3. HISTORY
NAME:NE
AGE: 53YRS
SEX:MALE
ADDRESS:MULAGO
C/O: Becoming difficult to focus for close work.
4. HOPC
• 53 year old with no known chronic illnesses presented with a 5 year h/o
difficulty reading small letters that are within arms long distance from self
associated to headachae and tearing,no h/o straining and pain on
prolonged reading of small letters
• No h/o itching,foreighn body sensation.No h/o traditional eye medicine
• ROS: unremarkable.
5. Past Ocular History
No h/o of traditional eye medicine use.
No h/o ocular surgery
No h/o use of spectacles
6. Past Medical and surgical History
Past Surgical Hx: not had any surgeries before
Past medical history:
no h/o DM,HTN
no h/o drug or food allergies
Seronegative
7. FSHx:
Father to 3 children
No familial illnesses reported
welder
8. GENERAL EXAMINATION
GENERAL EXAMINATION:
Middle-aged,no jaundice,anaemia,oedema,lymphnodes,dehydration
SYSTEMIC EXAMINATION:
RS:19bpm,not in distress,equal air entry bilaterally,normal breath sounds
CVS: BP; 124/64mmHg,PR; 68bpm,H1and 2 normal
P/A: normal fullness,no palpable organs.
10. Objective refraction:
With movement
Neutrality obtained
Working distance considered algebrically
11.
12.
13. Refraction report:
Objective refraction:
R +0.5 6/7.5
L +0.5 6/7.5
Subjective refraction:
R plano 6/7.5
L plano 6/7.5
Add +2.00DS 0.4 M @ 40 cm
14. Subjective refraction:
Placed the results of the objective refraction in the trial frames
We occluded both eyes in an alternating format and patients told to
identify the clearest line of letters.
The plus and minus lenses were presented
Patient preferred minus lense
15. Funduscopy:
• Sharp margins of the disk with normal colour
• Small central cup
• Arterials and venules have normal colour and course
• Background of normal colour
• Macula enclosed with arching temporal vessels.
17. SLE
Paremeter OD OS
External Normal Normal
Lids Normal Normal
Conjuctiva Light brownish changes Light brownish
discolouration
Cornea Clear Clear
A/C Deep and quiet Deep and quiet
Iris Flat and normal Flat and normal
Pupil CRRL CRRL
Lens Clear Clear
EOM Full Full
19. Management:
I suggested reading glasses since his main concern was trouble reading text
in arms distance
I proposed the idea of bifocals but because of financial issues,…
Progressives….
20. Summary
Hx: A 53 year old with a 5 years h/o difficulty reading small letters within arms
distance associated to headache and tearing
O/E: Light brownish discolouration of the conjunctiva
Ocular exam: brownish discoloration of the conjunctiva
Presenting Va: OD 6/5 OS 6/5
Refraction report:
Objective refraction:
R +0.5 6/7.5
L +0.5 6/7.5
Subjective refraction:
R plano 6/7.5
L plano 6/7.5
Add +2.00DS 0.4 M @ 40 cm
22. Definition
A gradual (slow) loss of accommodation as we grow older is called
presbyopia.
People that are aged 40-45 years are affected by presbyopia
People with presbyopia find it difficult to read or do any nearby task.
23. Epidemiology.
Globally,1.09 billion people are estimated to be affected by presbyopia.
The prevalence of presbyopia is estimated to be 35% in people aged 35
years and older and increases to 40% for people aged 50 years and older.
The women are more affected than the men.
24. Etiology.
Presbyopia is caused by the loss of accommodation ability that is
associated with ageing.
As we get older,the crystalline lens gradually gets harder and cannot
change shape easily when the ciliary muscle contracts.
People often make a mistake of thinking that presbyopia is due to
weakness of the ciliary muscle but this is not true.
27. Symptoms of uncorrected presbyopia.
I can read in bright light but not in dim light.
My arms are not long enough
My arms feel strained when I do a lot of sewing.
My eyes get tired when I read
The writing in the news paper is too small
I find it difficult to thread a needle
I find it hard to sort the stones from the rice when am cooking
The distance looks blurred when I look up after I have been reading for
along time.
28.
29. Refractive error and presbyopia
If a person has myopia or presbyopia,it will affect when they will need to
get spectacles for close work.
Lets look at an emmetrope,myope and hyperope
1. Never worn spectacles before
2. Having trouble with vision
3. All are 44 and share the same hobbies
All the 3 men have early presbyopia
31. What is his near vision like?
Only 4D of accommodation left.
F=100/F 100/4 25cm.
Asthenic symptoms like headachae and blurred vision.
32. A person can usually spend ½ of their total accommodation to spend a long
period of time without getting tired.
Half of his accommodation is 2D.
This will allow him to se objects that are 50cm away from him comfortably.
Remember:
f=100/F =100/2 =50cm.
You ask the man to show you how far away he likes to hold his newspaper and
you measure the distance to be 40cm.
33. This man will have difficulty reading his newspaper and will need reading
glasses to help him see.
Let imagine the man is 60 years of age?
He has no accommodation left and images will appear blurry and so needs
reading glasses to read his newspapers clearly.
34. Hyperope:
With a distance refractive error of a +2.00D
What is his distance vision like?
It will still be blurry unless he accommodates.
½ of his accommodation for (4/2) for long
periods without tearing his eyes
he will be able to see clearly and comfortably
In the distance by using half of his total
accomodation.
35. Time travel…
Now imagine the same man is 60 years of age
He has no accommodation left at all so his distance vision will be blurry.
This man will need spectacles to see the television clearly.
36. What is his near vision like?
With 4D of accommodation left,he can use all his accomodation to see things that
are only 50cm away from him
He has 2D to compensate for the 2D of hyperopia for distance vision and the
remaining 2D to look at near objects.
F= 100/F = 100/2 =50cm.
37. With the remaining 2D of accommodation,he will be able to see something that is
50cm away clearly
This means he cant read newspapers at a distance of 40 cm
If the man prefers to hold the newspapers at a distance of 50cm,he will use all his
accommodation(2D) to keep the near object clearer.
After long periods of reading,his eyes will get very tired and will certainly develop
asthenopic symptoms.
So he needs spectacles to read newspapers or else the images will appear blurry.
38. Time travel…
Now imagine the same man is 60 years old
He has no accommodation left and his vision will be blurry at all distances.
At 60,the man needs spectacles to read newspapers and see the television
clearly.
39. MYOPE:
A person with a distance refractive error of -2:00D
Some presbyopic myopes can see their close work clearly when they remove their
distance spectacles
What is the distance vision like?
40. Accomodation will not make his distance vision better.
Accomodation doesn’t affect myopia
Television will be blurry
He needs to wear spectacles to see clearly in the distrance.
41. Time travel:
We imagine the same man being 60 years old
He has no accommodation left but this still will not affect his distance
vision
He will need spectacles to see the television clearly as his distance vision
will be blurry.
42. what is his near vision like?
This man has myopia
The mans myopia is -2.00D.
f= 100/F =100/2 =50cm.
43. Because he has 2D of myopia,he has to be 50cm away from something if
he wants to see it clearly without spectacles.
However,if this man wants to see something that is closer than 50cm from
his eyes,then he will need to use accommodation.
A -2.00D myope has an extra has an extra 2D of forcusing power in his eye.
The extra 2D is from his myopia not his accomodation
44. So the man has a total power of 6D.
So if he is not wearing his distance spectacles,this man has a total of 6D
near forcusing power in his eye.
With this power,he can see things that are approximately 17cm away from
him.
Remember
f= 100/F =100/6 =16.7cm
45. If he uses all his forcusing power to see something 17cm away from him
for a long period of time, he will get very tired eyes.
If a person wants to spend along period of time doing near work,they can
usually use half of their total accommodation without getting tired.
His total accommodation is 4D
½ of his total accommodation is 2D.
46. This means he can use 4D of forcusing power.
This will allow him to see an object that is 25cm away from him
comfortably without getting tired.
Remember:
f= 100/F =100/4 =25cm.
If he holds anything closer than 25cm from his eyes,his eyes will get tired
after sometime.
47. But this man only wants to hold his newspaper 40cm away from him.
40cm is closer than 50cm so his myopia will not cause the newspaper to
be blurry.
40cm is further away than 25cm so he will be using less than ½ of his total
accommodation.
This man can see clearly and comfortably when reading his newspaper at
40cm without spectacles
48. Time travel…
Imagine the myope is 60 years old!
He has no accommodation left but he has his myopic forcusing power of 2D.
If something is exactly 50cm away from his eye,it will be clear without using any
accommodation.
This is because he is using his myopic forcusing power
f= 100/F =100/2 =50cm
49. So anthting less than 50cm from his eyes will require accommodation to
make it clear.
But at 60 with all accommodation gone,anything closer than 50cm will be
blurry
If the man is happy to hold the newspaper 50cm away from his eyes,he will
not need reading spectacles.
But if he wants to hold his newspaper 40cm away from him and still see it
clearly,he will now need reading spectacles.
50. Astigmatism and presbyopia
The person with astigmatism has poor vision both at near and at
distance,if they are not wearing the correct spectacles.
Every one including people with astigmatism gets presbyopia when they
get older.
Considering the three men mentioned above,what would happen if they
had astigmatism?
53. Methords for determining presbyopia
Tentative add methord:
Age/10-3.50D
For those who are < 55 years of age
Using the amplitude of accommodation:
2.50D-2/3 of amplitude of accommodation
54. Age expected addition:
From 40-42 +0.75D
From 43-45 +1.00D
From 46-47 +1.25D
From 48-50 +1.50D
55. Near addition:
Positive spherical lens power
Added to the hyperopia,myopia or astigmatism spectacle prescription.
Total power of the final spectacle prescription that will be needed for n ear
work.
The near addition will be the same for both eyes
56. Hyperopia or myopia or astigmatism
spectacle prescription
+
near addition
=
Reading/near spectacle prescription
57.
58. Reading spectacles:
Presbyopia is corrected by a pair of reading spectacles.
They make close vision clearer but distance vision blurry.
Second pair of spectacles to use for distance.
Near spectacles Vs distance spectacles
59.
60. Bifocal spectacles:
Near and distance focusing with only one pair of spectacles.
Two parts: top and bottom
Some bifocals have plano lenses in the top part of the lens for emmetropic
presbyopes
Some bifocals have plano lenses in the bottom part of the lens for myopic
presbyopes.
61.
62. Progressive spectacles:
Many names:PALs,graduated lenses,multifocal lenses,…
No line to separate the different parts
Provide clear intermediate distance.
Engravings
The disadvantage is that the vision gets blurry as one looks through the sides
of the lens
63. Presbyopic correction in contact lens
wear
Reading glasses/single vision contacts
Monovision
Bifocal contact lenses
Readers:
A reading spectacle worn over a contact lens distance has excellent
functional efficiency
64. MONOVISION
Lets take an example of a 60 year old who says they can see very well in distance
and very well in near.
How is this possible?
Remember: A 60 year old has no accommodation
Emmetropic
Myopic
Hyperopic
astigmatic
65. It is better to undercorrect than to over correct
The prisms relieve the convergency and the spheres relieve the
accommodation
66. Remember the lady uses both her eyes
Could the eyes be having different refractive errors?
What combination of refractive errors could help the lady see clearly at
both distance and near?
The lady has a combination of emmetropia and myopia
67. She uses the emmetropic eye to see the workers in the field and the
myopic eye to read the newspapers.
This is called monovision because she is only using one eye at a time
The brain chooses the clearest image depending on what distance she is
looking at.
68. Monovision and early cataract:
Sometimes an early cataract will cause myopia in one eye referred to as
“second sight”
Monovision and cataract surgery:
IOLs are available in different focusing powers
A cataract surgeon usually chooses IOL powers that will give the patient
emmetropic in both eyes
Sometimes the surgeon will choose an IOL for one eye which will make it
slightly myopic and a different IOL for the other eye that will make it
emmetropic.
69. Bifocal contact lenses:
Different variations;aspherical,..
Dominant and non dominant eye
Multifocal lenses
Popular asheric designs
70.
71. REFERENCES:
1.American Academy of Ophthalmologists
2.Dictionary of optometry and visual science
3.Principles and practices of ophthalmology
4.Duke-Elders practice of refraction
