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.