Patient's Vision Fluctuates Almost Daily.

[Loki]

Hi,
I was hoping with some help on this as it's thrown my entire practice.

We have a patient who, like the title says, has a prescription that is constantly fluctuating after starting some medication.
They first tested at R: -1.75 L: -4.25/-0.50 x 70 but after starting their meds came back with headaches and felt their specs weren't correct after about two months and at that time tested at R: -1.00 L: -3.75/-0.25 x 70
The meds don't have any reports of causing changes in vision before now that we can find.

Specs were made to this rx and px could see perfectly. However they ended up having to go back to the original specs. All in all they have had six tests with five different opticians and the prescription is somewhere different between the above values each time.
They can see perfectly with one prescription in the test, and then mins five later be unable to read even two lines on the chart.

When administered cycloplegic drops the patient could see almost perfectly without any correction.

As you can see the patient has gross anisometropia, and previously we have given them differing lens indices between each eye to balance out the retinal image size (px said it was best depth perception they've ever had). The left eye only has a low rx but the px doesn't get much vision from it, not fully amblyopic but definitely around there. The px was patched as a child rigorously (px family worked in optics for two generations) and px has started patching again to keep left eye active with some result, saying that eye feels more aware.

But every optician that looks at their record goes "oh wow" which is not helpful as you can imagine. They are currently bouncing between the first specs and the second pair daily, neither of them feeling 100% now.

If anybody has any ideas I know we'd all be grateful. My director has decided the patient is a 'medical oddity'

[optical24/7]

Blood sugar/diabetic?

[Loki]

Nope, patient has no history or signs of any blood sugar issues. They are a fairly healthy 27 year old woman, and the medication is an antidepressant rather than for a physical illness.

[optical24/7]

Then I take it she’s had an A1C test recently. If not recent, I would insist on one.

[Loki]

Not recently. I'll look into that.

[optical24/7]

It’s usually long term use of antidepressants that can cause a loss of glucose tolerance. Maybe she was borderline and the meds threw her quicker. Either way, ruling out this bio reason will get you closer to why the fluctuating Rx. Kinda like working on a car or complex electrical problem, you have to rule out the possible causes one by one. Good luck!

[Uncle Fester]

"Specs were made to this rx and px could see perfectly. However they ended up having to go back to the original specs. All in all they have had six tests with five different opticians and the prescription is somewhere different between the above values each time.
They can see perfectly with one prescription in the test, and then mins five later be unable to read even two lines on the chart."

At 27 I'd be referring to an MD with this statement.

[Uilleann]

MRI done at all? OCT? Fields? Neuro workup? Has pt been checked for accommodative spasm? Also any tests done for dry eye - that's a big one we see given our local climate, but can affect anyone, anywhere, any age, any climate. Worth a look. Any Hx of hypertension? Checked her BP? Does pt state any worse am vs. pm? Any particular visual settings that seem to bring on symptoms? Heavy computer user?

[drk]

When administered cycloplegic drops the patient could see almost perfectly without any correction.

Uh...IF big IF that's true she's in accommodative spasm royale.

Is she on topiramate for migraines, perchance?

[chamilun]

im sure drk is on this one, but I dont see the pts age. this is accommodative spasm. and pt is able to see 20/20 in each eye after cycloplegia?

I would find an eye doctor who does vision therapy and refer for further testing

[Uncle Fester]

Can this happen at any age? I have a long time patient who has been battling this for 6+ months now. He is in his early 80's.

[drk]

Sorry to hear about your vision, Fester...

[chamilun]

I'd say way less common 50 or older.

[Uncle Fester]

Sorry to hear about your vision, Fester...

That isn't what's making me go blind.

[drk]

Susanne Summers is gone. Your eyesight has hope.

[NAICITPO]

That isn't what's making me go blind.

Too much blue light?

[JrFuel186n]

Pregnant!!

[Uncle Fester]

Susanne Summers is gone. Your eyesight has hope.

Thank god for implants!

RIP Crissy Snow.

We are talking about my cataracts...No?

(sorry for the hijack Loki.)

[Loki]

Look guys I'll level with you - its me. I'm the patient. I didn't want to say that to start with as I was kind of embarrassed about being difficult but I'm honestly at my wits end. My blood sugar is fine, I'm 100% not pregnant, and my OCTs (of which I have had several) are all coming up clear. My optoms were thinking accommodative spasm but struggle to test that due to the lazy eye, and are getting (jokingly) annoyed with me I think.
I am starting to get headaches that I blame on bouncing between the two pairs of specs, and my vision is just not coming clear.
My main optom has suggested trying me in the myopia control lenses we offer despite my age just to see if that relaxes things but I can't afford them at the moment.

[Loki]

(sorry for the hijack Loki.)

Hijack away

[Uncle Fester]

PM drk with your medication is my thought at this point.

[drk]

You're not on migraine med recently, then? Topiramate causes severe accommodative spasm sometimes.

Barring that, monocular refractions in young people can be tricky. DEFINITELY use something like cyclopentolate and get an objective refraction (retinoscopy or autorefraction) and then get a subjective refraction. Add about -1.00 on top of that value, and learn to adapt to that power. It woudn't be a bad thing to put in a +0.75 progressive add to keep you from spazzing going forward.

It could take awhile to adapt.


One other possibility: If you're intermittently exotropic you could be using accommodation in order to stay fused. If that's the case, you'd need prism.

[Loki]

You're not on migraine med recently, then? Topiramate causes severe accommodative spasm sometimes.

Barring that, monocular refractions in young people can be tricky. DEFINITELY use something like cyclopentolate and get an objective refraction (retinoscopy or autorefraction) and then get a subjective refraction. Add about -1.00 on top of that value, and learn to adapt to that power. It woudn't be a bad thing to put in a +0.75 progressive add to keep you from spazzing going forward.

It could take awhile to adapt.


One other possibility: If you're intermittently exotropic you could be using accommodation in order to stay fused. If that's the case, you'd need prism.

Nope, no Topiramate.
My cyclo refraction was R: plano / -0.25 x 15 L: -2.25 / -1.00 x 175 and honestly my vision with nothing was fantastic when I had the drops in, better than that rx would suggest. For the second pair of specs we did essentially add that extra -1.00 you suggested. I did adapt to that for two months and the all of a sudden it just started going backwards. I flip backwards and forwards in the test room on what I can see with either rx.

No history of exotropia despite the amblyopia, my brain is just giving up on that eye.

Progressive add might be a good route. I'll have a chat with my optom

[drk]

You are somehow prone to accommodative spasm. Wear the right lens power (a little extra minus isn't the black death) and put it in a PAL to keep your spazz self more relaxed!

[Loki]

You are somehow prone to accommodative spasm. Wear the right lens power (a little extra minus isn't the black death) and put it in a PAL to keep your spazz self more relaxed!

When I can afford that I'll do it. Alas, I have £50 to my name.