Common and uncommon ocular problem and disorders
Most common and uncommon vision related problems and disorders can be identified without the aid of cutting-edge equipments in the optometric practices. Most of these problems can be managed and solved by employing appropriate spectacles and contact lenses in the optometric practices. Fewer optometric practices focus on non-surgical interventional vision therapies.
As such, comprehensive or general optometrists must possess the art to perform essential relevant facial and head measurements, advise spectacle frames selection and proper spectacle adjustment for best optical performance and comfort, which is equally important as comprehensive eye examination.
A 50 year old Chinese female teacher constantly wearing PAL spectacle since five years ago, presented with complained of persistent eyestrain, blurry near vision for the past two weeks. She also complained of blurry distance vision which lasted several hours after prolonged near visual tasks.
She has no past ocular and medical condition, and was not on medication.
General observation and eye examination revealed:
- Present one year old PAL lenses appeared clear with no surface degradation. Frame’s tilt and wrap were normal but the metal-arms nose pads were widely separated and nearly touching the lenses.
- Rx: OU-4.75DS ADD+2.00.
- DVA: OU 6/7.5
- NVA: OU N6 at 40cm with usual reading and laptop working posture.
- Binocular vision was normal.
- No external and internal ocular abnormality demonstrated.
- NCIOP was 12mmHg in OU
- Refraction: OU-4.75 (6/6+) Add+2.00 (N5) at 40cm for usual near visual tasks.
- When she wore her PAL spectacle, the nose pads resting close to the medial canthi, the fitting-crosses were situated at lower eyelid margins, and the back surface of lenses frequently touching her upper eyelids and eyelashes.
Her visual acuity reverted to normal and reported a “sense of de-stressed” after the metal-arms nose pads were adjusted allowing the PAL fitting-crosses back to the pupil centers and positioning the PAL back to 10mm BVD.
The consultation was concluded with reassurance to remove patient’s doubts and worried.
A male Chinese hand surgeon, age 26, with no previous ocular and medical condition, and not on any medication. He was wearing same spectacle OU-2.00DS for the past two years without any problem.
This young surgeon complained of central field of view duller and blurred vision when seeing distance and near in the left eye since last week while on vacation. He also noticed lines and edges of objects appeared slightly crooked.
General observation and eye examination showed:
- His spectacle was fitted properly and the lenses were in good condition.
- DVA: R6/6+, L6/18- (with and without PH)
- NVA: RN5+,
- No RAPD
- Slit Lamp examination revealed no abnormality of his anterior segments in both eyes.
- BIO examination in the left eye with Volk 90D lens showed a normal optic nerve head, the macular appeared duller, within a faint circular “watermark” about two optic discs area, absence of foveal light reflex. The rest of left peripheral and right fundi were insignificant.
- Amsler Grid test for the LE showed a central dark area with pericentral distorted pin cushion grids.
A tentative diagnosis of ICSR was made and its pathophysiology and prognosis were discussed with the young surgeon.
The next day he reported that his eye department colleague confirmed his left ICSR and opted for conservative management.
A 55 years old male Chinese art teacher complained of seeing “double objects” side-by-side, at times worse, for the past week. He also reported his double vision disappeared when he closed one eye.
He was on Atenolol 50mg OM monotherapy for the past ten years. BP maintaining at around 130/85 mmHg and has also quit smoking since then. No other major personal and family medical condition reported. His laboratory comprehensive blood test report from general medical check-up a year ago was unremarkable. Moderate bilateral cortical cataracts in BE were detected two years ago and no other significant ocular abnormality was demonstrated.
He also reported no past ocular or head trauma or body injury.
General observation and clinical examination showed:
- His current two years old PAL spectacle Rx was OU-5.75 : Add+2.75, well fitted on his nose-bridge and no lens defect.
- Unilateral DVA was OU6/7.5, NVA N5, and reported “unstable” vision and could not focus on test chart with BE opened.
- Both pupillary reflexes were equally round, reactive and brisk.
- Left corneal light reflex was about 2mm temporal to the pupil centre in primary gaze position, and he demonstrated a compensatory head turned to the left frequently.
- His left eye unable to abduct on ocular motility evaluation.
- External and internal ocular conditions were unremarkable.
- NCIOP was R15mmHg,
- Refraction: OU-6.00DS (6/7.5+) : Add+2.75 (N5).
In the process of examination, he also disclosed that he had few episodes of unexplained nose bleeding and frequent ear buzzing for the past few weeks but skeptical whether needed to seek medical attention.
The ethnicity, past smoking history, manifestations of recent epistaxis, tinnitus, acute abducens nerve palsy, which were highly suspicious of sinonasal lesion involving sixth cranial nerve. He was advised to consult with the Otorhinolaryngologist without delay.
Palliative care was provided by patching his left spectacle lens with the frosted surgical tape to eliminate his diplopia.
He was soon referred to the oncology centre by his ENT specialist where he received in-depth examination and treatments.
Three months later, the patient’s son reported that his father succumbed to the complications from the chemoradiation therapy for his nasopharyngeal carcinoma.
By Alan Chong Dip Optom, FBDO CL