Short Case Report
Topic : Compound Hyperopic Astigmatism in presbyopia
By Dr. Loft ,O.D.
Introduction
Today's short case is a 54-year-old female who presented for a routine eye exam. She complained of blurred vision at distance and near ,but far is not much blur because she can live without glasses but she had to wear reading glasses while reading.
She has had annual eye exams, most recently one year ago, with normal findings.
Case History
- Wears glasses only for reading, no distance glasses
- No history of headaches or double vision
- Overall good health
- Uses her eyes for general activities
Premininary Eye Exam
VAsc: OD 20/60, OS 20/25
Refraction
OD +1.25 -0.50 x 90 ,VA20/20
OS +0.50 -0.50 x 90 ,VA20/20
Monocular Subjective Refraction
OD +1.50 -0.62 x 70 ,VA20/20
OS +0.75 -0.37 x 90 ,VA20/20
Best Visual Acuity (on phoropter):
OD +1.75 -0.62 x 70 ,VA20/20
OS +0.75 -0.37 x 90 ,VA20/20
Best Visual Acuity (fine tuning on free space):
OD +1.75 -0.62 x 70 ,VA20/15
OS +0.75 -0.62 x 90 ,VA20/15
Binocular Function at distant : 6 m
Horz. phoria : 1 BI exophoria (normal)
Vert. phoria : Ortho
Binocular Function at Near 40 cm.
BCC: +2.00
NRA/PRA: +0.75 D/+0.75D
Assessment
1.Compound hyperopic astigmatism (with mild anisometropia) OD and OS
2.Normal binocular function
3.Presbyopia
Plan
1.Full RX:
OD +1.75 -0.62 x 70
OS +0.75 -0.62 x 90
2.Progressive additional lens: Add +2.00D
Done!
Discussion
The story is quite simple and there is not much to discuss. However, I would like to pick up one point. The patient came for a routine check-up and did not complain of any problems. It was as if she did not need to have he eyes checked.
Some optometrist/optician believe that if a hyperope (a person who is born with long-sightedness) does not complain, then they should not be corrected. He is used to it and he should just be left to be used to it. If he has any problems, then they should be corrected.
Therefore, in this case, a common mistake is to not check the patient's distance refraction cause of the patient says that he can see clearly, so why bother checking? and some seller doctor think that's It is better to spend the time selling him glasses and earning a commission. (and I so hate doctor that think like this)
then, seller doctor will try to find an addition by insert a plus lens until he can read clearly and let the patient choose which value he wants. If patient chooses the right value, then that is good. If they chooses the wrong value, then that is his responsibility of them.
However, have you(seller doctor) forgotten that accommodation is a system that receives one signal from the brain, but sends two signals back? This means that our focusing system cannot work independently of each other. If one eye focuses, then the other eye must also focus in same amount accommodation . They cannot focus separately because they must work together to balance each other out.
In this case, the patient has anisometropia, which means that his vision in both eyes is different. If you do not check his distance refraction and simply add an addition, then how is accommodation supposed to work? yes of course, It will not be able to balance itself out.
If one eye can see clearly, then the other eye will be blurry and they will not be able to see clearly at the same time. The focusing system will keep going back and forth, depending on which eye is working. This is called fluctuation of accommodation and it can lead to headaches, eye strain, and eye fatigue.
Therefore, do not assume that if a patient says that he can see clearly, then you should believe him ? The Buddha taught us to not believe anyone, even if they are a patient. We should check for ourselves and see for ourselves before making any corrections.
In addition, "clear" is subjective. It can be different for each person. However, we can still see how clear a patient's vision is by looking at the reflection of light from the pupil during retinoscopy.
For example, if we ask a one-year-old child if they said they can see clearly, we cannot expect him to give us a meaningful answer. they may just say "mama" or "papa" or something else that does not make sense.
In this case, we must be the ones to look at the quality of the image or the focus of the light that is happening on the retina. We must see if there are any eye problems that are causing the focus to be distorted. This can be done by using a retinoscope.
A retinoscope never lies. If it is neutral, then it will show that it is neutral. It is not like a autorefractometer that can be fooled and always lie to you . In fact, VA (visual acuity) is much more important in diagnosis than the vision that is obtained from a computer vision test.
final the I need to say is , You've to stand with objective test ,not subjective test . everything that's patient said to you ,you've to verify by objective test ,like retinoscope.
I hope you all need to bee good doctor ,not just seller doctor live for sale Glasses.
appreciate for your following .
Dr.Loft ,O.D.
Contact Us
Loft Optometry ,Wacharapol rd, ,tharang ,Bangkhen ,bkk
mobile : 090 553 6554
line : loftoptometry
website : www.loftoptometry.com
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