Patient information
Patient: Kim B
Age: 75 years old
Date of Visit: April 25, 2021
Patient Background
Kim B, a 75-year-old man, visited Burbank Optometric Center for a routine eye examination. He had noticed a gradual decline in his vision, particularly in his ability to read fine print and see clearly in low-light conditions. Kim had a history of age-related eye diseases in his family, which heightened his concern for his visual health.
Patient Visit Details
1.Preliminary Assessment:
Kim’s general health information, including any medications or conditions affecting his eyes, was recorded.
The optometrist asked about any symptoms or difficulties he had been experiencing regarding his vision.
2.Visual Acuity Test:
Kim’s visual acuity was tested using an eye chart, both for distance and near vision.
The test indicated a decline in his visual acuity compared to his last visit.
3.Refraction Test:
A refraction test was performed to determine John’s precise prescription for corrective lenses.
This step helps identify any refractive errors that may be contributing to his vision decline.
4.Intraocular Pressure Measurement:
The optometrist used a tonometer to measure the pressure inside John’s eyes, checking for signs of glaucoma.
Elevated intraocular pressure can be an indication of glaucoma, a common eye disease in the elderly.
5.Dilated Fundus Examination:
Kim’s pupils were dilated using eye drops, allowing the optometrist to examine the back of his eyes.
The doctor used a slit lamp and ophthalmoscope to assess the health of the retina, optic nerve, and blood vessels.
Diagnosis and Discussion
Based on the examination, the optometrist diagnosed Kim with the following conditions:
1.Age-Related Macular Degeneration (AMD):
The dilated fundus examination revealed signs of age-related macular degeneration in Kim’s eyes.
AMD is a progressive eye disease that affects the macula, leading to central vision loss.
2.Presbyopia:
Kim’s near vision difficulties were attributed to presbyopia, a natural age-related condition.
Presbyopia affects the eye’s ability to focus on close-up objects, making reading and fine tasks challenging.
Treatment Plan
1.Low Vision Aids:
Given the presence of age-related macular degeneration, low vision aids were recommended for Kim.
These aids, such as magnifiers and special lenses, can enhance his remaining vision and improve reading ability.
2.Presbyopia-Correcting Glasses:
Prescription glasses with progressive lenses or multifocal lenses were prescribed to address Kim’s presbyopia.
These lenses provide clear vision for multiple distances, allowing him to see both near and distant objects.
3.Monitoring and Lifestyle Recommendations:
Regular monitoring of Kim’s AMD progression was advised to detect any changes promptly.
Recommendations were given to maintain a healthy lifestyle, including a balanced diet, UV protection, and regular exercise.