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Mike Tyner
medicine forum Guru
Joined: 24 Mar 2005
Posts: 1299
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 Posted: Sat Apr 15, 2006 5:37 pm Post subject:
Re: 6 year old with low vision & no diagnosis- I thinink we need an advocate
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"William Stacy" <wstacy@obase.net> wrote
| Quote: | Dr L: Have you not
heard of meridional amblyopia?
I have not, admitting to my less than universal knowledge and my weakness
in the game of trivial pursuit.
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How about a high astigmat who didn't correct to 20/20 in their first pair of
glasses?
-MT |
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Dr. Leukoma
medicine forum Guru
Joined: 30 Apr 2005
Posts: 1283
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| Posted: Sat Apr 15, 2006 5:39 pm Post subject:
Re: 6 year old with low vision & no diagnosis- I thinink we need an advocate
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I had a similar situation involving a young girl with high hyperopia.
Her nickname was "puppydog" and she was always at her mother's "apron
strings," i.e. followed her very closely, clumsy, bumped into things.
She had no esotropia, and refracted at +6.50 in both eyes. Initially
she could not be corrected to 20/20 in either eye, but eventually it
came to pass that she developed 20/20 in one eye and remained very
slightly amblyopic in the other eye.
DrG |
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mom2kt
medicine forum beginner
Joined: 07 Apr 2006
Posts: 10
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| Posted: Sat Apr 15, 2006 5:47 pm Post subject:
Re: 6 year old with low vision & no diagnosis- I thinink we need an advocate
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William Stacy wrote:
| Quote: | mom2kt wrote:
Here is the information I'm trying to decipher from her chart...
(forgive me if I am incorrect in how I write this, the handwriting is a
bit tough to read and quite frankly, it's like learning a foreign
language to me)
age: 2.5 years:
static
OD +2.00+100x90
OS +2.75+75x90
Good eye movements, no restrictions. reflexes bright and normal o.y.
normal pupillary reflexes. Could not get patient to respond to
richmond paddle, or broken wheel test.
Did she get glasses at that time? No
age: 3.5 years:
left eye: 20/30
right eye: 20/40
static
OD +150
OS +150
broken wheel at 50 (assume cm?)
I take it no glasses from this exam? You are correct, no glasses yet.
age: 4.5 years:
Unaided acuity OD 200, OS 200 CU 200
Near acuity OD 20/70, OS 20/70, OU 20/70
static
OD +6.50
OS +6.50
Book ret.
OD +800
OS +800
Seems like a different child, but more likely a better exam/examiner. Same child, same examiner.
New RX
+400 (R20/140, L20/200)
+600 (R20/140, L20/200)
+200 (R20/140, L20/200)
I suppose that was her bifocal Rx? At least her first "full power Rx"
which it is not at all surprising that she would have low acuity at far
until her accommodation settles down. I'll bet she was better than 20/70
with that Rx within a day or so of full time wear. She did wear them
full time, right? Right????
She still didn't get glasses at this point. She wouldn't cooperate for dilation that day so we decided to go to another doctor and get an optomap and (dilation - if necessary) from another dr. We have a very shy child and we didn't want her regular dr. to upset her and then not be able to work with her after that.
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| Quote: | NPC 4" / 8"
Pursuits: gl. jerky (I guessed at these words- very difficult to read)
Normal eye movements, no restrictions, reflexes bright and normal.
stereofly - only fly
No sign of a cover test or even a Hirschberg/angles Kappa yet. May be
an incompetent doc.
I'm not sure what these tests are. There are a couple more notes in |
her file, but since I can't make heads nor tails out of them, I didn't
include it.
| Quote: |
It was after this appointment that our doctor told us to see our
pediatrician and request an MRI and neurologist visit. We did and that
was when they found the cyst in the pineal region (an incidental
finding?).
Since then, we have been working on trying to find out what caused her
vision loss and why it doesn't correct out.
Normal eye movements - no restrictions,
How long did she actually wear the strong bifocals? We still didn't have bifocals. We only received regular glasses 6 weeks after the initial yearly exam. I can't tell you what the prescription was because I can't understand the chart. Here's what it states.
retinoscopy: od +6.00-1.00x170, os +6.00-1.25x020 |
subjective: od+5.00-1.00x170, os+5.00-1.25x020 * compromised rx to
improve adapt.
| Quote: |
1.5 months later, we went to another eye doctor. He did that test with
the machine and the balloon while her eyes were not dilated and then
dilated. Here are the results of that:
Not dilated 1st test: right eye +3.75-.5 135 reflex 27
left eye -2.00-.5 156 reflex 44
Not dilated 2nd test: right eye +1.50-1.25 168 reflex 77
left eye -.25-1.75 20 reflex 57
dilated 1st test: right eye +6.25-0.75 174 reflex 55
left eye +6.00-1.25 21 relex 56
dilated 2nd test: right eye +6.50-1.25 167 relfex 26
left eye +5.50-1.25 21 reflex 63
The child needs to wear an Rx full time and recheck the acuities and
manifest refraction AFTER she has kept them on all day, every day for at
least a week. If you don't do that, of course you will get garbage. The
poor thing can't decide whether she wants uncomfortable clear double
vision or comfy blurred single vision. And her accommodative response
will be wound up tighter than a 7 day clock making a real binocularity
evaluation impossible. The full time Rx will settle that all down and
give her clear single vision.
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Upon receiving her glasses, she has been wearing corrective lenses of
some sort everyday since then. (Since August 2004) We've done
patching, we've added the bifocals, and now we've added the contacts.
We've had four different pairs of glasses and numerous different pairs
of contacts since then. She just went back to single vision glasses
yesterday.
| Quote: | I suspect she is a normal little hyperope who's been misdiagnosed and
mistreated several times. S**t happens...
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Do you really think that 4 different ophthalmologists and optometrists
(plus various specialists at Cal) all misdiagnosed her for the past 1.5
years? They all seemed to be stumped and we have become a ping pong
ball that is paddled between the fields of ophthalmology/optometry vs.
neurology.
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mom2kt
medicine forum beginner
Joined: 07 Apr 2006
Posts: 10
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| Posted: Sat Apr 15, 2006 5:50 pm Post subject:
Re: 6 year old with low vision & no diagnosis- I thinink we need an advocate
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This is very encouraging! How long did it take for her vision to
improve once she started wearing corrective lenses? Am I correct in
assuming that once a child learns to relax using their corrective
lenses, then they could possibly accept more and more correction until
they correct out fairly normal vision? |
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William Stacy
medicine forum Guru
Joined: 01 May 2005
Posts: 1177
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| Posted: Sat Apr 15, 2006 5:57 pm Post subject:
Re: 6 year old with low vision & no diagnosis- I thinink we need an advocate
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Mike Tyner wrote:
| Quote: | "William Stacy" <wstacy@obase.net> wrote
Dr L: Have you not
heard of meridional amblyopia?
I have not, admitting to my less than universal knowledge and my weakness
in the game of trivial pursuit.
How about a high astigmat who didn't correct to 20/20 in their first pair of
glasses?
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Of course. I guess I see why that could be called "meridional
amblyopia" but I would prefer something like "astigmatic macular
deprivation" or something. Anything but amblyopia, which to most people
means one eye not correcting up as well as the other, aka lazy eye, due
to strab or aniso.
w.stacy, o.d. |
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William Stacy
medicine forum Guru
Joined: 01 May 2005
Posts: 1177
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| Posted: Sat Apr 15, 2006 6:13 pm Post subject:
Re: 6 year old with low vision & no diagnosis- I thinink we need an advocate
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mom2kt wrote:
| Quote: | Seems like a different child, but more likely a better exam/examiner. Same child, same examiner.
New RX
+400 (R20/140, L20/200)
+600 (R20/140, L20/200)
+200 (R20/140, L20/200)
I suppose that was her bifocal Rx? At least her first "full power Rx"
which it is not at all surprising that she would have low acuity at far
until her accommodation settles down. I'll bet she was better than 20/70
with that Rx within a day or so of full time wear. She did wear them
full time, right? Right????
She still didn't get glasses at this point. She wouldn't cooperate for dilation that day so we decided to go to another doctor and get an optomap and (dilation - if necessary) from another dr. We have a very shy child and we didn't want her regular dr. to upset her and then not be able to work with her after that.
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OK now I think that first doc was incompetent. Anyone who doesn't
immediately correct a highly hyperopic child dilation or not is not
dealing with a full deck.
| Quote: |
It was after this appointment that our doctor told us to see our
pediatrician and request an MRI and neurologist visit.
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Based on what? He never even tried to correct her!
| Quote: |
Do you really think that 4 different ophthalmologists and optometrists
(plus various specialists at Cal) all misdiagnosed her for the past 1.5
years? They all seemed to be stumped and we have become a ping pong
ball that is paddled between the fields of ophthalmology/optometry vs.
neurology.
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She might be having fun with all of you. I can't say I blame her. I'd
just relax for a while. Maybe get a Snellen chart of your own and
casually, without pressure, check her acuities WITH GLASSES ON. Set it
by the TV. Turn off the sound when a program she likes is on and tell
her you'll turn it back up when she reads the next row. Baby steps. Get
several chart versions so she doesn't memorize it all. I'll bet you get
her back to 20/30 or better in no time.
w.stacy, o.d. |
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William Stacy
medicine forum Guru
Joined: 01 May 2005
Posts: 1177
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| Posted: Sat Apr 15, 2006 6:16 pm Post subject:
Re: 6 year old with low vision & no diagnosis- I thinink we need an advocate
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mom2kt wrote:
Am I correct in
| Quote: | assuming that once a child learns to relax using their corrective
lenses, then they could possibly accept more and more correction until
they correct out fairly normal vision?
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Voila! |
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Mike Tyner
medicine forum Guru
Joined: 24 Mar 2005
Posts: 1299
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| Posted: Sat Apr 15, 2006 6:16 pm Post subject:
Re: 6 year old with low vision & no diagnosis- I thinink we need an advocate
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"William Stacy" <wstacy@obase.net> wrote
| Quote: | Of course. I guess I see why that could be called "meridional amblyopia"
but I would prefer something like "astigmatic macular deprivation" or
something.
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Mm.. As I understood it, the pathophysiology is the same as amb ex anopsia.
In "meridional" the effect is limited to the retinal receptive fields with
less favorable orientations in each eye.
A +600 -400 x 090 might grow up without ever seeing horizontal lines.
-MT |
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William Stacy
medicine forum Guru
Joined: 01 May 2005
Posts: 1177
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| Posted: Sat Apr 15, 2006 6:24 pm Post subject:
Re: 6 year old with low vision & no diagnosis- I thinink we need an advocate
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Mike Tyner wrote:
| Quote: | "William Stacy" <wstacy@obase.net> wrote
Of course. I guess I see why that could be called "meridional amblyopia"
but I would prefer something like "astigmatic macular deprivation" or
something.
Mm.. As I understood it, the pathophysiology is the same as amb ex anopsia.
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Amblyopia can be very deep, 20/200 or worse, whereas "bilateral" types
are usually much shallower and often very temporary. Dare I say it, but
sometimes the cyl is not adequately corrected? Anyway, I think the
classical definition of amb. implies, even begs for a strong unilateral
component. I think the pathophys. is way different.
w.stacy, o.d. |
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mom2kt
medicine forum beginner
Joined: 07 Apr 2006
Posts: 10
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| Posted: Sat Apr 15, 2006 6:33 pm Post subject:
Re: 6 year old with low vision & no diagnosis- I thinink we need an advocate
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William Stacy wrote:
| Quote: | mom2kt wrote:
Additionally, at 3.5 years old, her vision was 20/30 left eye and 20/40
right eye Without corrective lenses.
Was one eye turning inward (seriously crossing) during the above test?
If not, then I'm having trouble believing your story, as high hyperopia
doesn't develop after age "3.5", unless something is pushing on the eyes
from behind, and I take it bilateral retrobulbar masses have been ruled out?
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Well, I guess you'll have a hard time believing my story, but NO her
right eye was not turning inward at that point. In fact, it wasn't
until about March 2005 (5.5 years old) that her eye doctor became
concerned with the fact that it was slightly turning inward. The
patching helped and we were told to stop patching. Eventually, the
inward turn slowly came back, only this time, it was much worse.
| Quote: |
We started seeing a new eye doctor in December and that is when talk of
contacts came up.
Came up? Who brought it up?
I inquired about it. The reason I did was because I noticed her |
looking above her glasses a lot. Additionally, her inward turn was
very pronounced at that point. Yes, when she used her glasses
correctly and didn't look over or under them, then her eye was
straight. But kids will be kids and it just wasn't working for her.
The doctor agreed to give contacts a try.
| Quote: |
Yes, our daughter was excited about the idea, but
what six year old with heavy bifocals wouldn't be?
Heavy bifocals? At that age they are tiny and very light weight.
Again, whose idea were the contacts?
Yes they are tiny, but no they are not VERY light weight. She is a bit |
sensitive to light so we opted for clip on sunglasses which just made
the weight unbearable, especially in the summertime heat. The place we
purchased her glasses from was not able to do her bifocal prescription
in light weight lenses with the Transitions. Hence, the heavy glasses.
| Quote: |
She has suffered
teasing from other kids telling her that her glasses were broken long
enough.
Long enough? For how many years did the child wear bifocal glasses?
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Obviously you are not a parent... Who can tolerate teasing of child
for any length of time? To answer your question, we got the bifocals
around the same time we started patching (March 2005)
| Quote: |
The contacts are incredible for straightening the right eye!
She doesn't complain about her eye looking at her nose anymore!
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I took the school district vision specialists with me to the
appointment when my daughter got her contacts. We were both absolutely
amazed at how her eye went straight the second that lens was put in.
The vision specialist at the school still comments on how profound the
change.
| Quote: |
Wrong answer. The contacts will not do as good a job as a spectacle
bifocal if one is warranted. Your credibility has gone negative.
w.stacy, o.d. |
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Neil Brooks
medicine forum Guru
Joined: 24 Mar 2005
Posts: 1148
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| Posted: Sat Apr 15, 2006 7:29 pm Post subject:
Re: 6 year old with low vision & no diagnosis- I thinink we need an advocate
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Ok, Docs ... I'm way out of my depth here, but this kid sounds like me
at that age.
How about:
- full Atropinised (x 4days) toric Rx in soft CLs
- over Rx prisms for non-accommodative component of 'tropia??
- perhaps bifocal to assist in near work (with prism included)
Monitor oh-so-closely for variations in refractive error, alignment, or
changes in accommodative function.
If this tends to work, I'm thinking evaluate for ICL (provided anterior
chamber depth is adequate) and--if the non-accommodative portion
warrants--strabismus surgery.
Thoughts? |
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CatmanX
medicine forum Guru
Joined: 17 May 2005
Posts: 367
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| Posted: Sun Apr 16, 2006 11:36 pm Post subject:
Re: 6 year old with low vision & no diagnosis- I thinink we need an advocate
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Sorry Neil, but this is not a good option, not for some time at least.
Before you start stuffing around with surgery, you need to know exactly
what is going on.
Given the kid is +6.00 and a bilateral amblyope with straight eyes, it
is a pretty easy diagnosis as to why she is the way she is. There are 3
presenting types for high hyperopes.
1) Want things clear, so accommodate and get turn and dense amblyopia
due to turn and misalignment.
2) Want things clear, so accommodate somewhat, get accommodative spasm
and end up with anisometropic amblyopia. Script roughly plano in one
eye and +6.00 in the other. As eyes are straight, amblyopia is less
dense as it is only due to blur, not suppression.
3) This kid: lets things stay blurry, is clumsy and lives in a blur.
Eyes stay straight due to defocus, amblyopia develops in both eyes due
to defocus, easy enough to get vision restore with correct
prescription, maybe some patching/occlusion required.
dr grant |
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mom2kt
medicine forum beginner
Joined: 07 Apr 2006
Posts: 10
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| Posted: Tue Apr 18, 2006 8:30 pm Post subject:
Re: 6 year old with low vision & no diagnosis- I thinink we need an advocate
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Our HMO has decided that our daughter now needs an OCT scan and a new
plan doctor before they will provide a referral to a
neuro-ophthalmologist. Can anybody tell me what this test looks for?
How is it done? I've been told that she will not be sedated -
therefore, I assume it's a fairly quick non-invasive procedure?? |
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