Patient information
Patient: Amy Q
Age: 8 years old
Date of Visit: May 10, 2022
Patient Background
Amy is an 8-year-old girl who was brought to Burbank Optometric Center by her parents for a comprehensive eye examination. Amy’s parents expressed concerns about her frequent headaches, difficulty reading, and sitting too close to the TV. They suspected that these issues might be related to her vision.
Patient Visit Details
1.Preliminary Assessment:
Amy’s height, weight, and general health were recorded.
Initial questioning was done to gather information about her symptoms, family history, and any previous eye-related concerns.
2.Visual Acuity Test:
Amy’s visual acuity was evaluated using an eye chart specially designed for children.
The test revealed that Amy had difficulty reading letters from a distance.
3.Refraction Test:
A comprehensive refraction test was performed to determine the exact prescription needed for Amy’s vision correction.
Special attention was given to make the process comfortable and engaging for Amy, as children may find it challenging to cooperate during the examination.
4.Binocular Vision Assessment:
The doctor assessed how well Amy’s eyes work together using tests such as the cover test and stereo vision test.
This evaluation helps identify any issues with eye teaming, focusing, or depth perception.
5.Eye Health Examination:
Amy’s eyes were examined using a variety of tools, including a slit lamp and ophthalmoscope, to evaluate the health of her eyes.
The doctor checked for any signs of ocular conditions or diseases that could be contributing to Amy’s symptoms.
Diagnosis and Discussion
Based on the examination, the optometrist diagnosed Amy with the following conditions:
1.Myopia (Nearsightedness:
Amy’s visual acuity test and refraction test indicated that she had myopia, a condition in which distant objects appear blurry while close-up objects remain clear.
Myopia is a common refractive error in children and can cause difficulties in school, such as reading from the board.
2.Accommodative Dysfunction:
Amy’s binocular vision assessment revealed difficulties with her eye focusing abilities, known as accommodative dysfunction.
This condition can lead to eye strain, headaches, and difficulty sustaining clear vision at near distances for an extended period.
Treatment Plan
1.Prescription Eyeglasses:
Based on the refraction test results, Amy was prescribed eyeglasses with lenses that correct her myopia.
The lenses were designed to optimize her visual acuity and provide clear vision for both near and distant objects.
2.Vision Therapy:
To address Amy’s accommodative dysfunction, a personalized vision therapy program was recommended.
Vision therapy consists of exercises and activities that help improve visual skills, eye teaming, and focusing abilities.