Melissa Valdellon

Patient case for July 7, 2023

I know we’ve been doing a lot of pediatric prescription cases lately (sorry, not sorry?), but here’s another one to get you thinking.

The patient is an 11 year old Hispanic female coming in for her first eye exam after failing a vision screening with her pediatrician. The patient reports that vision is blurry both distance and up close. She is otherwise healthy, has no allergies, and is not taking any medications.

Distance VA is OD 20/30-2, OS 20/40, and pinholes to 20/25 in each eye. Also, near VA is 0.4/0.5M-1 in each eye.

At this point, can you anticipate what kind of refractive error you’d expect here? Take a guess and keep those numbers handy.

Pupils, EOMs, confrontation fields are all normal. Cover test is ortho distance and near.

Auto-refraction results show:
OD: +0.75 -0.50 x 139
OS +1.25 -0.25 x 098

Refraction, however, yields you this:
OD: -0.75 -0.50 x 005  20/25
OS: -1.250 DS  20/30

Now what? The child is getting tired and annoyed at being here and she’s not feeling like she’s seeing dramatically better compared to when she first came in. What other testing should you do?

While the patient herself did not mention any headaches or eyestrain, a clue that this patient could have more binocular vision problems is the fact that her near visual acuities were also reduced. A minor amount of myopia or astigmatism really shouldn’t be enough to lose a whole line of acuity at near.

So we ended up checking accommodation. NPA on repetition was 8D, 7D, 5D with both eyes open. And after all that fatigue, NPC was 12cm. What are the patient’s age based norms for NPA and NPC?

We next dilated the patient with tropicamide and phenylephrine. Was cyclopentolate indicated for this exam? Would it have been wrong to use it?

Ocular health was unremarkable for both eyes.

Damp auto-refraction results were:
OD +1.25 -1.25 x 007
OS: +1.50 -2.50 x 171

What would you prescribe for this patient? What conditions are affecting this patient that you would discuss with mom about? And of course, what’s your follow up plan? Chime in below!

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