Case #2

This case is reposted from ODwire. 

This is a 42 y/o woman in no apparent distress and who awoke 3 weeks ago with the presentation above.

HPI - Slight temporal pain and discomfort. No loss of vision or diplopia reported. 

Physicial Exam. Best vision is OD -2.75 Sph 20/25- and OS -2.50 20/25. Confrontation fields and extraocular muscles are full (if the RUL is held up). The pupils were dilated before my examination but were noted to be APD minus. 

IOP 14 OU, CD 0.40 OU ONH diameters ~2.0mm, with no visible atrophy of the beta zone. Good disc color and sharp margins. The eye is quiet and the internal exam is negative. 

After 30 seconds of upgaze, the patient does have a worsening ptosis but the LUL is intact and unaffected.

What are your thoughts? next steps?

Case #1

I'll start us off with the first case out of the VA.   

55y/o WF presents for an annual eye exam. 

LEE: one year ago

OHx: The patient reports that she has always had a "bad left eye" since she was a child and that it has been "legally blind" for many years.  She wears her glasses the majority of the time and her prescription is one year old although her Rx hasn't changed in several years.   She thinks her first visit to an eye doctor was around age 10.

MHx: Unremarkable

VAcc:  

OD 20/20, 

OS 20/80, PH 20/50

Entrance Tests: all unremarkable

Habitual Rx:  

OD: +1.25 sph 

OS: +1.25 sph  

 +2.25 ADD

Subjective Rx: 

OD: +1.50 sph  20/20

 OS: +2.25-3.00x25  20/25

+2.00 ADD

The rest of the exam was unremarkable - this is mostly a good case about refraction-

I was confused as to why she had been walking around for 20+ years with this "bad eye" when it really wasn't bad in the first place.  I was so excited to have discovered this new-found vision for her but when I presented this case to my preceptor, he had a different opinion.  He asked me what I wanted to do and I said that I wanted to cut back the Rx I found, that I trial framed it and she liked it.  So I wanted to order her this Rx:

OD: 1.50sph

OS: +1.75-2.00x25

+2.00 ADD

We ended up doing that but my preceptor said that giving her the glasses was a "judgement call".  He said that someone else may have also found this Rx for her before and gave her the glasses and she hated them so they just kept everything the same (although the patient didn't remember this).  Since the patient didn't come in with any visual complaints, we could just leave her Rx the same and if we were in a private practice, we may not give her the glasses because we may end up eating them.   My argument was that I think that we should at least try and because the glasses are free in the VA, we should order her glasses and if she rejects them there is no monetary loss for her or us.  But, if we were in a private practice, why wouldn't we just educate the patient that she may not like the glasses and that we are not responsible if she can't adjust to them, sort of like she is buying them at her own risk?  What is your opinion on this?  If the patient hasn't told you that she tried a pair of glasses that she hated, are we doing her a disservice by not giving her the true Rx simply for money's sake?