NeuroVisual Medicine Network
Case Report 25 -Initial Exam
TITLE: Atypical SOP Correction
Doctor:JLP
SUMMARY OF PATIENT HISTORY
Patient is a 54 year-old female that was returning to our office for an annual neurovisual examination on 8/22/17, following an auto accident on 8/21/2015. Her resulting medical symptoms include dizziness, nausea, anxiety, headaches, neck pain, unsteadiness while walking, light sensitivity, and reading difficulties.
She has been our patient for one year, and has noticed a change in her symptoms in the past month. Her last progress assessment was in November 2016. Her symptoms this past month include an unsteady gait, which is her defining symptom. She is also experiencing nausea and neck pain, especially when in car. She will also get dizzy if she is looking down for too long. Her husband said that she recently fell forward while bending over to get something out of a cabinet. She experiences bouncing vision, especially at night, andhas daily headaches that come about from reading or computer work. She also experiences ear ringing from time to time. She also has a history of migraines.
The patient was referred to an audiologist at her last appointment due to her sound sensitivity, but has not yet made an appointment. She has difficulty in loud settings, she has trouble "zeroing in" on a single sound. She responded well to a noise cancelling device in our office in the past. She has not purchased the device yet.
Presenting Prescription:
Eye / Sphere / Cylinder / Axis / ADD / Vertical Prism / Horizontal Prism / VA Distance / VA NearOD / +0.25 / -2.50 / 15 / -- / -- / -- / 20/25 / --
OS / +0.75 / -2.50 / 170 / -- / 0.75 DN / -- / 20/25 / --
Near clip:
Eye / Sphere / Cylinder / Axis / ADD / Vertical Prism / Horizontal Prism / VA Distance / VA NearOD / +2.00 / -- / -- / -- / -- / -- / -- / 20/20
OS / +2.00 / -- / -- / -- / -- / -- / -- / 20/20
BVDQ Score: 47
SSI Daily =29
Dizziness / Nausea / Anxiety / Headache / Neck Ache / Unsteadiness while walking / Light Sensitivity / Reading DifficultiesDaily / 3/10 / 5/10 / 3/10 / 3/10 / 4/10 / 5/10 / 3/10 / 3/10
Before / 4/10 / 2/10 / 6/10 / 3-4/10 / 2/10 / 8/10 / 0/10 / 3/10
After / 0/10 / 0/10 / 0/10 / 1/10 / 0/10 / 0/10 / 0/10 / 0/10
Pertinent Medical History and Medications:
She is currently taking Lexapro, Ativan, levothyroxine, and cyclobenzaprine
EXAMINATION
Exam FindingsHead Tilt / Right shoulder
Gait Analysis / Before: right drift, arms out for balance, wide stance, wobble / After: smooth, straight gait. relaxed arms and no wobble
Stereopsis / Before: 9/9 / After:N/A
Red Lens Test (OD) / Vertical: Ortho / Horizontal: Ortho
Light Box Test (OD) / Vertical: 0.75 UP / Horizontal: 1.00 IN
Titmus* / Vertical: 4 / Horizontal: 11
Von Graefe Vertical (OS) / Distance: 1.00 DN / Near: 1.00 DN
Von Graefe Horizontal (OS) / Distance: 2.00 IN / Near: 9.00 IN
Cross Cylinder / OD: +2.00 / OS: +2.00
*Titmus( vertical): 4=ortho, Titmus (horizontal):8=ortho
<4=BU OD <8=eso
<4=BU OS >8=exo
9 Positions of Gaze:
*quantity not measured*
With presenting Rx:
+1 OD / +1 OD / 0OD+1 OD / +1 OD / +1OD
+1OD / +1 OD / 0OD
Hypothesis for diagnosis: At this point, I suspected that the patient would need more base down in her left eye.
Visual Fields:Full fields in both eyes, improved from previous visual fields in 2016 (which showed mild to moderate scattered depression in each eye)
Pertinent Trials and responses to trials:
Trial framing with current rx:
-rejected cyl change found in subjective
-rejected more DN OS-made her gait worse
-likes UP OD, 0.75 UP OD best—much smoother gait
Final Prescription: Distance Only
Eye / Sphere / Cylinder / Axis / ADD / Vertical Prism / Horizontal Prism / VA Distance / VA NearOD / +0.25 / -2.50 / 15 / -- / 0.75 UP / -- / 20/20 / --
OS / +0.50 / -2.50 / 172 / -- / 0.75 DN / -- / 20/20 / --
Final Prescription: Near Clip
Eye / Sphere / Cylinder / Axis / ADD / Vertical Prism / Horizontal Prism / VA Distance / VA NearOD / +2.00 / -- / -- / -- / -- / -- / -- / 20/20
OS / +2.00 / -- / -- / -- / -- / -- / -- / 20/20
SUMMARY AND DISCUSSION
- What is the probable etiology of the patient's misalignment?
TBI from the auto accident in 2015.
- What tests support the patient's diagnosis?
All BVD testing supports her prism correction.
- What tests contradict the patient's diagnosis?
I expected the patient to prefer more base down in the left eye. Her symptoms increase in downward gaze, so she fits the SOP profile. In fact, we have her in a reading clip to utilize straight ahead gaze for reading and near-point work. However, upon trial framing, and walking in the hallway, the only prism correction that improved her gait was base up in the right eye.
- Are there other conditions/factors, known or suspected, that may be contributing to the patient's symptoms?
Possible hyperacusis. I encouraged her again at this appointment to follow up with an audiologist, or to purchase a noise cancelling device on her own.
- Was there anything unusual about this case?
Each time this patient comes in, it is her gait that is affected most. Before the prism change, her gait is very wobbly, she holds her arms out to balance, drifts to the right, and has a very wide stance. Her motion is very unnatural and looks like a toddler who is just learning to walk. With the correct prism correction, her gait changes tremendously, and becomes smooth and natural again.