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 YOUNG ADULT PATIENT WITH PRESBYOPIA

AUTHOR/S: Benjamin Brifa Bempong

DATE PUBLISHED: March 23, 2017

Chief Complaint: reading difficulties, blur vision and headaches asthenopic symptoms and intermittent
diplopia.

History of the Present Illness

On September 5, 2016, a 29-year-old male postgraduate student visited the Optometry Clinic at the
Kwame Nkrumah University of Science and Technology and complained of reading difficulties, blur
vision, and headaches. Unclear when the symptoms began but worsened over the weeks. Occasional
double vision when reading.

Past Ocular History: None

Past Medical and Surgical History: None
Medications: had instilled methylcellulose eye drops on both eyes (condition remained unchanged)
Family History: No history of family medical histories
Social History: student
Review of Systems: All systems negative

OCULAR EXAMINATION 9/ 5/ 2016

Visual Acuity (standard Snellen chart at 20 feet and the near visual acuity)

DVA: Right Eye (RE): 20/30 Left Eye (LE): 20/30

NVA: OD: N6 OS: N6 Both Eyes (BE): N5 (with difficulty)

Slit Lamp Examination and funduscopy

OD: Normal (eyelid, eyelash, conjunctiva, cornea, anterior chamber, iris, pupil, lens, vitreous)
OS: Normal (eyelid, eyelash, conjunctiva, cornea, anterior chamber, iris, pupil, lens, vitreous)

FUNDUSCOPY

OD: Normal (Optic disc, Macula, Peripheral Retina)

OS: Normal (Optic disc, Macula, Peripheral Retina)
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

Binocular Vision Assessment 9/ 5/ 2016

EOM SAFE
Objective Refraction RE: + 07.5/ -0.25× 180
(Retinoscopy) LE: +0.75/ -0.25× 180
RE: +0.75DS 20/20
Subjective Refraction LE: +0.75DS 20/20
IPD= 71/67mm
NPC 26cm
AA (Push-up to blur) 3D
Distance Phoria Orthophoria
Near Phoria 3X’
AC/A (Calculated) 4.8:1
Base-Out Near 17/22/10
Base-In Near 13/21/13
Vergence facility 12(cycles per minute) cpm
NRA 2.5
PRA -1.25
BAF 5cpm (difficulty clearing –ve lenses)
Impression

Hyperopia

Accommodative Insufficiency

Plan

Patient educated on his condition and the treatment options available.

Vision therapy was prescribed (Pencil push-ups: Three separate 20-minute sessions in a day for 2weeks).

2nd Visit – 19/09/2016

Patient reported slight reduction of symptoms compared to his initial visit. The patient lacked time and
was unable to execute the vision therapy because of his academic works.

Ocular Examination

Slit lamp examination and funduscopy showed nothing remarkable.

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

Binocular Vision Assessment 19/09/2016

EOM SAFE
Objective Refraction RE: + 07.5/ -0.25× 180
(Retinoscopy) LE: +0.75/ -0.25× 180
RE: +0.75DS 20/20
Subjective Refraction LE: +0.75DS 20/20
IPD= 71/67mm
NPC 25 cm
AA (Push-up to blur) 3D
Distance Phoria Orthophoria
Near Phoria 3X’
AC/A (Calculated) 4.8:1
Base-Out Near 17/21/10
Base-In Near 13/21/13
Vergence facility 12(cycles per minute) cpm
NRA 2.5
PRA -1.25
BAF 6cpm (difficulty clearing –ve lenses)

Binocular Vision Assessment (wearing his distance prescription (+0.5) and a +1D lens for near work.)

NPC 12 cm
AA (Push-up to blur) 8D
Distance Phoria 2X
Near Phoria 7X’
AC/A (Calculated) 4.8:1
Base-Out Near 17/21/10
Base-In Near 13/21/13
Vergence facility 12(cycles per minute) cpm
NRA +2.5 D
PRA -1.25 D
BAF 12cpm (difficulty clearing –ve lenses)
IMPRESSION (IMP)

Hyperopia and Accommodative Insufficiency

Rx OD: +0.75DS 20/20 OS: +0.75DS 20/20 ADD: +1.00DS N5

(Dispensed as a bifocal)
Review was scheduled for the following month.
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

3rd Visit - 10/19/2016

The patient stated the condition had greatly improved. He could read for a longtime without any
difficulty.

Ocular Examination

Slit lamp and funduscopy revealed nothing remarkable.

IMPRESSION (IMP)

No abnormality was Detected.

DISCUSSION

The initial refraction and Binocular vision assessment, it showed a hyperopia of 0.75D for each
eye. Accommodation (AA) was below the expected value for his age which was 3 D instead of 7.75 D.
Near point of convergence (NPC) was receded. Positive relative accommodation (PRA) was also less than
the expected value which was -1.25D instead of -2.50D. Binocular Accommodative Facility (BAF) was
below the expected value of 12 cycles per minute (cpm), he had 5 cpm with difficulty clearing the minus
(-ve) lenses. Other findings were within the normal range. This puzzle suggests strongly that the patient’s
problem is from an accommodative dysfunction rather than a binocular vision anomaly.

He had an amplitude of accommodation of 2D less than the minimum value for that age, failing
of the monocular and binocular accommodative facility coupled with difficulty clearing minus lenses of
±2D flipper lenses, and positive relative accommodation ≤ 1.25 is diagnostic of accommodative
insufficiency.

The foundation for treatment of accommodation and vergence dysfunction is to aid the patient
in performing well in school, at work, and/or in sporting activities Another goal is help alleviate the
visual, bodily, and psychological symptoms of these illnesses.

Vision therapy was prescribed but ineffective because he was compliant enough and as a result
plus lens of 1D was prescribed for near work in addition to the distance correction. The positive lenses
reduced the accommodative demand and as such, he was now relieved of the unbearable ocular
symptoms reported earlier.

REFERENCES

https://www.mathewsopenaccess.com/scholarly-articles/a-case-of-hyperopia-combined-with-
accommodative-insufficiency-in-a-young-adult.pdf
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 29-year-old male with a case of hyperopia combined with
accommodative insufficiency, I found out that he accommodative insufficiency which occurs when the
amplitude of accommodation is lower than that expected for the patient’s age and was prescribed for
vision therapy but was incompliant due to his academic works, on his second visit the patient reported a
slight improvement and was prescribed a +1.00D lens for near work. The lenses relieved the
accommodative demand and now reported great improvements.

Young adults especially college students spend an average time between 1 and 2 hours on
gadgets and millennials spend nine hours per day on gadgets too. For these people to function in their
environment they need the ability to read near everyday activities without the difficulties like
headaches, diplopia, and blurring of vision. This is why we must take care of our eyes even though we
don’t have any family history of ocular problems in the case of this 29-year-old male it was unclear why it
happened. More importantly, evaluate the patient’s life because not everyone has time for vision
therapy.

In closing my understanding of the case, although the cause was not clearly stated, it was
probably due to the increased academic activities which required him to overwork his eyes, It is critical
that these young adults cases are detected and treated as early as possible because more and more
young adults have situations of visual stress which could cause this case.

Terminologies:

Ametropia - a state where refractive error is present, or when distant points are no
longer focused properly to the retina.

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

Myopia - a common vision condition in which you can see objects near to you
clearly, but objects farther away are blurry.

Accommodative insufficiency - a non-strabismic binocular vision anomaly that is characterized by an

inability to focus or sustain focus for near vision.

Near point convergence - (NPC) measurement of the point where the visual axes intersect
under the maximum effort of the convergence.

Binocular accommodative facility- (BAF) tests the patient´s ability to make sudden and accurate
accommodative changes under binocular conditions by reading short and simple words under special
conditions. helps to distinguish primary accommodative from primary binocular abnormalities.

Negative Relative Accommodation-(NRA) a measure of the maximum ability to relax accommodation

while maintaining clear, single binocular vision.

Positive relative accommodation - (PRA) a measure of the maximum ability to stimulate eye
accommodation while maintaining clear, single binocular vision.
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

Vergence facility - testing attempts to assess the ability of the fusional vergence system to
respond rapidly and accurately to changing vergence demands over time
[defined as the number of cycles per minute (cpm) that a stimulus can
be fused through, alternating base-in (BI) and base-out (BO) prisms]

Amplitude of accommodation - (AA) s a measure of the closest point at which the eyes can focus: it is
the range from the far point to the near point in dioptres.

Vision therapy - consists of personalized exercises that make use of lenses, prisms,
filters, occluders, and other equipment— aimed at developing visual
skills and efficiently processing information from the visual system.

Vergence dysfunction - describe a wide range of motor disorders of the visual system and
includes convergence insufficiency, convergence excess, divergence
insufficiency, divergence excess, decompensated heterophoria as well as
inefficient and inaccurate pursuits and saccadic eye movements.

Accommodative Convergence/ Accommodation Ratio (AC/A Ratio)- indicates the relationship between
the amount of convergence produced by a stimulus to accommodate and the amount of accommodation
which produces that convergence.

Objective Refraction - the inital part of the assessment of the refractive error and astimatism (if any).
The objective measurement can be taken using an automated machine called an
'autorefractor' or manually using an instrument called a 'retinoscope'.

Subjective Refraction - is a technique to determine the combination of lenses that will provide the
best corrected visual acuity (BCVA).