Download - CASE PRESENTATION BV
CASE PRESENTATION
MIKAH TCHALE
ACKNOWLEDGEMENTS
MR SYMON CHIKUMBA, optometristMR JALLIFF CHITSEKO, optometrist
PATIENT’S PARTICULARS
NAME: RTAGE: 21SEX: FLOCATION: AREA 1BOCCUPATION: SECONDARY SCHOOL STUDENT
CASE HISTORY
CHIEF COMPLAINTTearing and eyestrain with prolonged near work
OCULAR Hx: has an ocular allergy and currently on treatment ie sodium cromoglycate
MEDICAL Hx: N/SFAMILY Hx: N/S
OCULAR EXAMINATION
VISUAL ACUITYi. DISTANCE
OD: 6/6OS: 6/6
ii. NEAR OD:N5 OS:N5
ANTERIOR SEGMENTOD OS
NAD LIDS NAD
PAPIILLAE CONJ PAPILLAE
CLEAR CORNEA CLEAR
RRLA PUPILS RRLA
DEEP & QUIET AC DEEP & QUIET
CLEAR LENS CLEAR
DIRECT OPTHALMOSCOPY
OD OS
0.3 CD RATIO 0.3
HEALTHY OPTIC DISC HEALTHY
NAD MACULA NAD
2:3 AV RATIO 2:3
WNL PERIPHERY WNL
NON CYCLOPLEGIC REFRACTIONOD: +0.25D….6/6OS: +0.25D….6/6
The patient was sent home and told to come the next day for binocular vision assessment and cycloplegic refraction
OCULAR MOTILITY: SAFE
COVER TESTi. DISTANCE: 4∆ XOPii. NEAR: 6∆ XOP
NPC: 5/8 cm
IPD: 62mm
CONFRONTATIONAL VISUAL FIELDS (PERIPHERAL FINGER COUNTING AND FACIAL AMSLER)FULL (ou)
AMPLITUDE OF ACCOMMODATIONOD: 4.4DOS:4.5DOU:5.0D
NRA: +0.50PRA: -1.00
DYNAMIC RETINOSCOPYOD: +0.75OS: +0.75
ACCOMMODATIVE FACILITYOD:2cpmOS: 2cpmOU: 1cpm
CYCLOPLEGIC REFRACTIONOD:+0.25…6/6OS: PLANO…6/6
CALCULATED AC/A RATIOIPD (cm) + NFD (m) [Hn-Hf]5.4:1
AC/A ratio is a key element in the appropriate managementHigh AC/A ratio→ plus lensesLow/normal AC/A ratio→ prisms/vision therapy
EXPECTED FINDINGS
1) NPC Break point: 5cm±2.5 Recovery: 7cm ±3.0
2) Accommodative facility Children (monocular| binocular)
6yrs old: 5.5cpm±2.5 | 3cpm±2.5 7yrs old: 6.5cpm ±2.0 | 3.5cpm±2.5 8-12yrs old: 7cpm±2.5 | 5cpm±2.5
Adults13-30yrs old: 11cpm±5 | 10cpm±5.030-40 yrs: not quantified
4) Relative accommodation NRA: +2.00D±0.50 PRA: -2.73D±1.00
5) MEM: +0.50±0.256) AC/A Ratio: 4:1±2
DIFFERENTIALS
Basic exophoriaAccommodation insufficiencyFusional Vergence dysfunction
FINAL DIAGNOSIS
FUSIONAL VERGENCE DYSFUNCTION
TREATMENT
Jump exercises 3x/day for 1 monthReview after 1 month
LITERATURE REVIEW
FUSIONAL VERGENCE DYSFUNCTIONSYMPTOMS
Eyestrain and headaches after relatively short periods of near work
Inability to concentrateExcessive tearingBlurred visionLoss of comprehension over time
ETIOLOGY AND PREVALENCEEtiology is not knownPrevalence is not clearly defined in literatureSome researchers reported a prevalence of 0.6% in
children of 6-18 yrs; 1.6% in university students
SIGNSNormal AC/A ratioPhoria within expected values at distance and nearBinocular instabilityDo not have a high degree of RELow NRA and PRA (these can be considered an indirect
measure of fusional vergence)Low accommodative facility
TREATMENTVision therapyPlus lenses (increase integration of accommodation
and vergences that then facilitates stable binocular function)
VISION THERAPY FOR FVDi. 1st PHASE: Normalise accommodative and
vergence amplitudesii. 2nd PHASE: Increase the speed of response to
accommodative and vergence stimuliiii. 3rd PHASE: Utilise step &/or jump vergence stimuliiv. 4th PHASE: Integrate vergence and
accommodation to automate both accommodative and vergence response