case presentation bv
TRANSCRIPT
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CASE PRESENTATION
MIKAH TCHALE
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ACKNOWLEDGEMENTS
MR SYMON CHIKUMBA, optometristMR JALLIFF CHITSEKO, optometrist
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PATIENT’S PARTICULARS
NAME: RTAGE: 21SEX: FLOCATION: AREA 1BOCCUPATION: SECONDARY SCHOOL STUDENT
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CASE HISTORY
CHIEF COMPLAINTTearing and eyestrain with prolonged near work
OCULAR Hx: has an ocular allergy and currently on treatment ie sodium cromoglycate
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MEDICAL Hx: N/SFAMILY Hx: N/S
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OCULAR EXAMINATION
VISUAL ACUITYi. DISTANCE
OD: 6/6OS: 6/6
ii. NEAR OD:N5 OS:N5
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ANTERIOR SEGMENTOD OS
NAD LIDS NAD
PAPIILLAE CONJ PAPILLAE
CLEAR CORNEA CLEAR
RRLA PUPILS RRLA
DEEP & QUIET AC DEEP & QUIET
CLEAR LENS CLEAR
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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
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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
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OCULAR MOTILITY: SAFE
COVER TESTi. DISTANCE: 4∆ XOPii. NEAR: 6∆ XOP
NPC: 5/8 cm
IPD: 62mm
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CONFRONTATIONAL VISUAL FIELDS (PERIPHERAL FINGER COUNTING AND FACIAL AMSLER)FULL (ou)
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AMPLITUDE OF ACCOMMODATIONOD: 4.4DOS:4.5DOU:5.0D
NRA: +0.50PRA: -1.00
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DYNAMIC RETINOSCOPYOD: +0.75OS: +0.75
ACCOMMODATIVE FACILITYOD:2cpmOS: 2cpmOU: 1cpm
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CYCLOPLEGIC REFRACTIONOD:+0.25…6/6OS: PLANO…6/6
CALCULATED AC/A RATIOIPD (cm) + NFD (m) [Hn-Hf]5.4:1
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AC/A ratio is a key element in the appropriate managementHigh AC/A ratio→ plus lensesLow/normal AC/A ratio→ prisms/vision therapy
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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
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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
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DIFFERENTIALS
Basic exophoriaAccommodation insufficiencyFusional Vergence dysfunction
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FINAL DIAGNOSIS
FUSIONAL VERGENCE DYSFUNCTION
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TREATMENT
Jump exercises 3x/day for 1 monthReview after 1 month
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LITERATURE REVIEW
FUSIONAL VERGENCE DYSFUNCTIONSYMPTOMS
Eyestrain and headaches after relatively short periods of near work
Inability to concentrateExcessive tearingBlurred visionLoss of comprehension over time
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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
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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
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TREATMENTVision therapyPlus lenses (increase integration of accommodation
and vergences that then facilitates stable binocular function)
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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