2016 tmc refraction pretest with answers
TRANSCRIPT
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E X E R C I S E S E T TMC , MAR CH 1 6 , 2 0 1 6
EYEGLASSPRESCRIBINGINCHILDREN
PRESENTEDBY:APSANTIAGO,MD
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PRESCRIBINGEYEGLASSESIN
CHILDRENEXERCISESA P S AN T I AGO , MD
TMC,16March2016
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CASE1A
Ø Orthotropic
Ø Age2years
Ø VA:OUfixes,follows,canCSM,nopreference
Ø Manifestdifficult:-3.00OD,-3.5OS
Ø CycloplegicrefracTonOD-1.50D OS-2.00D
Whatwillyoudo?
1. PrescribemanifestrefracTon?
2. PrescribecycloplegicrefracTon?
3. Observefornowbecauseachild’sworldisatnear?
4. PrescribecycloplegicrefracTonascontactlenses?
5. Giveatropinetohaltprogressionofmyopia?
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CASE1B
Ø IntermiZentexotropia
Ø Age2
Ø VA:OUfixes,follows,canCSM,nopreference
Ø Manifestdifficult:-3.00OD,-3.50OS
Ø CycloplegicrefracTonOD-1.50D OS-2.00D
Ø Whatwillyoudo?
1. PrescribemanifestrefracTon?
2. PrescribecycloplegicrefracTon?
3. Observefornowbecauseachild’sworldisatnear?
4. PrescribecycloplegicrefracTonascontactlenses?
5. Giveatropinetohaltprogressionofmyopia?
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CASE1C
Ø Esotropic,intermiZent
Ø Age2yr
Ø VA:OUfixes,follows,canCSM,nopreference
Ø Manifestdifficult:-3.00OD,-3.50OS
Ø CycloplegicrefracTonOD-1.50D OS-2.00D
Ø Whatwillyoudo?
1. PrescribemanifestrefracTon?
2. PrescribecycloplegicrefracTon?
3. Observefornowbecauseachild’sworldisatnear?
4. PrescribecycloplegicrefracTonascontactlenses?
5. Giveatropinetohaltprogressionofmyopia?
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CASE2A
Ø 3/Ffailedapreschoolvisionscreening
Ø VA:OD20/50linearAllen,
20/30singlefigures
OS20/30linearandsinglefigures
Ø Orthotropic
Ø ManifestrefracTonØ OD:-3.00D
Ø OS:-1.00D
Ø CycloplegicrefracTonØ OD:-2.50D
Ø OS:-1.00D
Ø Whatwillyoudo?
1. Observefornow,child’sworldatnear.
2. PrescribemanifestrefracTon,childisstarTngschool.
3. PrescribecycloplegicrefracTon
4. PrescribecycloplegicrefracTonandstartamblyopiatherapy.
5. RepeatrefracTonin3months.
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CASE2B
Ø 3yrsold,recentonset30PDE(T)’
Ø Neurologically,systemicallynormal
Ø VA:OU,fixes,follows,canCSM
Ø OnlyleaeyealwaysturnsinintermiZently
Ø Manifest:+0.50-1.00x90OU
Ø CycloplegicrefracTon:(cyclopentolate1%)
Ø +3.00-1.00x90OU
Ø Whatwillyoudo?
1. PrescribemanifestrefracTon
2. Cutplusby1.0DfromcycloplegicrefracTon:+2.00-1.00x090OU
3. GivecyclopentolatecycloplegicrefracTon
4. DoatropinerefracTonandprescribethis
5. PrescribecycloplegicrefracTonwithbifocals.
6. PaTent’scaserequiressurgery.
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CASE2CØ 3/Fwith25PDofX(T)
Ø VAOU:20/20eithereyeoccluded,unaided
Ø Eithereyedeviatesoutwardwithnoobviouseyepreference
Ø DryManifestRefracTon:+2.00-1.00x180
Ø UnabletocooperateforsubjecTverefracTon
Ø CycloplegicrefracTon+3.00-1.00x180
Ø Whatwillyoudo?
1. NoprescripTonifpaTentdoesnotwantsurgery.
2. PrescribeRxevenifpaTentdoesnotwantsurgery.
3. Dosurgeryfor25PDXTandprescribeRxaaersurgeryforunder-orovercorrecTon
4. DoatropinerefracTonandprescribethisifpaTentwantssurgery.
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ENDOFPRETEST
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PRESCRIBINGEYEGLASSESFORCHILDREN
AN SWER S T O P R E T E S T
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CASE1A
Ø Orthotropic
Ø Age2years
Ø VA:OUfixes,follows,canCSM,nopreference
Ø Manifestdifficult:about-3.0OD,-3.5OS
Ø CycloplegicrefracTonØ OD-1.50D OS-2.00D
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1A:WHATWILLYOUDO?
Ø Age2:potenTalforamblyopia
Ø Myopia<-2.0DlesspotenTalforamblyopiaalthoughmaysTllbe“amblyogenic”
Ø Child’sworldisatnear
Ø Nomisalignment
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1A:LOGICALMANAGEMENT
Ø ObserveØ Child’sworldatnearØ LowpotenTalforamblyopia
Ø Butneedtomonitorclosely
Ø Willnotinterferewith“emmetropizaTon”
Ø GivecycloplegicrefracTonØ PotenTalforamblyopiaandsymptomstodeveloplater
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CASE1A,1A:2Y,ORTHO,MYOPIA<-2.0D
Ø Orthotropic
Ø Age2years
Ø VA:OUfixes,follows,canCSM,nopreference
Ø Manifestdifficult:-3.00OD,-3.5OS
Ø CycloplegicrefracTonOD-1.50D OS-2.00D
Whatwillyoudo?
1. PrescribemanifestrefracTon?
2. PrescribecycloplegicrefracRon
3. Observefornowbecauseachild’sworldisatnear
4. PrescribecycloplegicrefracTonascontactlenses?
5. Giveatropinetohaltprogressionofmyopia?
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CASE1B
Ø IntermiZentexotropia
Ø Age2
Ø VA:OUfixes,follows,canCSM,nopreference
Ø Manifestdifficult:about-3.0OD,-3.5OS
Ø CycloplegicrefracTonØ OD-1.50D OS-2.00D
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1B:WHATWILLYOUDO?
Ø ChildhasX(T)
Ø Age2:potenTalforamblyopiaØ Strabismic
Ø Ametropic:Myopic
Ø Myopia<-2.0Dmaybeasensorydestabilizingfactor
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LOGICALMANAGEMENT:1B
Ø Givemyopic(full)cycloplegicrefracTonØ Startwithlowestminus
Ø ImprovedVAmaybeenoughtocontrolX(T)
Ø GivemanifestrefracTonbecauseofroleofoverminuslensesinX(T)
Ø Mayevengivehigherminus(upto-3.0D)ifdeviaTonsmall(<20D)–Jampolskyetal
Ø Childrentolerate“overminus”well
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CASE1B
Ø IntermiZentexotropia
Ø Age2
Ø VA:OUfixes,follows,canCSM,nopreference
Ø Manifestdifficult:-3.00OD,-3.50OS
Ø CycloplegicrefracTonOD-1.50D OS-2.00D
Ø Whatwillyoudo?
1. PrescribemanifestrefracTon
2. PrescribecycloplegicrefracRon
3. Observefornowbecauseachild’sworldisatnear
4. PrescribecycloplegicrefracTonascontactlenses
5. Giveatropinetohaltprogressionofmyopia
C
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CASE1C
Ø Esotropic,intermiZent
Ø Age2yr
Ø VA:OUfixes,follows,canCSM,nopreference
Ø Manifestdifficult:about-3.0OD,-3.5OS
Ø CycloplegicrefracTonØ OD-1.50D OS-2.00D
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1C:WHATWILLYOUDO?
Ø ChildhasE(T)
Ø Age2:potenTalforamblyopiaØ Strabismic
Ø Ametropic:Myopic
Ø Myopia<-2.0DmaybesTmulaTngexcessaccommodaTon&convergence
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LOGICALMANAGEMENT:1C
Ø Givemyopic(full)cycloplegicrefracTon
Ø NoroleforgivingmanifestrefracTonoroverminuslenses
Ø MonitoreffectofRxonalignment
Ø Monitorfordevelopmentofamblyopia
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CASE1C
Ø Esotropic,intermiZent
Ø Age2yr
Ø VA:OUfixes,follows,canCSM,nopreference
Ø Manifestdifficult:-3.00OD,-3.50OS
Ø CycloplegicrefracTonOD-1.50D OS-2.00D
Ø Whatwillyoudo?
1. PrescribemanifestrefracTon
2. PrescribecycloplegicrefracRon
3. Observefornowbecauseachild’sworldisatnear?
4. PrescribecycloplegicrefracTonascontactlenses?
5. Giveatropinetohaltprogressionofmyopia?
C
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CASE2A
Ø 3/Ffailedapreschoolvisionscreening
Ø VA:OD20/50linearAllen,20/30singly
OS20/30linearandsingly
Ø Orthotropic
Ø ManifestrefracTon
Ø OD:-3.00D OS:-1.00D
Ø CycloplegicrefracTonØ OD:-2.50D OS:-1.00D
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CASE2A:WHATWILLYOUDO?
Ø 3y:visualsystemimmature
Ø AlreadyamblyopicØ Linearacuityshowsatleast2linedifference
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2A:LOGICALMANAGEMENT
Ø GivecycloplegicrefracTon(lowestminus)
Ø MonitorVAimprovement(usuallyamonth)
Ø Startamblyopiatreatmentifnecessary
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CASE2A
Ø 3/Ffailedapreschoolvisionscreening
Ø VA:OD20/50linearAllen,
20/30singlefigures
OS20/30linearandsinglefigures
Ø Orthotropic
Ø ManifestrefracTonØ OD:-3.00D
Ø OS:-1.00D
Ø CycloplegicrefracTonØ OD:-2.50D
Ø OS:-1.00D
Ø Whatwillyoudo?
1. Observefornow,child’sworldatnear.
2. PrescribemanifestrefracTon,childisstarTngschool.
3. PrescribecycloplegicrefracTon
4. PrescribecycloplegicrefracRonandstartamblyopiatherapy.
5. RepeatrefracTonin3months.
C
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CASE2B
Ø 3yrsold,recentonset30PDE(T)’
Ø Neurologically,systemicallynormal
Ø VA:OU,fixes,follows,canCSM
Ø OnlyleaeyealwaysturnsinintermiZently
Ø Manifest:+0.50-1.00x90OU
Ø CycloplegicrefracTon:(cyclopentolate1%)Ø +3.00-1.00x90OU
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2B:WHATWILLYOUDO?
1. CyclopentolaterefracTonalready>+2.00,higherlikelihoodthatatropinerefracTonwilluncovermoreplus
2. LikelytobearefracTveaccommodaTveintermiZentET
3. Righteyepreference(onlyleaeyeintermiZentlyturnsin)suggesTveofamblyopiathoughmild
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2B:LOGICALMANAGEMENT
Ø Atropinecycloplegia
Ø GivefullcycloplegicrefracTon
Ø DetermineeffectonalignmentandcontrolofintermiZentesodeviaTon
Ø Bifocalsiff:Ø RepeatatropinesamerefracTonasprevious
Ø ETcontrolledatdistance,residualET’atnear
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CASE2B
Ø 3yrsold,recentonset30PDE(T)’
Ø Neurologically,systemicallynormal
Ø VA:OU,fixes,follows,canCSM
Ø OnlyleaeyealwaysturnsinintermiZently
Ø Manifest:+0.50-1.00x90OU
Ø CycloplegicrefracTon:(cyclopentolate1%)
Ø +3.00-1.00x90OU
Ø Whatwillyoudo?
1. PrescribemanifestrefracTon
2. Cutplusby1.0DfromcycloplegicrefracTon:+2.00-1.00x090OU
3. GivecyclopentolatecycloplegicrefracTon
4. DoatropinerefracRonandprescribethis
5. PrescribecycloplegicrefracTonwithbifocals.
6. PaTent’scaserequiressurgery.
C
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CASE2CØ 3/Fwith25PDofX(T)
Ø VAOU:20/20eithereyeoccluded,unaided
Ø Eithereyedeviatesoutwardwithnoobviouseyepreference
Ø DryManifestRefracTon:+2.00-1.00x180
Ø UnabletocooperateforsubjecTverefracTon
Ø CycloplegicrefracTon+3.00-1.00x180
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CASE2C:LOGICALMANAGEMENT
1. Trytoimprovecontrol:Ø DetermineiftheEORadestabilizingfactor?
Ø withholdingglassessimilartogiving“overminus”?
Ø TrialwithEOR,mayneedtoTtratehyperopiccomponent
Ø RoleoforthopTcs,convergenceandanTsuppressionexercises
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CASE2C:LOGICALMANAGEMENT
2.Ifforsurgery:Ø Needtouncoverfullplus(atropine)refracTon,givemaximumplus
toasclosetocycloplegicaspossible
Ø RemeasurewithRxfortargetangleforsurgery
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CASE2CØ 3/Fwith25PDofX(T)
Ø VAOU:20/20eithereyeoccluded,unaided
Ø Eithereyedeviatesoutwardwithnoobviouseyepreference
Ø DryManifestRefracTon:+2.00-1.00x180
Ø UnabletocooperateforsubjecTverefracTon
Ø CycloplegicrefracTon+3.00-1.00x180
Ø Whatwillyoudo?
1. NoprescripTonifpaTentdoesnotwantsurgery.
2. PrescribeRxevenifpaTentdoesnotwantsurgery.
3. Dosurgeryfor25PDXTandprescribeRxaaersurgeryforunder-orovercorrecTon
4. DoatropinerefracRonandprescribethisifpaRentwantssurgery.
C
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2C:3Y,HYPEROPICX(T)
1. NoprescripTonifpaTentdoesnotwantsurgery.Ø (significantEOR)
2. PrescribeRxevenifpaTentdoesnotwantsurgeryØ (doesnottellyouifdryorwet)
3. Dosurgeryfor25PDofexotropiaandprescribeRxaaersurgeryforunder-orovercorrecTon
Ø (TargetanglesTlluncertainwithouttryingmaxplus)
4. DoatropinerefracRonandprescribethisifpaRentwantssurgery.
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ENDOFDISCUSSIONOFANSWERS