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