Help me with this patient please.

[ilanh]

Today I saw a 38 year old friend of mine as a patient. He complains of constantly having to close his left eye at distance, computer and near gaze. He cannot quite explain why he closes his left eye.

On exam his BCVA was 20/20 OD and 20/25- OS. His refraction was -1.25 OD, -2.00 OS. When looking through his left eye he complains that the letters "are jumping around" and just not that clear. There is no measurable deviation at either distance or near, uncyclopleged or cyclopleged. The 8 prism base out diopter test is negative for a microtropia. He seems to have a mild exophoria which is elicited with difficulty. When I place a total of 5 diopters of base in prism in front of both eyes the exophoria seems to improve somewhat. Dilated retinal exam in entirely WNL. His main request is that he would love not to have to close his left eye all the time.

Any advice or help would be appreciated. As of now, I've made him spectacles with 2BI prims OD and 3BI prism OS. I can't say that I've ever run into this issue before.

[peregrinerose]

Today I saw a 38 year old friend of mine as a patient. He complains of constantly having to close his left eye at distance, computer and near gaze. He cannot quite explain why he closes his left eye.

On exam his BCVA was 20/20 OD and 20/25- OS. His refraction was -1.25 OD, -2.00 OS. When looking through his left eye he complains that the letters "are jumping around" and just not that clear. There is no measurable deviation at either distance or near, uncyclopleged or cyclopleged. The 8 prism base out diopter test is negative for a microtropia. He seems to have a mild exophoria which is elicited with difficulty. When I place a total of 5 diopters of base in prism in front of both eyes the exophoria seems to improve somewhat. Dilated retinal exam in entirely WNL. His main request is that he would love not to have to close his left eye all the time.

Any advice or help would be appreciated. As of now, I've made him spectacles with 2BI prims OD and 3BI prism OS. I can't say that I've ever run into this issue before.

What were his phorias? Vergences? NRA/PRA? This sounds like a great case for someone who specializes in binocular vision... find a COVD OD somewhere in your area (if you go to www.covd.org I believe there's a doctor locator function). Although I don't specialize in binocular vision, I refer to a couple local docs and patients think the world of me for it, as they typically have good improvement)

[icare]

I'm not convinced that your patient's problem is truly optical. Perhaps it's organic. These are tough cases. I'd be interested in his health history, medications, hereditary background, history of symptom presentation, color and stereo perception and red saturation (red cap) perception. Because the patient is complaining, I'm assuming that his problem is not yet chronic.

I'd consider obtaining central 10 degree automated perimetry, an evaluation of retinal correspondence, complete blood panel and possible OCT of the central retina. I'm also wondering if the patient may be developing a nystagmus. Basically, I'd want to rule out anomalous retinal correspondence, subretinal retinal macular defects and neurological disease. I know a lot of ODs that will refer out to an OMD for unexplained loss of vision. I'm sure that you're aware of the concerns.

If all of the above yields no insight, I'd refer out to a developmental optometrist for a comprehensive binocular evaluation.

[braheem24]

Trial frame him and undercorrect his right eye, if that does not work try undercorrecting both eyes but do not allow the OD VAs to surpass OS.

Good Luck :cheers:

[Ory]

Nothing you've posted explains the poorer VA OS. No amblyogenic factors, no trauma. Are you sure he doesn't have -0.50D of cyl hiding (I know, you're particular about your refractions!)

How about an early cataract? Any family Hx? Wouldn't surprise me to find he has some posterior opacity 6 months from now.

Did you do topography?

Until you can explain the decreased VA OS, I'd ignore BV.

[IndianaOD]

How was stereopsis? Visuoscopy? I agree with the BV consult with a good optometrist focusing on those problems.

[john-atlanta]

The key really revolves around the history of decreased BCVA OS. Is this of recent onset, or a life long problem? If it is been just a few weeks, I would be working to R/O optic neuritis. I would also be looking at an OCT, especially for tangential traction on the macula from the posterior vitreous face.

Another test has often helped me if a pinhole is inconclusive is to use an diagnostic RGP CL to rule out early keratoconus.

With the decreased VA, it seems less likely to binocular / functional and more likely a medical cause.

Just my 2 cents. Always a bit tricky to chime in on these without talking to the patient and a complete history and ROS.

john

[Ian Jordan]

The symptoms are consistent with a visual processing disorder.
We have a specialist practice in the UK which specialises in these difficulties - they are causative in many optical conditions which don't respond to standard interventions eg non comitant strab, alternating strab, Pulfrich phenomenon problems. We have specialist instrumentation / techniques available.
They respond to stimulus control - timing, mapping and sequencing.

the problem sounds like a mapping problem - possibly in the magnocellular system, whether temporal or the relationship between dorsal /ventral streams is not clear. Happy to give some private advice - send me an email on jordans.ayr@btconnect.com

If it is magnocellular it should respond immediately to treatment - but timing difficulies may require tuning of timing of visual processing of either ganglion responses or cone cell pathways

[shindog1961]

If you are confident its not pathological, I would consider trial framing a mild monovision Rx. Does he only close the OS with the Rx on? Or is it with Rx on and off? I would consider the monovision especially if its only with the Rx on that he closes his OS.

[drk]

Uh, shindog, the patient moved to Australia six months ago.

[shindog1961]

2009 huh!