Complicated Refractive Cases and their Management

Transcription

1 Complicated Refractive Cases and their Management COPE GO Kristin Anderson, OD, FAAO

2 Complicated Refractive Cases and Prescribing Considerations Kristin K. Anderson, OD Professor Southern College of Optometry COPE ID: GO Disclosures Institutional Advisory Board Allergan Luxottica Objectives Review examination sequences to evaluate patient complaints which are often ambiguous Describe refractive management considerations for binocular dysfunctions Highlight best refractive management for addressing most common vergence and accommodative disorders 1

3 General Guidelines Some refractive guidelines can be applied to most patients but the art of prescribing lenses is in knowing when to look beyond these refractive conditions and evaluate the state of visual efficiency. Visual Acuity Efficiency and Comfort Prescribing Considerations Age Accommodative Status Binocular Function Visual Demands Previous Spectacle Rx Nearpoint assessment of accommodative and binocular status is part of my exam protocol for: A. New and established patients at each exam B. Only new patients (with or without complaints) C. New and established patients with complaints suggestive of a problem D. I do not perform nearpoint assessment as part of my standard examination protocol 2

4 Not all Myopes are Created Equal 24 y.o. WM presents with a complaint of BLUR Case 1 Difficulty reading road signs while driving Daytime = Night Mild Gradual change Near vision is good LEE and Rx: 2 years ago POHx/PMHx non-contributory Patient Data Habitual Rx OD: DS OS: DS Visual Acuity Dist: 20/20-2 OD, OS Near: 20/15 OD, OS Cover Test Dist: ortho Near: ortho Retinoscopy X X050 Refraction (M=B) DS 20/ DS 20/

5 Patient Data Phoria Dist: ortho Near: 2EP NEAR ASSESSMENT Vergence Ranges BI: X/18/14 BO: 24/30/18 AMP: 10D OD, OS MEM: OD, OS NRA: D PRA: D Prescribing Considerations Age Accommodative Status Binocular Status Complaints and Visual Demands Complaint Occupation: delivery truck driver Hobbies: waterskiing & fishing Assessment 1. Myopia 4

6 Final Rx Spectacle Rx OD: DS OS: DS Full time wear Why does this make sense? Additional Considerations? Sunglasses? Contact Lenses? 24 y.o. BF presents with a complaint of BLUR Case 2 Distance, only when not wearing glasses Moderate Relief with habitual spec wear Near vision is good with and without glasses LEE and Rx: 2 years ago POHx/PMHx non-contributory Patient Data Habitual Rx OD: DS OS: DS Visual Acuity Dist: 20/20-1 OD, OS Near: 20/15 OD, OS Cover Test Dist: ortho Near: ortho Retinoscopy X X050 Refraction (M=B) DS 20/ DS 20/

7 Patient Data Phoria Dist: ortho Near: 2EP NEAR ASSESSMENT Vergence Ranges BI: X/18/14 BO: 24/30/18 AMP: 10D OD, OS MEM: OD, OS NRA: D PRA: D Prescribing Considerations Age Accommodative Status Binocular Status Complaints and Visual Demands Complaint: none with current spectacles Occupation: kindergarten teacher Hobbies: gardening Assessment 1. Myopia 6

8 Final Rx Spectacle Rx OD: DS OS: DS Full time wear Why does this make sense? Additional Considerations? Clinical Pearls It s difficult to improve on an asymptomatic state 24 y.o. HF presents with a complaint of BLUR Case 3 Distance >> Near Mild Worse at the end of the day Near vision is just all right LEE and Rx: 2 years ago POHx/PMHx: (+) HA frontal/temporal 3-4 times per week; dull, pounding, Tylenol with some relief 7

9 Patient Data Habitual Rx OD: DS OS: DS Visual Acuity Dist: 20/20-1 OD, OS Near: 20/20 OD, OS Cover Test Dist: ortho Near: 4 EP Retinoscopy X X050 Refraction (M=B) DS 20/ DS 20/20 +2 Patient Data through MR Phoria Dist: ortho Near: 6 EP Phoria thru Add 1XP NEAR ASSESSMENT Vergence Ranges BI: X/08/05 BO: 24/30/18 AMP: 10D OD, OS MEM: OD, OS NRA: D PRA: D Prescribing Considerations Age Accommodative Status Binocular Status Complaints and Visual Demands Complaint: distance and near blur with HA Occupation: 911 dispatcher Hobbies: reading non-fiction 8

10 Assessment 1. Myopia 2.??? A. Accommodative Insufficiency B. Basic Esophoria C. Convergence Excess D. Convergence Insufficiency Assessment 1. Myopia 2. Convergence Excess Profile of CE Final Rx Spectacle Rx OD: DS OS: DS Distance only Why does this make sense? Built in add Allow for adequate vergence compensation for all near activities 9

11 Final Rx Spectacle Rx OD: DS OS: DS Add: +1.25D Why does this make sense? Full-time option; allowing for adequate vergence compensation and distance correction simultaneously Disadvantages Computer use (multifocal design issues) 24 y.o. BM presents with a complaint of BLUR Case 4 Distance >> Near Mild Worse at the end of the day Near vision is OKAY LEE and Rx: 2 years ago POHx/PMHx: (+) eyestrain At near, with associated fatigue; (-) diplopia, but loses focus frequently when working Patient Data Habitual Rx (wears for distance only) OD: DS OS: DS Visual Acuity Dist: 20/20-1 OD, OS Near: 20/20 OD, OS Cover Test Dist: ortho Near: 7 XP Retinoscopy X X050 Refraction (M=B) DS 20/ DS 20/

12 Patient Data Phoria Dist: ortho Near: 7 XP Phoria thru Add 10 XP NEAR ASSESSMENT Vergence Ranges BI: X/18/15 BO: 04/08/06 AMP: 10D OD, OS MEM: OD, OS NRA: D PRA: D Prescribing Considerations Age Accommodative Status Binocular Status Complaints and Visual Demands Complaint: distance blur; eyestrain Occupation: market analyst Hobbies: computer games Additional Additional Tests NPC 9cm/13cm 11cm/15cm 11cm/15cm AC Facility Testing OD: 10 cpm OS: 10 cpm OU: 4 cpm NPC thru cm/17cm X 3 (+) more difficult 11

13 Assessment 1. Myopia 2. Convergence Insufficiency Final Rx Spectacle Rx OD: DS OS: DS Full time wear Why does this make sense? Additional Considerations Previous self-prescribed distance only correction exacerbated the near problem! Management Considerations Vision Therapy Lens correction alone is inadequate to address vergence ability Good success when treating Convergence Insufficieny 12

14 24 y.o. WM presents with a complaint of BLUR Case 5 Distance >> Near Mild Worse at the end of the day Near vision is OKAY LEE and Rx: 2 years ago POHx/PMHx: (+) eyestrain At near, with associated fatigue; (-) diplopia, but loses focus frequently when working Patient Data Habitual Rx (full time) OD: DS OS: DS Visual Acuity Dist: 20/20-2 OD, OS Near: 20/20-1 OD, OS Cover Test Dist: ortho Near: 7 XP Retinoscopy X X050 Refraction (M=B) DS 20/ DS 20/20 +2 Patient Data Phoria Dist: ortho Near: 7 XP Phoria thru Add 10 XP NEAR ASSESSMENT Vergence Ranges BI: X/18/15 BO: 4/08/05 AMP: 6D OD, OS MEM: OD, OS NRA: D PRA: D 13

15 Additional Testing? A. YES B. NO NPC 9cm/13cm 11cm/15cm 11cm/15cm Additional Tests AC Facility Testing OD: 3 cpm OS: 4 cpm OU: 4 cpm (-) more difficult NPC thru cm/7cm X 3 BO (+1.00 add) 15/21/13 Prescribing Considerations Age Accommodative Status Binocular Status Complaints and Visual Demands Complaint Occupation: accountant Hobbies: lead guitarist for the Taxmen 14

16 Assessment 1. Myopia 2. Accommodative Insufficiency Final Rx Spectacle Rx OD: DS OS: DS Add: D Why does this make sense? Additional Considerations? Distance only? Sure, but good history to confirm feasibility of design. Management Options Vision Therapy Patient s age supports this option Accommodative amplitude can be increased through many therapeutic techniques TREATS CONDITION, NOT SYMPTOM! Disadvantage Patient motivation and commitment factors 15

17 This is the art of prescribing Key Points: Low to Moderate Hyperopia Often ASYMPTOMATIC Exhausted from prolonged demand Insufficient ability DISTANCE BLUR does not usually occur until accommodative amp is reduced ASTHENOPIA at NEAR Eyestrain and frontal headaches 21 y.o. HF presents with a complaint of EYESTRAIN Case 6 Near only Mild Worse at the end of the day Near vision is just all right LEE and Rx: 2 years ago POHx/PMHx: (+) HA Onset 8/2010; frontal/temporal 3-4 times per week; dull, pounding, Tylenol with some relief 16

18 Patient Data Habitual Rx OD: none OS: none Visual Acuity Dist: 20/20-1 OD, OS Near: 20/20 OD, OS Cover Test Dist: 4EP Near: 8 EP Retinoscopy X X050 Refraction (M=B) DS 20/ DS 20/20 +2 Patient Data Phoria Dist: ortho Near: 4 EP Phoria thru Add ortho NEAR ASSESSMENT Vergence Ranges BI: X/14/12 BO: 24/30/18 AMP: 10D OD, OS MEM: OD, OS NRA: D PRA: D Prescribing Considerations Age Accommodative Status Binocular Status Complaints and Visual Demands Complaint: eyestrain at near Occupation: finance major at Rhodes College Hobbies: hunting 17

19 Assessment 1. Hyperopia Final Rx Spectacle Rx OD: DS OS: DS Near only Why does this make sense? Allows for full time wear without distance blur Allow for adequate vergence compensation 21 y.o. WM presents with a complaint of EYESTRAIN Case 7 Near > Distance Moderate Worse at the end of the day Near vision is just all right LEE and Rx: 2 years ago POHx/PMHx: (+) HA Onset 8/2010; frontal/temporal 3-4 times per week; dull, pounding, Tylenol with some relief 18

20 Patient Data Habitual Rx OD: none OS: none Visual Acuity Dist: 20/20-1 OD, OS Near: 20/20 OD, OS Cover Test Dist: 4EP Near: 13 EP Retinoscopy X X050 Refraction (M=B) DS 20/ DS 20/20 +2 Patient Data Phoria Dist: 3XP Near: 6 EP Phoria thru Add 1XP NEAR ASSESSMENT Vergence Ranges BI: X/13/05 BO: 24/30/18 AMP: 10D OD, OS MEM: OD, OS NRA: D PRA: D Prescribing Considerations Age Accommodative Status Binocular Status Complaints and Visual Demands Complaint: eyestrain at near > distance Occupation: bank teller Hobbies: yoga 19

21 Assessment 1. Hyperopia 2.??? A. Convergence Insufficiency B. Basic Esophoria C. Convergence Excess D. Divergence Insufficiency Assessment 1. Hyperopia 2. Convergence Excess Final Rx Spectacle Rx OD: DS OS: DS Add Why does this make sense? Allows for full time wear without distance blur Allow for adequate vergence compensation What about a RORx option?? 20

22 23 y.o. WM presents with a complaint of EYESTRAIN Case 8 Near > Distance Moderate Worse at the end of the day Near vision is just all right ; worse with computer work LEE and Rx: 2 years ago POHx/PMHx: (+) HA - frontal/temporal 3-4 times per week; dull, pounding, Tylenol with some relief Patient Data Habitual Rx OD: none OS: none Visual Acuity Dist: 20/20-1 OD, OS Near: 20/20 OD, OS Cover Test Dist: 8 EP Near: 8 EP Retinoscopy X X050 Refraction (M=B) DS 20/ DS 20/20 +2 Patient Data Phoria Dist: 4 EP Near: 8 EP Phoria thru Add 4 EP NEAR ASSESSMENT Vergence Ranges BI: X/13/05 BO: 20/24/18 AMP: 6D OD, OS MEM: OD, OS NRA: D PRA: D 21

23 Tentative Assessment A. Hyperopia B. Latent Hyperopia C. Convergence Excess D. Accommodative Insufficiency Additional Tests DISTANCE Phoria repeat through Vergence ranges CYCLOPLEGIC REFRACTION OD: DS 20/15 OS: DS 20/15 Prescribing Considerations Age Accommodative Status Binocular Status Complaints and Visual Demands Complaint: eyestrain at near > distance Occupation: Office Administrator Hobbies: golf 22

24 Assessment 1. Latent Hyperopia Final Rx Spectacle Rx OD: DS OS: DS Full time wear Why does this make sense? Allows for full time wear Will require adaptation reasonable Contact Lenses? Allows for adequate vergence compensation Follow-up Considerations TEST SELECTION Review of symptoms Visual acuity Refraction Near assessment 23

25 Case 9 34 year old BF: NO COMPLAINTS Visual Acuity: DIST OD: 20/20 OS: 20/20 OU: 20/20 Visual Acuity: NEAR OD: 20/20 OS: 20/20 OU: 20/20 Cover Test 3XP 5XP AMP 8D OD, OS Keratometry 43.00@180/44.50@ @180/44.50@ year old BF: NO COMPLAINTS Retinoscopy X180 20/ X180 20/20 Monocular Subjective X170 20/ X010 20/20 Phoria 3XP 6XP Grad AC/A 4:1 Vergences NEAR BI 11/17/13 BO 15/20/18 BINO: same NRA PRA ASSESSMENT 1. Hyperopia 2. Astigmatism 24

26 PLAN NO Rx Asymptomatic Good VA Binocular Status Accommodative Status Rx? 34 year old BM: NO COMPLAINTS Retinoscopy X180 20/ X180 20/30 Monocular Subjective X180 20/ X180 20/30 Phoria 3XP 6XP Grad AC/A 4:1 Vergences NEAR BI 11/17/13 BO 15/20/18 BINO: same NRA PRA ASSESSMENT 1. Astigmatism- decreased BCVA (meridional amblyopia) 2. Hyperopia 25

27 PLAN Rx Considerations First Rx Significant cyl decreased VA NO complaints Binocular Status Accommodative Status Rx? OPTIONS FULL cylinder correction Optically offers best potential VA PARTIAL cylinder correction Best adaptation Adaptation Spatial distortion Clinical Pearls: First Rx Be cautious of prescribing more cylinder than you scoped! Max sphere with least cyl to BVA for best comfort Work toward full cylinder in cases of refractive amblyopia 26

28 Clinical Pearls: Rx Changes Change in Cylinder Power Suggested Change In Degrees unlimited < <30 >2.00 <10 Werner & Press 2002 Clinical Pearls: It is difficult to improve on asymptomatic states It is OK to change lenses in stages Maintain spherical equivalent A lens change of less than 0.50 D seldom eliminates a complaint..but can create one! Accommodative and Binocular efficiency is essential component of visual health Optometric expertise and contribution to readiness. Putting it all together 27

29 32 year old BM with complaint of BLUR distance>near; esp. when driving home from work onset: 3 months ago frequency: everyday associated symptoms: occassional headache frontal, dull, pounding Tylenol or rest for relief Secondary complaint(s): asthenopia Occupation: Computer Programmer Hobbies: video games & reading science fiction Do the complaints alone suggest: A. Refractive problem B. Accommodative problem C. Binocular problem D. Any of the above Why? Examination Data Visual Acuity Distance (sc) 20/40 OD Near (sc) 20/20 OD 20/40 OS 20/20 OS 20/40 OU 20/20 OU Cover Test Distance 3 XP 40 cm: 5 XP Refraction: OD: X180 20/20 OS: X176 20/20 28

30 Do we have enough data to recommend a management option? A. YES B. NO Why or Why not? Phoria (cc) Distance: 2XP 40 cm: 6 XP thru +1.00: 10XP Vergences Distance BI: X/18/14 40 cm: BI: X/16/13 BO: X/10/02 BO: X/04/02 FCC: plano OD, OS NRA:??? PRA: D Amplitude of Accommodation: 7.5 D OD, OS Predict the findings of NPC? A. Normal B. Reduced, but improved with plus C. Reduced, and further reduction with plus D. No way to predict 29

31 Accommodative facility testing will be: A. Reduced monocularly with the (-) more difficult B. Reduced monocularly with the (+) more difficulty C. Reduced binocularly with the (-) more difficult D. Reduced binocularly with the (+) more difficult E. Reduced MONO and BINO with the (-) more difficult F. Reduced MONO and BINO with the (+) more difficult Convergence Insufficiency Normal to High XP Low to normal AC/A ratio Reduced NRA Normal PRA Reduced BO vergences Normal Accommodative Amplitude Low Accommodative Lag ACCOMMODATIVE SUBJECTIVE Complaints History REFRACTIVE OCULAR HEALTH SYSTEMIC HEALTH Anterior Segment Posterior Segment BINOCULAR 30

32 Suggested Desk Reference THANK YOU! 31