Case Questions
Chief Complaint: I am squinting
Demographic
Age: 9
Biological sex: Female
Race: Asian
Ethnicity: Not Hispanic or Latino
Medications
None
Before you continue, what questions do you want to ask this patient?
ROS
Constitutional: Denies
Genitourinary: Denies
ENT: Denies
Musculoskeletal: Denies
Cardiovascular: Denies
Neurologic: Denies
Pulmonary: Denies
Psychiatric: Denies
Endocrine: Denies
Immunologic: Denies
Dermatological: Denies
Hematologic: Denies
Gastrointestinal: Denies
Obstetrical: Denies
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Pachymetry/topography to rule out keratoconus
OCT macula to rule out retinal pathology
VEP to rule out amblyopia
Format: [Testing] [Reason]
Example: Fundus photos to rule out retinal disease
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Refractive Amblyopia, OD
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Patient and parent educated on findings. Dispensed full spectacle Rx for patient: OD -2.00-3.50x180, OS -1.50-1.00x180; with polycarbonate lenses. Discussed importance of full time wear of glasses. RTC 3 months for VA and stereoacuity check. Consider future referral to vision therapy if VA/stereo not improved.
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Patient and parents educated on the diagnosis of amblyopia, which is reduced vision in one or both eyes due to abnormal visual development, often caused by strabismus, refractive error, or visual deprivation. In this patient's case, the amblyopic eye is a result of an asymmetric refractive error between the two eyes. Prognosis is good with full time spec wear, but additional treatment such as patching or atropine treatment may be required if spectacles do not work. Full time spectacle wear is crucial for proper binocular vision development. RTC immediately if symptoms such as eye turn, double vision and headaches occur.