Arianna’s mother works for a local optometrist, Dr. M. She has gradually progressed in myopia, and he tried to fit her with CRT lenses but her corneal astigmatism got in the way of success. She currently wears soft lenses and had been complaining of blur in her right eye. Her sphere power is -7.00 in the left and -5.50 in the right, and when she presented on her most recent exam with 20/40 acuity in that eye, Dr. M. was expecting to increase the minus lens power in that eye but any higher minus that what she already had created double vision.
When conducting binocular testing through her habitual Rx, I noticed that Arianna would elevate her chin slightly in order to maintain fusion. When I asked her to tip her chin downward, she reported diplopia. I asked her mother if she had noticed that Arianna preferred to look at things downward and she said: “Sure – I keep asking her why she looks down so much when she’s using her phone or a tablet. Arianna – show the doctor how you look at your phone!”
Further testing revealed why Arianna has such a difference depending on her angle of gaze: “A” pattern esotropia, with the inward turn of the right eye increasing in upgaze and eliminated in downgaze.
At our conference to review the findings, we agreed to hold the minus power the same in the right eye and prescribed optometric vision therapy to expand Arianna’s range of fusion. We considered prescribing base-up yoked prism at the outset to enable Arianna to maintain a more normal head posture, but she preferred not to use a spectacle Rx initially and to accomplish as much as she could without it. I anticipate that Arianna will do very well, and that in the future she’ll find plenty of other reasons to hold her head high.
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