
CT distance	Alternating XT ( fixating more on LE)
PCT Distance Near	30 BI 25 BI
PFV Distance Near	x/2 cannot be measured
NPC	9cm, 9cm, 8cm ( RE deviates out)
4 BO TEST	Unable to perform since patient is attentive and uncoperative

BV & Paeds Clinic Registration/ Appointment

Please refer to Flow of procedure for BV and Paeds Clinic Registration/ Appointment. Click the link below

appendix-i-flow-chart-for-registration-at-bv-paeds-clinic

If your patient needs to be referred to BV & Paeds Clinic, please leave the management part including prescibing a correction (Rx) during PCO visit.

This practice is to avoid from giving improper management to pateint.

The management part only will be determined during BV & Paeds Clinic visit.

For BV and Paeds Clinic appointment, please consult with Br Najib, do not make an appointment (give a date) by your own or without inform to Br Najib.

Now, Br Najib is on leave, please inform and advise me for any BV & Paed Clinic Appointment. For your info also, our BV & Paeds Clinic is not on every Wednesday as usual. It is alternate week. For instance, this week is BV & Paeds Clinic day, but in next week is LV day.

For 4th year student, I'm seeking your help to convey this important message for 3rd year student.

PEDIATRIC CLINIC on 17/3/2010

Please be informed that Pediatric Clinic will be running as usual. InsyaALLAH, two patients will be attending on the clinic day. Please consult Br Najib regarding pt appointment.

1) 9.00 a.m. .Please conduct test on this pt at PCO clinic room.

At 9.00p.m I've own pt at Pediatric clinic. Normally by 10 am, I can finish my case.Iif you have any query on that time, please consult me at there.

2) 11.00 am-please conduct test on this pt at PCO Clinic room.

Syah

clinical BV 20/1/2010 (week 7) by Group 1

:: bismillahirrahmanirrahim ::

File no: 6084

SND/22/F/M/STUDENT/READING

The patient came to the clinic (29/12/2009)complaining of blurring of vision after prolonged near wear (no specific time). She complained of pareital HA & pulling sensation to focus at far (more frequent since 3 weeks ago), usually after prolonged near work. No vision problem at near & no reported diplopia. She never wears spectacle before and her last eye check-up was 6 month ago at retail shop but no spectacle was prescribe to her. She does take spirulina for supplement and have no unknown allergies. She has gastric problem and often take medication for it. She also has myopic sister and has hypertensive dad.

Diagnosis:

1. Accommodation infacility & weakness

2. Mild myopia

Management: refer to BV clinic (20/01/2010)

Comment & action (by the examiner):

1. According to clinical findings, the patient have accommodation infacility & weakness and her Rx might help to stimulate her accommodation

2. However, Rx are not given due to the very low degree of myopia and further evaluation and management of her condition would be done at BV clinic (perform MEM, NRA+PRA which wasn’t done today)

Week 7 (20/1/2010)

BV & ORTHOPTIC CLINIC

History & symptoms: She complains of having bluring of vision at distance after near work frequently and had no problem when looking back at near. This occurs since last semester. She also have parietal HA (throbbing pain) after prolonged distant vision & eye strain and resolved it by taking a short break. She reported no problem when looking at near & no diplopia experinced. She has gastritis and on painkiller under doctor prescription (take only when needed or necessary).

RE                                      LE

VA Unaided: (D)    6/12 ph: 6/6^{-2                        6/6-2 pH: 6/24}

(N)    N4.5 @ 40cm               N4.5@ 40cm

Sub. Rx:     -0.50/ -0.25 X 165 (6/6⁺³)   -0.25/ -0.25 X 180 (6/6⁺³)

AA (expected 11±2 D):

11/9, 10/9, 10/9                     9.5/8.5, 9.5/8.5, 9.5/8.5 (before correction)

12/9, 12/9, 12/9 11/8, 11/8, 11/7 (after correction)

MEM:        +1.00 DS +0.75 DS

Facility:       9 cpm 8 cpm

BE: 8cpm

Hirschberg: center & symmetry

CT:

(D):No movement detacted  small XP

(N): moderate recovery

Vergence function:

Phoria (∞): orthophoria (Howell card)

Phoria (N): 2XP (Howell card)

NRA: +2.00 DS

PRA: -2.00 DS

Could anyone state the possible diagnosis and proper management for this case?

Let's discuss together-gether~

Username & Password

Attention to all my students,

I have added all of you 4th year student as a subsciber for this blog. You must log in to post comment for each post. Please check your email to get the username and email.

For Nurul Ain and Zulhilmi,

May you provide me new email adrress not opia...and j_purchrane..because these email were used in previous.

Thank you.