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    OPN465 TEMPLATE Case Report

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    Anonymous OO9rzUM
    1. A 62-year-old female presented with deteriorating intermediate and near vision, headaches, and eye strain after computer use. 2. Examination found a large exophoria, uncorrected refractive error, and mild dry eyes. 3. The diagnosis was large exophoria combined with uncorrected near prescription and mild dry eyes. She was prescribed new glasses and advised to follow up to assess binocular vision and investigate narrow angles.

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    OPN465 TEMPLATE Case Report

    Uploaded by

    Anonymous OO9rzUM
    54 views4 pages
    1. A 62-year-old female presented with deteriorating intermediate and near vision, headaches, and eye strain after computer use. 2. Examination found a large exophoria, uncorrected refractive error, and mild dry eyes. 3. The diagnosis was large exophoria combined with uncorrected near prescription and mild dry eyes. She was prescribed new glasses and advised to follow up to assess binocular vision and investigate narrow angles.

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    1. A 62-year-old female presented with deteriorating intermediate and near vision, headaches, and eye strain after computer use. 2. Examination found a large exophoria, uncorrected refractive error, and mild dry eyes. 3. The diagnosis was large exophoria combined with uncorrected near prescription and mild dry eyes. She was prescribed new glasses and advised to follow up to assess binocular vision and investigate narrow angles.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    54 views4 pages

    OPN465 TEMPLATE Case Report

    Uploaded by

    Anonymous OO9rzUM
    1. A 62-year-old female presented with deteriorating intermediate and near vision, headaches, and eye strain after computer use. 2. Examination found a large exophoria, uncorrected refractive error, and mild dry eyes. 3. The diagnosis was large exophoria combined with uncorrected near prescription and mild dry eyes. She was prescribed new glasses and advised to follow up to assess binocular vision and investigate narrow angles.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 4

    Case Report 1 – Presenting Information

    • Background information
    • 62, Female, medical receptionist, drives
    • PC: Wants to improve intermediate/near vision through her current SVN
    18months old and finds her distance vision is also deteriorating but she
    has no distance specs.
    • She also complained of headaches localised near the front of her
    forward and thinks it is due to her eyes getting tired after working on
    the computer the whole day, been happening for past 3-4months.
    • MH: she said she uses nasal spray for her post nasal drip, sometimes
    gets hayfever like symptoms during summer/spring, allergic to pollen
    and dust.
    Case Report – Clinical Exam Findings
    • Relevant clinical information
    • UVA: R 6/9.6 L6/9.6 OU6/7.6 Motility: upgaze reported some eye strain
    • Phoria D 2exo N 10exo. (Howell dwyer)
    • Prev Rx: SVN R+2.50/-0.50x110(N6) L+2.50/-1.00x90(N6) @30cm
    • Final Subj Rx: R +0.75 / -0.75x130 6/6++ L +1.25 / -1.50 x 85 6/4.8-
    • Add +2.25 N5 @ 34cm, intermediate Add +1.50 N8 @ 45cm
    • Anterior: RE unremarkable, LE nasal pterygium on limbus, on lid eversion unremarkable, NAFL staining nil, TBUT 10sec OU
    • VH: 0.1:1OU very narrow, IOP 14mmHG, lens NS gr 2
    • Posterior: C/D 0.2 OU, RE Drusen above macula, LE unremarkable

    • Potential differential diagnoses that you considered


    • Large exo phoria at near , uncorrected near refractive error
    • Sinusitis, force/mass pushing against frontal lobe
    • Aquifers deficient dry eyes maybe related to Sjogren’s Syndrome, Allergic eyes, pterygium causing irritation
    Case Report – Diagnosis and Treatment
    • Most likely or final diagnosis
    • Large exophoria combined with uncorrected near rx and mild dry eyes
    • Outline details regarding your management and treatment
    1. Update prescription: one office progressive for work and multifocal for
    everyday wear, she will update after next visit at QUT
    2. Next QUT Visit: before dispense specs need to investigate her binocular
    vision, check fusional reserves and see if she will require prism. Also
    investigate narrow angles with gonioscopy
    3. Booked visit at QUT in 2 weeks
    4. After her next visit report to GP about our findings so he can assess
    possible sinusitis/post nasal drip symptoms
    Case Report – Discussion and Comments
    • Provide a short discussion or comments relating to the case
    • Key features of the symptoms/clinical findings that refined your diagnosis
    • Once I gave her subjective correction for dist and at near she could appreciate a difference in her vision and especially at near although the
    near specs only gave her 1 line improvement I could tell that her reading was much more smoother and she didn’t hunch and bring in the
    reading as close. Her lids did not have any papillae so no signs of allergy. Her dry eyes were borderline and more from objective tests rather
    than patient symptoms. So overall it seemed in today’s consult that her headaches and near strain would correctable by spectacles.
    • Would you have managed the case differently?
    • If the patient had complain more of eye surface irritation perhaps from pterygium, not blinking as much from working on computer I could
    give her Systane complete to use PRN when at work. If I had more time during the consult I should have been able to do the BV work up to see
    if she was able to compensate her 10exop so she would require 20PFV at near which may be likely but fatiguing towards end of day. I could
    also have done a VF/OCT to rule out any cognitive/brain lesions that might be related to her frontal localised headache however her optic
    nerve looked normal and healthy.
    • Any unusual features of the case?
    • It was strange that as the testing went on the strain/pain in the inner corner above her LE was getting more painful. Perhaps it was
    exacerbated by the lights and manipulation of her lids but it was strange that she was composing that it worsened and she kept needing to
    blow her nose and it was getting itchy/irritated.
    • I begun to question were her front headaches actually related to perhaps sinusitis and her post nasal drip, so after her next visit at qut and
    when she will be dispensed glasses and she will wear them for awhile to see if her H/A goes away.
    • What are the key learnings from the case
    • If a patient comes in complaining of a front localised headache it is hard to determine exactly the cause, although we can narrow down to the
    most possible causes, it takes time to test the variables before coming to a conclusion. Like in her case her sinusitis might be contributing to
    her headache as well as her large exophoria at near. That’s why its important to work with GP tog ain insight to her case.

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