Name: Tancinco, Tito Jhon Isaac Sched: Mon-Sat (8:00A.M - 4:00P.

M) OPT 0015- Clinical Refraction

Yr.& Sec: DOPT 3-A Date: August 20, 2022 Prof: Dr. Liza Cana Bautista

CASE STUDY TITLE: CLINICAL ASSESSMENT OF A GERIATRIC PATIENT WITH PRESBYOPIA

AUTHOR/S: Nancy B. Carlson, OD, FAAO, and Aurora Denial, OD, FAAO

DATE PUBLISHED: 2016

Chief Complaint: blur at near both with and without the OTC readers, difficulty driving at night

History of the Present Illness

A 52-year-old patient reported good vision at distance but difficulty driving at night.

Past Ocular History: unremarkable

Past Medical History: hypertension, seasonal allergies but no allergies to medications
Medications: lisinopril daily for hypertension for 20 years, Flonase for nasal congestion
Family History: No history of family medical histories
Social History: restaurant maître d’ and personal trainer
Review of Systems: All systems negative

OCULAR EXAMINATION

• Visual acuity at distance without correction

OD: 20/25 OS: 20/80 PH: 20/40

• Visual acuity at near without correction

OD: 20/80 OS: 20/120

• Entrance tests (color vision, cover test, Randot 2, NPC, EOMs, pupils, screening visual fields)

normal

• Retinoscopy

OD: +1.50 OS: +2.50

• Distance subjective refraction

OD: +1.00 20/20 OS: +2.00 20/20

• NRA/PRA through a tentative add of +2.00 (tentative add based on the patient’s age)

+1.50/-1.50

The distance subjective refraction was trial framed, and BD noted that things looked clear and
comfortable at distance looking at the Snellen chart and also down the hall from the clinic and out the
window at cars in the parking lot. The add of +2.00 (net near Rx was OD +3.00 and OS +4.00) was trial
framed over the distance Rx, and BD found that his vision was better from his OTC readers of +2.00.
BD’s range of clear vision through the trial-framed add was 10” – 20”. The initial case history, BD did not
Name: Tancinco, Tito Jhon Isaac Sched: Mon-Sat (8:00A.M - 4:00P.M) OPT 0015- Clinical Refraction
Yr.& Sec: DOPT 3-A Date: August 20, 2022 Prof: Dr. Liza Cana Bautista

tell the clinician about his OTC glasses. Until BD became comfortable with the clinician, now reported
using readers for several years. They were not prescribed, he did not think of his readers as “glasses” and
he was somewhat embarrassed to admit to using them. BD said, “Oh, these are not glasses, they just
magnify things so I can see them.” The tonometry readings were OD: 14 mmHg and OS: 14 mmHg at
2:10 p.m. He was dilated with one drop of 1% tropicamide and one drop of 2.5% phenylephrine in each
eye. The dilated fundus exam with the binocular indirect ophthalmoscope and 78D lens and slit lamp
was normal. Progressive addition lenses with an Rx of OD +1.00 OS +2.00 Add +2.00 were
recommended.
Additionally, BD was informed that although he mostly required glasses for close work, the
prescribed lenses would also be good for distance, particularly for nighttime driving. He was told that
even when wearing the glasses for close vision, he could still see perfectly at a distance. It would be most
practical for him to always wear the spectacles for his position as maître d'.He might opt to wear the
glasses exclusively for close activities while working as a personal trainer. BD was told to come back after
a year to take a comprehensive exam. Presbyopia was explained to BD as a typical age-related decline in
vision, and it was said that his eye exam had not revealed any signs of systemic or ocular disease.
BD was also told that it was expected that he would need to wear his glasses more frequently as
he continued to age and that it was expected that the prescription would need to be changed over time.
About a week after he received his glasses, BD called and said, “You’ve ruined my life!” He went on to
explain that he thought his apartment was clean but now that he had glasses, he could see that it was
not and he had a lot to do to clean it up.
He claimed he had assumed he could get by with only his OTC readers, but he is now noticing
that he wears the progressive addition glasses practically constantly. He discovered that he preferred
comfortable, clear vision over foggy vision. He again expressed appreciation for his improved vision and
said he looked forward to his next exam. Despite reminders by mail and phone, BD did not return for an
examination for three years. He was still taking 10 mg of lisinopril daily for high blood pressure. He
reported that his last physical exam was one month previous and his doctor found no problems with his
health but recommended that he have an eye examination.
• Visual acuity at distance with correction (OD +1.00 OS +2.00, add +2.00)

OD: 20/200 PH: 20/40 OS: 20/60 PH: 20/30 OU: 20/70

• Visual acuity at near through the add

OD: 20/120 OS: 20/120 OU: 20/120

• Entrance tests (color vision, EOMs, Pupils, screening visual fields)

Normal

• Retinosocpy

OD: +1.50 OS: +2.00

• Distance subjective refraction

OD: +3.00 20/20 OS: +3.25 20/20

Name: Tancinco, Tito Jhon Isaac Sched: Mon-Sat (8:00A.M - 4:00P.M) OPT 0015- Clinical Refraction
Yr.& Sec: DOPT 3-A Date: August 20, 2022 Prof: Dr. Liza Cana Bautista

• NRA/PRA through a tentative add of +2.75 over the distance subjective (add chosen based on the
patient’s near visual acuity through his old glasses)

+1.00/-1.00

Refractive data summary First Visit, age 52 Second visit, age 56

Visual Acuity Without correction: With correction:
OD: 20/25, 20/80 at 16” OD: 20/200, 20/120 at 16”
OS: 20/80, 20/120 OS: 20/60, 20/120
Calculated amplitude of 2.00 D 1.25 D
accommodation
Subjective refraction OD: +1.00 20/20 OD: +3.00 20/20
OS: +2.00 20/20 OS: +2.75 20/20
Add +2.00, range 10” – 20” +2.75, range 11” – 18”
Total new near Rx OD: +3.00 OD: +5.75
OS: +4.00 OS: +5.50
Change in distance Rx from first OD: +2.00
to second visit OS: +0.75
Change in near Rx from first to OD: +2.75
second visit OS: +1.50
Goldmann tonometry was OD 12 mmHg, OS 12 mmHg. The patient was again dilated with one drop of
1.0% tropicamide and one drop of 2.5% phenylephrine in each eye. The dilated fundus exam was
normal.

Diagnosis

hyperopic presbyopia

Conclusion

Hyperopic presbyopia in BD is a common condition that future optometrists will encounter. very early
Students find their education, the testing procedure, and the prescription decision-making process to be
a little strange, in part because It is so much beyond what they can see. Due to his unique circumstances,
BD's case is more intriguing than a typical case of presbyopia. both during his first and second
appointment, a response to his symptoms. Each patient deserves the clinician's undivided attention.
concerns and students need direction in learning how to create a setting where patients feel at ease.
Putting their issues in words. Students will benefit from case discussions like this, as well as clinical
patient care experience develop into capable doctors.

References

https://journal.opted.org/article/hyperopia-and-presbyopia-a-teaching-case-
report/?fbclid=IwAR1XkEtifnaxz5p5zEnUgR9UP_IPk90DTnhGs7FLWt_DqS2TyABlc5423Tc&pdf=3851
Name: Tancinco, Tito Jhon Isaac Sched: Mon-Sat (8:00A.M - 4:00P.M) OPT 0015- Clinical Refraction
Yr.& Sec: DOPT 3-A Date: August 20, 2022 Prof: Dr. Liza Cana Bautista

Insights and learnings:

After reading the case study of a 52-year-old male with a case of hyperopic presbyopia, I found
out that hyperopic presbyopia in BD is a problem that future optometrists will frequently run against.
Because of how BD responded to his symptoms at both his first and second visits, his case is more
intriguing than a typical one of presbyopia. Every patient deserves the whole clinician's attention to their
concerns, and students require instruction in how to create a setting where patients feel at ease
discussing their personal issues.

Geriatric patients or any kind of patient can have trouble telling clinicians the truth. In this case
BD had not informed the clinician about him using OTC reading glasses. This is why as health care/eye
care specialists we must be patient for not all patients are the same. We must be kind, good, and
understanding because some patients can be tough to work with. Some will lie, and some will be shy, our
role as clinicians is to investigate our patients too. If your data doesn’t make any sense, then the patient
might be hiding the missing piece of your puzzle.

In closing my understanding of the case, students will learn how to become competent
optometrists through case discussions like these and experience in clinical patient care. BD was a
common case but made unique because of the complications the patient gave due to personal human
factors. We also must reassure the patient’s concerns like what BD was eagerly asking in the case.

Terminologies:

Presbyopia - is a refractive error that makes it hard for middle-aged and older adults
to see things up close. It happens because the lens (an inner part of the
eye that helps the eye focus) stops focusing light correctly on the retina
(a light-sensitive layer of tissue at the back of the eye).

Hyperopia - a common vision condition in which you can see distant objects clearly,
but objects nearby may be blurry.

OTC glasses - Over-the-counter reading glasses are simply magnifiers. Your provider
will tell you if ready-made OTC readers are enough to help with your
vision.

Retinoscopy - is a technique to objectively determine the refractive error of the eye

(farsighted, nearsighted, astigmatism) and the need for glasses.

PH -Pinhole

Tonometry -a test to measure the pressure inside your eyes.