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Dr. James
Dr. James, Board Certified Ophthalmologist
Category: Eye
Satisfied Customers: 2282
Experience:  Eye Physician and Surgeon
20222826
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Mod: (Do NOT Lock)(NOT a duplicate)(NOT a followup)

When cyclopleged (Atropine) and +2.5 readers, my vision is clear at a distance of 30.5cm (as you know it should be 40cm) and with +1.25 readers it's 51cm (should be 80cm). These measurements seem to indicate I'm either myopic by a magnitude around -0.5 (not a large amount)... or my accommodation was not completely paralyzed.

I'm trying to determine the next steps to figure out my prescription/solution. Non-cyclopleged, if I stop straining and let my eyes come to a normal relaxed state, vision seems clearest at a distance of 23/28cm (R/L). A -3 lens may compensate for the over-accommodation but it won't correct the action of the accommodative muscles, so my eyes may still cross inward because they think they are pointing to a near object? Also, a -3 CL will take away my near vision. So a -3 isn't the solution?

Here's an observation that may provide additional insight: When I pinhole to remove elements of refractive error, it still requires straining to get the image into focus. When I'm straining, adding pinhole does provide better clarity, indicating a small part of the problem is refractive error, but the fact that the biggest improvement is produced when I strain suggests the issue must be something besides refractive error?

*((One part I still don't understand, is if my eye's relaxed state is over-accommodation, thus blurry, then when I do the action of "straining", what am I doing? Counter corecting for the over-accommodation, or am I using muscles to force the accommodative system (lens) to flatten?))
Submitted: 2 years ago.
Category: Eye
Expert:  Dr. James replied 2 years ago.

Dr. James :

Hello.

Dr. James :

I'm available tonight. I'll try to get you while you are online.

Dr. James :

Just message me when you are online.

Customer:

I am online and will wait here for you.

Customer:

I am still here

Customer:

let me know when you come online.

Customer:

I am still here

Customer:

.

Customer:

I am still here

Customer:

still here

Dr. James :

Hello.

Dr. James :

message me when you come back online.

Dr. James :

will try to get back online tonight.

Customer:

but I'm online now.

Customer:

I hope this thing is working right.

Customer:

I'll continue to wait. you must be on the west coast?

Dr. James :

hello.

Customer:

hi

Dr. James :

good to see you online.

Dr. James :

Are you still on the atropine?

Customer:

no

Dr. James :

when did you stop it?

Customer:

some time ago. I was on it for 2 weeks

Dr. James :

what problems are you having with your eyes now?

Customer:

same

Dr. James :

which is?

Customer:

do you think we should start with the initial question?

Dr. James :

it seems that there have been many questions. i am a little confuse what the goal of your self-test has been.

Dr. James :

that is why i wanted to catch you online.

Dr. James :

if it is not much of a bother, i'd like for you to start from the beginning.

Customer:

If I don't strain my eyes, the vision is blurry and double.

Customer:

When I pinhole to remove elements of refractive error, it still requires straining to get the image into focus. When I'm straining, adding pinhole does provide better clarity, indicating a small part of the problem is refractive error, but the fact that the biggest improvement is produced when I strain suggests the issue must be something besides refractive error?

Dr. James :

have you seen an optometrist?

Customer:

I don't know what change I'm inducing when I "strain"

Customer:

many many

Customer:

in several cities

Customer:

so what am I doing?

Dr. James :

can you tell me what their prescription has been for eyeglasses?

Customer:

they all say they don't know, or give me different ones.

Dr. James :

can you give me an idea of what their numbers are?

Customer:

everything from +.75 to -4

Dr. James :

have you had a cycloplegic refraction?

Customer:

7 of them

Dr. James :

what medicine was used for them?

Customer:

dilation lasted between 2-5 days

Dr. James :

was the -4 during one of those cycloplegic refractions?

Customer:

I don't think so

Dr. James :

do you wear glasses now?

Customer:

no

Customer:

the glasses I've bought made vision worse

Dr. James :

do you have trouble seeing far away? trouble seeing up close? trouble far and near?

Customer:

straining I can see both, not-straining neither

Dr. James :

you likely have hyperopia (i.e. farsightedness).

Customer:

except maybe the specific distance of about 13 inches

Dr. James :

your amount of accommodation is very strong since you've been accommodating most of your life to be able to see clearly far and near.

Dr. James :

it is difficult to give the full prescription to a hyperope.

Customer:

so maybe I didn't need the lasik I had 13 years ago?

Dr. James :

you may need to force yourself into a partial plus prescription first for a few months, then increase the prescription in a stepwise fashion.

Dr. James :

what was your prescription before the lasik?

Customer:

don't remember.

Customer:

why can't I see clearly once I'm cyclopleged, so matter what lens, but I can non-cyclopleged without any lens.

Customer:

*no matter

Dr. James :

it seems that you may have accommodative spasms.

Dr. James :

+.75 to -4 is a very wide range to fluctuate.

Dr. James :

having lasik done can also cause some straining effect on your eyes as well.

Customer:

but we ruled out spasm with the atropine.

Customer:

and I never had straining issues after the lasik

Customer:

when people have spasm (habit of over-accommodation), their eyes cross?

Dr. James :

not always.

Customer:

when people have spasm (habit of over-accommodation), pin-holing helps, or does not help?

Dr. James :

pin holing helps for all types of refractive error. helps little in your case.

Dr. James :

doesn't really say how much refractive error you have though.

Customer:

so are you saying spasm is not refractive error?

Dr. James :

spasm causes a refractive error, but it is variable and transient.

Customer:

then maybe that's not what I have, because it never changes for past several years.

Dr. James :

what never changes?

Customer:

my distance of clearity, it's always 13 inches

Dr. James :

your vision is always clear at 13 inches?

Customer:

Yes. Maybe I should ask a different way. If someone has spasm, their focus distance is close up. Is it locked there, or can they change their focus distance, and if so how?

Dr. James :

so if you vision is always clear at a single distance, that means you accommodate very little.

Customer:

I don't follow

Customer:

wouldn't it mean I'm nearsighted?

Dr. James :

yes it suggest you are a little nearsighted.

Customer:

so what muscles am I using to flatten my lens?

Dr. James :

the ciliary muscles.

Customer:

I thought those are for curving it?

Dr. James :

when the ciliary muscles contract, it relaxes the lens and fattens it.

Dr. James :

when it relaxes, it pulls on the lens and flattens.

Customer:

that does not make sense

Dr. James :

look it up on youtube. the ciliary muscles works slightly opposite compared to other muscles.

Customer:

how can opposite actions create the same result?

Customer:

contracting and relaxing both flatten the lens?

Dr. James :

contractions relaxes the lens, causing it to bulge a bit.

Customer:

yes, that's what I thought

Customer:

you said it flattens it

Dr. James :

sorry, typo.

Customer:

are you watching TV?

Dr. James :

i meant fatten

Customer:

or.. if you look at this screen for example.

Customer:

the text to me looks light grey, but

Customer:

if I pin-hole I realize it's black.

Customer:

I'm thinking that's due to astigmatism.

Customer:

which is mild, so let's set that aside from the picture.

Customer:

so, following the logic...

Customer:

are you saying that when I "strain" I'm relaxing my ciliary muscles?

Dr. James :

though you see it light grey, is the text clear?

Dr. James :

you have some irregularity of your cornea.

Dr. James :

especially since you have had lasik.

Customer:

right, and that part I can live with fine.

Dr. James :

irregular astigmatism cannot be fully corrected by glasses.

Customer:

it's minor and I'm ok with it.

Dr. James :

pin holing can improve the irregular astigmatism.

Customer:

right. but that's a small change, so not the problem I'm concerned with.

Dr. James :

this may be your problem rather than over accommodation.

Dr. James :

have you had a corneal topography done?

Customer:

yes

Dr. James :

and?

Customer:

it came out fine

Customer:

I also tried hard contacts

Dr. James :

do they help?

Customer:

no change. that's because the cornea is not the issue.

Customer:

Are you saying that when I "strain" I'm relaxing my ciliary muscles?

Dr. James :

I'm assuming when you say strain you mean accommodate.

Customer:

I'm meaning strain

Dr. James :

when you accommodate, you contract your ciliary muscles.

Customer:

yes, I know.

Customer:

but..

Dr. James :

Strain is a vague term, so would't know what your eyes would be doing.

Customer:

you said if my focus is close, then I need to relax those muscles to see far.

Customer:

I'm getting to that.

Customer:

right?

Dr. James :

it depends on if you are nearsighted or farsighted.

Customer:

but we already determined that?

Dr. James :

i'm not sure if we did.

Dr. James :

you mentioned your vision is clear at 13 inches.

Dr. James :

this suggest that you are slightly nearsighted.

Dr. James :

but you always say you can see well at distance when you accommodate which suggest farsightedness.

Customer:

Would relaxing my ciliary muscles feel strenuous, give headache and get tired over time? It seems that tensing them would produce those sensations?

Dr. James :

at your age, your range of accommodation is mild.

Dr. James :

i don't that you are able to accommodate as much as you suggest.

Dr. James :

*doubt

Customer:

Would relaxing my ciliary muscles feel strenuous, give headache and get tired over time? It seems that tensing them would produce those sensations?

Dr. James :

relaxing your ciliary muscles would not feel strenuous.

Dr. James :

yes, accommodating requires work.

Customer:

ok then, so that means if I'm straining all the time, then I'm farsighted?

Dr. James :

yes, it is suggestive of that.

Customer:

but how can I be farsighted if vision is clear at 13 inches?

Dr. James :

your eye strain may not be accommodation.

Dr. James :

eye strain can be due to dry eyes, uncorrected astigmatism.

Customer:

that doesn't make sense to me, how can straining your eyes make them wet or correct astigmatism?

Customer:

when I strain, I'm doing something to make the vision clear at all distances... so I'm still trying to understand from you what I'm doing?

Dr. James :

i think we're going around in circles.

Dr. James :

i'm not sure if i'll be able to give you a satisfying answer.

Customer:

The question of this ticket was how to stop straining, and to do that I figure we need to determine why I'm straining.

Customer:

so that's what I'm trying to help you determine.

Customer:

I thought you were going to ask the questions.

Customer:

and that's why you wanted to chat.

Dr. James :

if you are over-accommodating, then glasses with plus diopters will help relax your eyes and stop them from accommodating.

Customer:

ok, but when I try that I can't see anything, relaxed or straining.. suggesting to me it's the wrong prescription.

Dr. James :

is these prescription glasses?

Customer:

OTC

Customer:

and contacts

Dr. James :

what power contacts?

Customer:

contacts were +.5 and glasses were +1 to +3

Customer:

so every power was tried.

Customer:

higher the power, the worse the vision got

Dr. James :

i'm sorry, i don't think i will be able to help you further. there seems to be many things going on with your eyes.

Customer:

I'm not saying it's true, but just to give you an idea from my shoes and from what I'm experiencing it gives the perception eye Dr don't know what they are doing or just don't want to try.

Dr. James :

that's not a fair statement.

Customer:

I can't imagine it being so hard to determine if someone is near or far sighted.

Dr. James :

it's not that hard.

Dr. James :

in your case, there must be other things going on that an in person exam would be helpful.

Customer:

but no in person examiner has been able to answer that question.

Dr. James :

have you been to an ophthalmologist?

Customer:

yes, many.

Customer:

and several neuro-ophthalmologists

Customer:

at Duke, Mayo, etc.

Customer:

they all just say they don't know.

Dr. James :

and you believe it's because they are incompetent or not trying?

Customer:

well, like you said, it's not that hard.

Dr. James :

yes, it's not that hard.

Dr. James :

it seems to be very difficult in your case.

Customer:

so that's why I"m perplexed.

Dr. James :

me too.

Customer:

so far, I've figured out a lot more than they have.

Dr. James :

what are your conclusions?

Customer:

they don't know much about eyes.... for example.. my eyes are clearly crossing inward, yet they prescribe BI prism.. does that make sense?

Customer:

yes/no? BI for eyes crossing pre-target?

Dr. James :

no.

Customer:

so see what I mean.

Customer:

all have prescribed BI. When I asked if BI was right for eyes crossing in, they said yes.

Customer:

It didn't make sense to me.

Customer:

let me just ask this...

Customer:

when I go for an exam, they should be able to find a lens that get's me at least close to what I see when I strain, or when I pin-hole, right? Unless it is that I have spasmed accommodation, right?

Dr. James :

pinhole vision is artificial and cannot be replicated with a lens.

Dr. James :

you are correct in a a lens should get you close to when you strain.

Customer:

And they should be able to determine in the exam if I have spasm, right?

Dr. James :

not necessarily.

Dr. James :

spasms are variable. so you can be one prescription at one time, and another prescription another time.

Customer:

if my accommodative muscles are locked in a tensed state, does that mean they can't find a lens during the exam?

Dr. James :

no, a lens can still be found.

Dr. James :

it just means that it can be one thing during the exam, when you get glasses it changes, so the lens is not right anymore.

Customer:

(correct lens)

Customer:

but this whole thing is mute, because as you said earlier, if i'm straining, then i'm tensing the ciliary muscles, which means in my case they are not spasmed?

Customer:

b/c if they were spasmed, I would be relaxing them.

Customer:

not tensing them.

Dr. James :

no.

Dr. James :

spasm of accommodation is still activating the ciliary muscles.

Customer:

right, so they would get sore from the spasm, not relaxing.

Dr. James :

ok.

Customer:

but it's the opposite, they get sore from when I make my vision clear, which suggests I'm tensing them to get my vision clear

Customer:

which means it can't be spasm

Dr. James :

let me ask you this, without glasses are you 20/20 at distance

Dr. James :

?

Customer:

with contacts with only correction for VERY slight astigmatism, I'm 20/20

Dr. James :

what is your vision at distance without glasses or contacts?

Customer:

my vision is also very good up close. naked my distance vision is close to 20/20 but don't know the exact number

Dr. James :

so, is your distance vision clear or blurry?

Customer:

clear

Dr. James :

is your near vision clear or blurry without glasses or contacts?

Customer:

clear

Customer:

but both give me headaches and takes more effort to get clear as the day goes on.

Dr. James :

so, your problem is not clarity of vision, but rather eye strain. is that correct?

Customer:

well I have eye strain or no vision, so I'm forced to choose strain.

Customer:

e.g. right now I've got a bad tension headache around my eyes, and if I relax them, I can't see anything.

Customer:

my eye balls hurt.

Dr. James :

ok. sounds likes farsightedness.

Customer:

*sockets

Dr. James :

sounds like dry eyes.

Customer:

dry eyes make my forehead hurt? I 'm not sure it's that b/c wetting drops don't help

Customer:

ok.. so summary... I'm slightly far sighted and this makes my accommodation over work and get tired?

Dr. James :

i don't think it is as simple as that.

Dr. James :

i think you have some degree of uncorrected hyperopia.

Dr. James :

i think you have some degree of dry eyes.

Dr. James :

both of which can cause eye strain/ache.

Dr. James :

you may have also some eye misalignment, esophoria or exophoria.

Dr. James :

this can also cause eye strain, sometimes double vision.

Dr. James :

it may be combination of these factors.

Customer:

I'm going to post final clarifications as new questions so you get multiple credits. hold one sec.

Customer:

ok, those others have been posted.

Customer:

so, a plus lens should relieve the straining?

Dr. James :

if it is due to accommodation.

Customer:

which would be the straining i'm doing?

Dr. James :

part of it.

Dr. James :

if the strain is from dry eyes, then plus lens don't do anything of that.

Dr. James :

for that

Customer:

flax oil?

Dr. James :

flaxseed oil can help with dry eyes.

Dr. James :

omega-3 fatty acids.

Dr. James :

lid scrubs.

Dr. James :

warm compresses.

Customer:

ok, need to end this conversation. What do I ask for when go for next exam so I can get clear vision without strain?

Customer:

use phoropter to find plus power for farsightedness?

Customer:

if yes, must i be cyclopleged for this?

Dr. James :

the phoropter is just a bunch of lens in one convenient place. the doctor should determine if you are farsighted or nearsighted.

Dr. James :

but ask the doctor to check if you have any hyperopia.

Customer:

how does she do that?

Dr. James :

you shouldn't need to be cyclopleged, but with your past difficulties it would be helpful to do a refraction without drops, then one with cycloplegia -- cyclogyl.

Dr. James :

start with a high plus power and go down from that.

Customer:

ok, thanks, XXXXX XXXXX think anyone has known to do that.

Dr. James :

it's standard teaching. hopefully that was part of your refractions in the past.

Customer:

right, but if they couldn't determine before, then I'm not sure what they were doing.. anyway, maybe it will help now that i'm asking them to check for hyperopia

Dr. James :

hopefully.

Dr. James :

keep me updated on their conclusions.

Customer:

they hyperopia doesn't mesh though with my cyclopleged readings we discused, which indicate i'm myopic?

Customer:

When cyclopleged (Atropine) and +2.5 readers, my vision is clear at a distance of 30.5cm (as you know it should be 40cm) and with +1.25 readers it's 51cm (should be 80cm).

Dr. James :

true.

Dr. James :

but if you were myopic, then your distance would not be 20/20 regardless of how much you accommodate.

Customer:

I have no idea what will happen, but I'll let you know what does. I'm so lost.

Customer:

wish me luck.

Customer:

good night.

Dr. James :

good luck and good night.

Dr. James :

:)

Dr. James, Board Certified Ophthalmologist
Category: Eye
Satisfied Customers: 2282
Experience: Eye Physician and Surgeon
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