Case Study
Topic : compound hyperopic astigmatism with Presbyopia
by Dr.LOFT ,O.D.
Case History
Patient 60 years old male ,came with complain about blur while reading or near task but distant is OK . He have a problem with adapt to progressive lens since 20 year ago until now. Another problem is Driving at night because of Glare ,blue ,flare in night time and light sensitive in day time.He've met Ophthalmologist every year to routine check eye health and doctor said eyehelth is lookign good just some dry eye and prescribe artificial tear.
No Headache ,no Diplopia just blur at near.
The Physical is Healthy , but mild of Hypertension and mild triglyceride.
He is the CEO of the company so visual demand is variety ; driving , mobile ,computer ,see people , each a little bit but all necessary to see clear.
clinical finding
Preliminary eye exam
VA ; OD 20/25-1 ,OS 20/20-1
CoverTest : Ortho ,Ortho’
Refraction
Retinoscopy
OD +2.00D -1.25 x 95 ,VA20/20
OS +1.25D -0.50 x 90 ,VA20/20
Monocular Subjective
OD +2.00 -1.00 x 100 ,VA20/20
OS +1.50 -0.50 x 100 ,VA20/20
Best Visual Acuity,BVA(on phoropter)
OD +1.75 -1.00 x 100 ,VA20/15
OS +1.25 -0.50 x 100 ,VA20/15
Best Visual Acuity ( on free space )
OD +1.75 -0.87 x 96 ,VA20/15
OS +1.25 -0.50 x 100 ,VA20/15
Binocular Function ; Accommodation / Convergence test @ distant 6 m.
Horz.phoria : 2 BO
BI-reserve : x/10/0
Vertical Phoria : Ortho
Binocular Funciton ; test @ 40 cm
Horz.phoria : 2 BI (mild exophoria)
BCC : +1.75
NRA : +1.00D /-1.00D
Assessment
1.compound hyperopic Astigmatism
2.presbyopia
3.mild esohporia
4.Neclear Cataract Suspect
Plan
1.Full Rx
OD +1.75 -0.87x 96
OS +1.25 -0.50 x 100
2.Add Rx : +1.75D [ progressive additional lens Rx ; Rodenstock Multigressiv MyView 2 ,M-coridor +DNEye Technology]
3-4.F/U : 6 month
Discussion
1.Refraction
when the patient said he/she doesn’t have problem with vision at distant, it may be dose's not mean he has no refractive error ,because of he has compound hyperopic astigmatism will let the crystalline lens accommodate to make image sharpper and to do like that the patient will have problem with eyestrain or asthenopia cause too stress.
The autorefractometer almost make a mistake with the patient like this like over minus in myopia , under plus in hyperopia, wrong astigmatism and far away wrong with compound hyperopic astigmatism or mixed hyperopic astigmatism. so whe you heard somethine like ,this machine is the most accuracy in the world , you have to becareful in that marketing wording. because the autorefractometer (in medical term) it just for screening but can’t rely on it (hight repeatability but very reliability) , Retinoscopy skill is the best for all refractive error but have to practice.
The fact is almost of optical service in Thailand provide by optician and seller that almost rely autorefractometer and use this machine for marketing gimmick , some optometrist use the same way of optician like optical shop than optometrist professional clinic ,and very a few optometrist work in professional way.
So if anyone have a vision problem ,the first thing that you have to looking for is the professional Optometrist that have eye exam room length 6 meter and always use retinoscopy because that mean the professional’s way dose it. And avoid the shop that just rely on autorefractometer ,never use retinoscope and have exam room less than 6 metter because of they ignore all importance factor that will make a mistake.
2.Binocular Function
Esophoria :While the patient look and fix the target at far 6 m. after correction ,his eye have mild esophoria ( mean resting positioning ,the position of the eye not straight ,but cross in ) so lateral rectus of extra ocular muscle have to pull eye temporary (lateral) all the time. This is cause of eye strain and asthenopia.
But in my idea ,It’s may be induced form uncorrected refractive error for long long time , so cause binocular dysfunction and I think that all will go normal after full correction. So I don’t prescribe prism for this case.
3.Presbyopia
Presbyopia is physiological change with age when get older ,cause of weak of lens ability to accommodate and not flexible to focus the object at near task cause near task blur. this symptom will strart around 40 year old up.
But point of this case is ,the patient is 60 years old ,so in the statistic said the addition or plus have to prescribe is more than +2.50D for reading at 40 cm. But result from exam is just +1.75D like a patient around 48-50 years old. And this is sign of precataract but it’s will disturb the patient maybe 5-7 next year because of the lens still look very clear
.
Result after prescribe
The patient 60 years old Never use progressive lens before because of he can’t adopt to it and he believe he can’t ,so I’ve to guaranty to him that he not need to pay for anything that use less to you.
After he got a new glassed he can adapt to this glasses in millisecond. Absolutely zero adaptation time with normal technology of progressive lens it's not a crazy hi-end like some marketing word try to cheat patient like word ultra ,super or something.
Value of glasses is CORRECTION not beautiful marketing wording.
The Refractive error have to be corrected first ,not select the brand first. You can’t buy brand if your disease not yet right diagnose.
The promotion will suck cheatign in this way , because of they Prescribe without diagnosis. More cheaper more less value , but expensive may not can say It may be better ,too.
The professional looking for the best reasonable solution in each case , not promote promotion to invite patient come and SELL.
in the end
I hope you will get some ideas about visual problem ,sign and symptom and resolve, If any of you have any question about your vision please contact me directly
thank you for your attention
Dr.Loft ,O.D.
Contact
578 Wacharapol rd. ,Tharang subdistrict ,Bangkhen District ,BKK 10220
Mobile : 090-553-6554
lineID : loftoptometry
Product
LINDBERG : thintitanium
Model : 5509 ,55#17
temple : 850 ,140 mm
Color : 10/10/10 GC97 Gun Metal
Lens : Rodenstock Multigressiv MyView 1.6
tags #OptometryThailand #LINDBERGThailand #Rodenstock #thintitanium
