Optometry case study: Failure to follow advice

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by Michael Tran, Specsavers Beenleigh & Ipswich, Australia

February 2011

History
20 year old male
Px presented 14/02/2011 for an eye examination c/o constant binocular diplopia, worse at distance and night. There were no other problems reported.

Examination
RE: +0.50/-0.25 x 110 VA 6/6
LE: +0.25 VA 6/6
Cover test 2 esoP for distance
Diplopia corrected with 1 ? base out
Pupils – normal
External eye – normal
Ophthalmoscopy – normal

Provisional diagnosis
Decompensating heterophoria

Management
Prescribed SVD Rx with prism and advised 3 cats stereogram exercises. Referred for ophthalmological evaluation.

April 2012
Px returned for another eye examination, he had decided not to attend his appointment with the ophthalmogist.

History
Diplopia is now worse, especially on extreme left gaze.

Examination
RE: +0.50/-0.25 x 120 VA 6/6
LE: +0.25 VA 6/6
Diplopia now corrected with 3? base out
Pupils – normal
External eye – normal
Ophthalmoscopy – normal
Visual field test carried out – no points missed

Provisional diagnosis
Deviation now incomitant, query CN VI palsy.

Management
Emphasised the importance of the px being examined by an ophthalmologist. Initially the patient declined this but eventually agreed after his father offered to pay for the consultation.

Consultant Response

Initial response from consultant

 

 

 

Follow up from consultant

 

 

 

Discussion

A chordoma is a rare type of cancer that develops from the notochord, the notochord forming the spine in a developing baby in the womb. After about six months, most of the notochord is replaced by the bones of the spine. However, small amounts of the notochord may remain and these can sometimes develop into a chordoma. About 40% of chordomas occur in the base of the skull, the rest occur in the spine itself. If a chordoma occurs at the base of the
skull, symptoms can include headache and diplopia.

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