You know the old clinical maxim: You may not see a certain type of case for awhile, and then several of them seem to show up in quick succession. We feel that way with Jersey Shore weather patterns of late after having been spoiled by a mild and storm free winter until late January. Just when the waters have receded and the beach is trying to return to normal following Winter Storm Jonas, the full moon strikes with high tide overnight, and coastal flooding is again of concern in the morning hours tomorrow – right about the same time that Governor Christie mops things up in the New Hampshire primary.
Well that’s the way it seems with appreciable latent hyperopia. We can go for weeks without seeing a patient who has a significant difference between dry and wet conditions, and then have several within days of each other who unleash a torrent of plus power on cycloplegia, prompting the search for a full moon.
The many faces of hyperopia are revealed in the AOA CPG on the subject about which we blogged last week. Sure enough, the very next day, Brayden came in to my office, a young hyperactive 5 year-old with accommodative esophoria and high bilateral latent hyperopia. This afternoon I saw Megan an 8 year-old whose mother reported to be capable of grade level reading, but shied away from books.
Megan had failed her school screening. Nothing on the school nurse’s form indicated why, and when I looked at the open view autorefractor data from diagnostic testing she appeared to near emmetropia in the right eye (+0.50) but close to +3.00 in the left eye. Keystone Visual Skills testing showed a clear convergence insufficiency pattern with orthophoria and good fusion at distance but an exo shift and exo diplopia at near — what some might refer to as pseudo convergence insufficiency based on accommodative problems.
Naturally when I put up the standard VA chart I wasn’t surprised to see Megan cruise down to the 20/20 line with her right eye, and when covering the right eye seeing her squint on the 20/40 and 20/30 lines through the left eye and really struggle with 20/25. Better than you’d expect with 2.50D of hyperopic aniso, isn’t it? But wait … there’s more. When I switched the paddle back to the left eye and asked her to read the 20/25 line with the right eye, casually mentioning that it should look a lot better than through her left eye, she replied “Hmm … not really. It’s fuzzy now too.”
The vectographic acuity slide clarified what was happening when Megan used both eyes together. The top row can only be seen by the right eye, bottom row only by the left eye, and middle row by either eye.
Megan began to read the chart: H,R.O,N,C haltingly. Then the next line quite easily, reading N,C,K,Z,O, and stopped. There was no bottom line. I covered the right eye and she could now read all but the last letter of the bottom line. Megan’s mother, sitting in the room, was taken aback at how completely Megan was suppressing the left eye. On cycloplegia, Megan refracted +2.75 with the right eye and +3.25 with the left eye. As in Brayden’s case, there is wiggle room on how to Rx for her hyperopia. I can only think of one approach that is wrong, and that would be discouraging the use of an Rx because she’s not yet struggling enough.