Optometrist's Note

Date of Examination: 14/05/2024

• Glasses prescription issued OD: -1.75 / -0.50 x 095, Dist Prism: Nil, VA: 6/6, Near Add: +1.75, Near Prism: Nil, Near VA: N5; OS: -2.00 / -0.75 x 085, Dist Prism: Nil, VA: 6/6, Near Add: +1.75, Near Prism: Nil, Near VA: N5

• Dispensing recommendations Advised varifocal lenses with anti-reflective coating (MAR) for VDU use and night driving. Discussed occupational lenses as an alternative for prolonged desk work.

• Treatments: sodium hyaluronate 0.1% (Hylo-Tear®) 1 drop OU QID PRN for dry eye symptoms; warm compresses and lid hygiene BD.

• Follow-Up: 24 months for routine sight test. Return sooner if experiencing flashes, floaters, sudden vision loss, or persistent ocular pain.

• Patient Education: Discussed presbyopia progression and expected adaptation period for first-time varifocal wear. Advised on the 20-20-20 rule to manage digital eye strain and demonstrated proper lid massage technique for meibomian gland dysfunction.

• Referrals: None required at this stage; routine community optometry management.

Current Glasses

OD: -1.50 / -0.50 x 090; OS: -1.75 / -0.50 x 085 (Distance only, measured via focimetry, 3 years old).

Subjective

• Chief Complaint: Gradual blurring of near vision over the past 6 months and mild end-of-day asthenopia.

• History of Present Illness: 49-year-old female reports difficulty reading small print and focusing on her smartphone, especially in dim lighting, requiring her to hold material further away. Also notes mild, intermittent grittiness OU after prolonged computer use. Distance vision feels slightly less sharp when driving at dusk. Denies diplopia, photopsia, new floaters, or ocular pain.

• Past Ocular History: Myopia and astigmatism since adolescence. Last sight test 3 years ago. No history of ocular trauma, amblyopia, strabismus, or eye surgery.

• Medical History: Hypertension (diagnosed 2021, well-controlled). No diabetes mellitus.

• Medication History: amlodipine 5 mg PO OD.

• Allergies: Penicillin (rash).

• Family Ocular History: Mother has primary open-angle glaucoma (diagnosed age 68); father had age-related cataract surgery.

• Social History: Non-smoker, social alcohol intake (4 units/week). Works as an accountant (8 hours/day VDU use). Drives daily.

• Other information Patient is keen to avoid switching between multiple pairs of spectacles at work.

Objective

• Vision: OD: 6/24; OS: 6/30

• Pinhole Vision: OD: 6/7.5; OS: 6/7.5

• Visual Acuity: OD: 6/7.5; OS: 6/7.5

• Retinoscopy: OD: -1.75 / -0.50 x 095; OS: -2.00 / -0.75 x 085

• Intraocular Pressure: Goldmann Applanation Tonometry at 14:15: OD 15 mmHg, OS 16 mmHg. Normal diurnal range.

Anterior Segment

Slit-lamp biomicroscopy performed under diffuse and focal illumination.

• Lids and lashes: Mild meibomian gland capping OU; lashes clean, normal lid apposition OU.

• Cornea: Clear and avascular OU. Trace inferior punctate epithelial erosions with fluorescein staining OU. Tear breakup time (TBUT) 7 seconds OU.

• Anterior Chamber: Deep and quiet OU, no cells or flare. Van Herick grade 4 (wide open angles) OU.

• Pupil Reactions: PERRLA, no RAPD.

• Media: Clear OU, no pigment or Shafer's sign.

• Lens: Clear OU, trace nuclear sclerosis consistent with age.

Posterior Segment

• Macula: Flat, healthy, positive foveal reflex OU, no drusen or pigmentary changes.

• Peripheral retina: Flat and intact 360 degrees OU, no holes, tears, or detachments.

• Optic Discs: Pink, distinct margins, healthy neuroretinal rim obeying ISNT rule OU. C/D ratio 0.35 round OU.

• Retinal Vessels: Normal calibre and tortuosity, A/V ratio 2:3 OU, no AV nipping.

Indirect fundus biomicroscopy performed using a 90D Volk lens; undilated examination achieved good views.

• Additional Tests: Humphrey 24-2 SITA Fast Visual Fields (performed due to FHx glaucoma): Full and reliable OU. Macular and ONH OCT: Normal retinal nerve fibre layer (RNFL) thickness and intact macular architecture OU.

Assessment

• Binocular Refraction: Cover test: 2 Δ exophoria at distance, 4 Δ exophoria at near with rapid recovery. Ocular motility full and smooth in all positions of gaze, no pain or diplopia. Mallett unit: No fixation disparity at distance or near.

• Foveal Suppression: No suppression detected on Mallett unit OU.

• Refraction Notes: Binocular balance achieved via Humphriss immediate contrast method; +0.25 DS binocular addition accepted comfortably. Near addition determined for 40 cm working distance with comfortable range 33 cm to 60 cm.

• Compound myopic astigmatism (H52.13), Presbyopia (H52.4), and Evaporative dry eye syndrome / Meibomian gland dysfunction (H02.889).

• Computer vision syndrome / digital eye strain.