Case Study of a Patient with Simple Anisometropia

Subjective

  • Chief Complaint: A 32-year-old woman was admitted with a short history of visual acuity in the left eye lasting for a couple of hours.
  • History of Present Illness: Jessica, a math’s teacher, had suffered a blurred vision related to getting heated,
  • This condition improved when she got in a cool, air-conditioned environment.
  • The patient experienced pain while moving her eye, but none when she rests.
  • She was also unable to detect colours.

Past History

  • Past medical history: The patient had suffered from a blurred vision that improved without being hospitalized.
  • Social history: Mrs Jessica is a teacher with no history of alcohol or use of cigarette.
  • Psychiatric history: She is always alert and active.
  • Family history: The patient had no record of diseases.
  • Medications & indications: She had not received any form of medication.
  • Allergies: The patient denied any form of allergy.
  • Immunizations: Apart from childhood immunization, she had not received other forms of vaccination.

Health Maintenance

  • The patient mentioned a healthy diet
  • She rests when her condition is unwell.
  • She exercises regularly.
  • The patient does not visit medical check-up.
  • The patient does not receive immunization.

Screenings

  • Jessica denied chills, fever, weight loss, and fatigue.
  • She denied night sweats, and polydipsia.
  • She denied polyuria, nasal congestion, and swelling in the legs.
  • She denied changes in hearing, vaginal discharge, and dysuria.
  • She denied abdominal pain, headache, and sore throat chest pain.

Review of Systems

  • Constitutional: The patient was alert but appeared anxious.
  • Eyes: She had 20/200visual acuity and 20/30 visual acuity in the left and right eye, respectively. The pupil in her left eye responded slowly to light while the one in the right eye was brisk.
  • Ears/nose/mouth/throat: She had normal mouth, throat, no epistaxis, or hearing problems.
  • Cardiovascular: The patient presented intact I-XII in the cranial nerves, horizontal nystagmus, and normal muscles.
  • Respiratory: She had no history of cough, pleurisy, asthma, hemoptysis, wheezing, or pulmonary.
  • Gastrointestinal: The patient did not present melena, hematemesis, or endoscopy.
  • Genitourinary: Had normal menstrual cycle and genitourinary organ.

Review of Systems

  • Musculoskeletal: Her muscles had normal bulk and tone.
  • Integumentary: She had normal endoscopy and hematocrit.
  • Neurological: Her cranial nerves had I-XII intact, and horizontal nystagmus.
  • Psychiatric: She experienced anxiety.
  • Endocrine: She did not present thyroid disease.
  • Hematologic: She had no blood or clotting disorders.
  • Allergic: She is not allergic.

Vital Signs

  • The patient was alert but appeared anxious
  • HR: 64bpm and regular
  • RR:16 per minute
  • T:98.5 0 C
  • BP:135/85 mm Hg.

Physical Exam

  • She had 20/200 and 20/30 visual acuity in the left and right eye, respectively.
  • She presented clear conjunctivae and white sclera and could not detect visual fields on the left eye.
  • She had intact visual fields on the right eye.
  • Pupil in her left eye responded gradually to light while the right eye was brisk
  • Apart from the blurred vision and anxiety, the patient had no symptoms.

Assessment

Possible Diagnosis

  • Simple anisometropia – arises when one of the eyes has a refractive error.
  • Refractive error – common among diabetic.
  • Opacities of the ocular media – results in hemorrhage, and it is common among people with diabetes with abnormal retinal bleeding blood vessels.
  • Retinal disorders – it is related to macular degeneration, common among aged people.
  • Optic nerve disorder – manifests in pain exacerbated by eye movements.
  • Disorders of the retinal vasculature – its symptoms include swellings of blood vessels.
  • Working diagnosis: Simple anisometropia.

Differential Diagnoses

  • On performing the Bruckner test using a direct ophthalmoscope in both eyes, Jessica was suffering from simple anisometropia.
  • According to Tegegne et al. (2021), simple anisometropia is characterized by one eye having a refractive error. It can occur when either one of the eyes is bigger than the other, resulting in asymmetrical nearsightedness.
  • An individual suffering from this condition experience blurred vision, pain, and discomfort.

Plan /Treatment

  • Treatments can include corrective lenses or contact lenses.
  • For contact lenses or corrective lenses to be effective, they should be prescribed differently to meet each eye’s visual needs (Bailey & Jackson, 2016).
  • The patient should be educated on the importance of wearing lenses.
  • The patient should maintain balance diet.
  • She should exercise regularly

References

Bailey, I. L., & Jackson, A. J. (2016). Changes in the clinical measurement of visual acuity. In Journal of Physics: Conference Series (Vol. 772, No. 1, p. 012046). IOP Publishing.

Tegegne, M. M., Assem, A. S., & Merie, Y. A. (2021). Prevalence and Associated Factors of Amblyopia Among School-Age Children at Bahir Dar City, Northwest Ethiopia: A Community-Based Cross-Sectional Study. Clinical Optometry, 13, 143.

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