Blur: the chief complaint that is music to our ears. When we hear that, especially as a new clinician on the clock, we think phew! This one should be straightforward. A little plus or a little minus with a dash of regular astigmatism correction will solve this problem. But you may soon discover, it’s not always so basic. Let’s solve this case and try to answer the questions as you read.
G.O. 10 year old Caucasian male, comes into the clinic with mom for his first eye exam.
Chief complaint: Blurry vision
Before asking the next few HPIs, keep in mind that this is a 10 year old boy who may not be able to answer those “precision questions” such as “how long has this been happening” and “how many hours a day do you notice it?” Questions that would be the most fruitful include:
- Is it far away or up close? “up close”
- Does anything make it better? “stop reading or wearing readers”
- Do you ever get headaches when things get blurry? “yes”
You, being the astute clinician, wonder about the origin of the reading glasses since this is his first eye exam. Do they belong to a parent, did he borrow them from a friend? Upon further inquiry, mom reveals that G.O. has been wearing self-prescribed OTC +1.50 readers to help with the “blur”. The glasses were a result of trial and error while waiting in line at the local department store. However, patient does report that the glasses help reduce the symptoms at near.
Let’s pause. Based on his chief complaint and the information disclosed by patient and mom, what do you expect to find in the rest of the exam? Let’s assume all ocular health finding are unremarkable, what could be on your list of differentials?
Hyperopia is one possibility since he is wearing the +1.50 readers to help him see clearly up close. If that is the case, you could expect his uncorrected near visual acuity to be reduced. Here are the findings:
- DVA: 20/15 OD, OS, OU
- NVA: 0.4/0.4M OD, OS, OU
- Retinoscopy: +0.75DS OU
So, would refraction solve the problem? Most likely not because his low hyperopia can be corrected by his robust accommodation system – he is 10 years old!
Let’s reassess the chief complaint. Blur at near, which is accompanied by headaches. Perhaps it has a binocular vision component, and if so, what type of ocular posture would be relieved by a plus lens?
- DCT: ortho
- NCT: 4EP’
- BI ranges @ near: 6/10/8
- AC/A: 4/1
Diagnosis: Basic Esophoria with reduced compensating ranges
Light bulb! With the +1.50 OTC readers, the originally decompensated phoria now falls within normal limits. The patient’s ocular posture moves from 4EP’ to 2XP’ thus relieving his symptoms at near. But, consider this: does he actually need the full +1.50? These glasses were picked out without proper testing after all, so it’s possible that a lower add power such as +1.00 would relieve his symptoms without decreasing the near point of focus. A little plus goes a long way – words to live by.
- NCT with +1.00: ortho
- Final Rx: +1.00 DS OU for near work and a happy patient!
So here are some lessons learned from this, not so basic, case
- Blur does not always mean decreased visual acuity. It can often be interchanged by patients for discomfort so make sure you dig a little deeper in the case history.
- Beware of the closet Esophore. Always perform a good cover test, even in Primary Care.
- Confirm your findings and prescribe accordingly. Even if the patient tells you they stumbled upon an option, reassess the diagnosis and give them the best solution.