Ophthalmic Case study 5 ( Anisometropic Amblyopia)

 

Chief Complaint:

Referred for unequal vision

History of Present Illness

A 5-year-old boy was referred by his local ophthalmologist due to suspected decreased vision in his left eye found during a screening examination. His mother had not noticed any vision problems. He has had normal growth and development.

Past Ocular History: None

Past Medical and Surgical History: None

Medications: None

Family History: No history of amblyopia or strabismus

Social History: Lives at home with mother and father

OCULAR EXAMINATION

On presentation Stereo test: Titmus fly: Negative Pupils: No relative afferent pupillary defect (RAPD)

Extraocular motility: Normal versions, exophoria on primary gaze in far and near positions

Visual acuity by Lea pictures (distance without correction): OD: 20/30 OS: 20/160 Confrontation visual fields: No deficits or with toys

Intraocular pressure: Soft on palpation

External examination: Normal

Anterior segment examination

Eyelids: Normal: no ptosis Conjunctiva/Sclera: Clear and white Cornea: Clear Anterior chamber: Deep and quiet Iris: Normal Lens: Clear Vitreous: Normal

Posterior segment examination:

Discs: Normal size, no excavation or pallor Macula: Crisp foveal reflex Vessels: Normal Periphery: Normal

Cycloplegic refraction

OD: +0.75 +0.50 x 090                        OS: +2.75 +1.75 x 105 

Diagnosis

Anisometropic amblyopia

Treatment

The patient received their cycloplegic refraction of -0.75 D to encourage adherence and was followed up at three-month intervals (see exams below).

FROM: TO OD:+0.75 +0.50 x 090 OS:+2.75 +1.75 x 105 -0.75 D -0.75 D Prescribed refractive plan: plano / +0.50 x 090 +2.00 / +1.75 x 105