Compound Myopic Astigmatism & Mild Ametropic Amblyopia

Intan Karmila (H1A016042)

Supervisor: dr. Gede Suparta, Sp.M
Agenda Style
01 Background

02 Case Report

03 Analysis

04 Conclusion
 Background
 Amblyopia is clinically defined as reduction of visual acuity in one or both eyes, caused
by abnormal binocular interaction during the critical period of visual development.

 Astigmatism is a type of refractive error in which the eye

doesn’t focus at a single point on the retina.

 There are several types of amblyopia, one of them is

refractive amblyopia. High astigmatism can lead to this
type of amblyopia.
 Amblyopia is an important public
health problem because of its
prevalence among children and
because visual impairment from
amblyopia is lifelong and can be
profound.

With an incidence of 3% to 6%, amblyopia is

second only to uncorrected
refractive error as the most common cause
of poor vision in children and young people.
CASE REPORT
Patient’s Identity
Name : Ms. F
Age : 18 years old
Gender : Female
Profession : Student
Religion : Islam
Tribe : Sasak
Address : Labuapi, West Lombok
Inspection Date : Wednesday, July 22nd 2020
No. RM : 144784
 Main Complaint

“Pain and watery in her right eye

since 7 days.”
Current Medical History
Patient presented with complains of pain and watery in her right eye
since 7 days and blurred vision in both eyes since her childhood.
Patient also claimed to experience throbbing pain on the right side of
her head.

factors that aggravate symptoms: Complain of pain in patient’s eyes

worsen when patient stares her handphone, laptop or television for
hours.
Meanwhile, patient claim the complaints improved by sleeping..
Past Medical History
• Patient has been wearing glasses (Concave lens)
for 6 years.
• History of similar complaints are denied.
• History of hypertension, diabetes mellitus, asthma
are denied
• History of ocular trauma is denied.
• History of surgery is denied.
• Patient denied to have allergy.

Family Medical History

• Similar complaints in the family are denied.
• Family history of hypertension, DM, and asthma
are absent.
Medication History
• On July 20th, 2020, the patient examined her eyes
at the Mataram University’s Hospital and she is
suspected of having increased orbital pressure,
then referred to the West Nusa Tenggara’s
Hospital. Before that, the last time patient checked
her eyes was 6 years ago.

Social History
• The intensity of patient staring her
laptop’s/handphone’s screen are high (>5
hours/day)
 Physical Examination
 General condition : Well
 Consciousness/GCS : Compos mentis/E4V5M6
 Vital signs
 Blood pressure : 110/60 mmHg
 Respiration rate : 18 bpm
 Heart rate : 88 bpm
 Body temperature : 36.5 ℃
 Body weight : 48 kg
 Height : 158 cm
 Ophtalmology Status
Examination OD OS
Visual acuity
• Naturalis 4/60 6/60
• Pinhole 6/60 6/30
• Previous eye glasses 6/30 6/12
• Best Correction S-4.50 C-3.50 x 10 vision 6/12 S -2.5 C -4.00 x 168 vision 6/9
• Binocular vision 6/9, patient did not feel dizzy
Visual field
Fingers Fingers
count + count +
Fingers Fingers Fingers Fingers
count + count + count + count +
Fingers Fingers
count + count +

Ocular Aligment
1. Hirschberg test Ortoforia Cant be evaluated
2. Cover-Uncover test Ortotropia Cant be evaluated

Ocular motality Good in all directions Good in all directions

 Ophtalmology Status
Examination OD OS
Lids and lashes Normal Normal

Conjungtiva tarsal Normal Normal

Conjungtiva bulbi Normal Normal

Cornea Normal Normal

 Ophtalmology Status
Examination OD OS
COA Normal Normal
Iris Normal Normal

Pupil Normal, react to light (+) Normal, react to light (+)

Lens Normal Normal

Intraocular pressure Normal Normal

palpations
CASE ANALYSIS
• Patient presented with complains of pain and watery in
Subjective
her right eye
• Patient have blurred vision in both eyes since her
childhood.
• Patient also claimed to experience throbbing pain on
the right side of her head.
• Patient has been wearing glasses (Concave lens) for 6
years.
• The intensity of patient staring her
laptop’s/handphone’s screen are high (>5 hours/day)
 Objective

Examination OD OS
Visual acuity
• Naturalis 4/60 6/60
• Pinhole 6/60 6/30
• Previous eye glasses 6/30 6/12
• Best Correction S-4.50 C-3.50 x 10 vision 6/12 S -2.5 C -4.00 x 168 vision 6/9
• Binocular vision 6/9, patient did not feel dizzy
 Assessment
Patient have astigmatism types:

OD OS
Based on refractive component Compound Myopia Asigmatism Compound Myopia Asigmatism
Based on severity High High
Based on location of the steepest Oblique With the rule
meridian
 Assessment
Patient have amblyopia:

• This patient has mild refractive amblyopia subtype ametropic amblyopia.

• This is because in patient’s both eyes can not achieve normal sharp vision
(6/6) even with the best correction. Patient also had high astigmatism in
both eyes (> 2.5 D).
• Based on the level of severity, this case is classified as mild amblyopia
because of her Best Corrected Visual Acuity in OD is 6/12, meanwhile OS
6/9
Astigmatism
Astigmatism is a common vision condition that causes blurred vision. It
occurs when the cornea is irregularly shaped or sometimes because of
the curvature of the lens inside the eye. As a result, the image does not
focus at a single point.
Signs and symptoms
 Asthenopia
 Distortion or blurring of vision
 Dizzy
 High astigmatism can lead to amblyopia
 Classification of Astigmatism
Based on refractive component
 simple myopic astigmatism → C (-)
One meridian is myopic (object is focused in front of the retina), and the other
emmetropic (object are focused on the retina).
 simple hypermetropic /hyperopic astigmatism → C (+)
One meridian is hyperopic (object is focused in front of the retina), and the other
emmetropic.
 compound myopic astigmatism → S (-) C (-)
The two meridians are myopic
 compound hypermetropic/ hyperopic astigmatism → S (+) C (+)
The two meridians are hyperopic
 mixed astigmatism → Minus/plus & |S|<|C|
One of the meridians is myopic and the other hyperopic
Classification of Astigmatism
Based on magnitude

01 Low: 0,25-1,5 D

02 Medium: >1,5 to <3 D

03 High: >3 D
 Classification of Astigmatism
Based on location of the steepest meridian

01 With the rule astigmatism

 When the greatest refractive power (steepest meridian) is the

vertical meridian (between 60⁰-120⁰).
 Correction with concave cylinder at axis 180⁰±20⁰ or convex at
90⁰±20⁰.
 Most common type
 Classification of Astigmatism
Based on location of the steepest meridian

02 Against the rule astigmatism

 When the greatest refractive power (steepest

meridian) is the horizontal meridian (between 0⁰-30⁰ or
150⁰-180⁰).

 Correction with concave cylinder at axis 90⁰±20⁰ or

convex at 180⁰±20⁰
 Classification of Astigmatism
Based on location of the steepest meridian

02 Oblique Astigmatism

When the greatest refractive power (steepest

meridian) is the oblique meridian (between 30⁰-60⁰
or 120⁰-150⁰).
Amblyopia
Amblyopia is present when the best corrected visual

acuity (BCVA) cannot reach 20/20 or 6/6. Amblyopia is

caused by an abnormal visual input early in life.

 Classifications of Amblyopia
Strabismic amblyopia
Strabismic amblyopia is thought to result from competitive or
inhibitory interaction between neurons processing the
nonfusible inputs from the two eyes, which leads to domination
of cortical vision centers by the fixating eye and chronically
reduced responsiveness to input by the nonfixating eye.

Visual deprivation amblyopia is caused by complete or

partial obstruction of the visual axis, resulting in a Visual Deprivation
Amblyopia
degraded retinal image.
 Classifications of Amblyopia
Refractive amblyopia
Anisometropic amblyopia, a form of unilateral amblyopia, develops when unequal refractive
error causes the image on one retina to be more poorly focused than in the fellow eye. Bilateral
refractive amblyopia (isoametropic) is a less common form of refractive amblyopia that results
in a bilateral reduction in visual acuity.
Ambliogenic refractive errors.
 Classifications of Amblyopia

Classification of Best Corrected Visual Acuity in amblyopia

Severity of Amblyopia BCVA

Mild amblyopia 20/25-20/40 ft (6/7-6/12 m)
Moderate amblyopia 20/40-20/100 ft (6/12-6/30 m)

Severe amblyopia 20/100-20/400 ft (>6/30 m)

 Planning Diagnostic
On visual examination, crowding phenomenon is a
typical sign of amblyopia, which is difficulty
Crowding identifying letters if the letters are displayed /
Phenomena Test contained in a linear sequence together with other
letters such as on a snellen chart, rather than
letters displayed individually.

To ensure that there are no structural abnormalities in Slit Lamp & Fundus
the external and posterior eye examination
 Planning Therapy
01 Eye Glasses
• We need to get rid of or modify amblyopiagenic factors. In this case the amblyogenic factor is
astigmatism refractive disorder. Eye glasses is the first choice for astigmatism correction.
• In cases of high astigmatism, contact lenses can provide correction better vision than glasses. It
also provides sharper vision and larger visual field.
• Another option for treating astigmatism is surgery refractive ie LASIK (laser in situ
keratomileusis) or photorefractive
Conseling, Information & Education
Explain the patient's current condition related to the diagnosis of
01 complaints

Explain the purpose of therapy given

02
Avoid risk factors that can cause complaints in the eye (Example: 20-20-20 rule)
03
 Prognosis

Reasons
ad sanationam Dubia ad malam If amblyopia is not treated until 6-9 years
age, visual defect may not improve.

ad functionam Dubia ad bonam The visual function can be optimized with

eye glasses

ad vitam Bonam Amblyopia is not life threating

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