NBEO PEPs Study Cases
1. 40-year-old fe- Diagnosis: Anterior Uveitis
male presents Ancillary Tests:
with unilateral First time - no testing needed
eye pain, pho- Management:
tophobia, and Prednisolone acetate 1% q1-2h while awake
blurred vision for Cyclopentolate 1% BID
three days. No Monitor IOP at follow-up
discharge. Slit Patient Education:
lamp shows 2+ "You have inflammation inside your eye, similar to arthritis in the eye."
cells and flare "We are treating this with steroid drops and a dilating drop to relieve discomfort."
in the anterior "This condition can sometimes come back, and if it does, we may need additional
chamber. No ker- testing."
atic precipitates. RTC: 2-5 days for IOP and response to treatment, then weekly until resolved
IOP is 12 mmHg.
What is the most
likely diagnosis?
2. A 32-year-old Diagnosis: Recurrent Anterior Uveitis (Likely Associated with a Systemic Condition)
male with a his- Ancillary Tests:
tory of anteri- HLA-B27 testing (if not already diagnosed)
or uveitis pre- Additional systemic workup (if indicated): ANA, RF, chest X-ray (sarcoidosis),
sents with eye syphilis testing (RPR, VDRL)
pain, photopho- Management:
bia, and blurred Prednisolone acetate 1% q1-2h, then taper
vision in his right Cyclopentolate 1% BID
eye. He reports Referral to rheumatology for autoimmune workup
similar episodes Patient Education:
in the past. Slit "Since this is not your first episode, we need to evaluate whether an underlying
lamp shows 2+ systemic condition is contributing to it."
anterior chamber "This may be linked to autoimmune diseases such as ankylosing spondylitis or
cells and ker- sarcoidosis."
atic precipitates. "Proper treatment and monitoring can prevent complications like glaucoma or
, NBEO PEPs Study Cases
What is the most vision loss."
likely diagnosis? RTC: 2-5 days for IOP and response to treatment, then weekly until resolved
3. A 16-year-old fe- Diagnosis: Accommodative Excess
male complains Ancillary Tests:
of headaches and Binocular accommodative facility (reduced with plus lenses)
blurred vision af- FCC (lead of accommodation)
ter prolonged NRA/PRA (low NRA, high PRA)
near work. Symp- Cycloplegic refraction (to rule out latent hyperopia)
toms improve Management:
when she takes Near vision correction if latent hyperopia is present
breaks but wors- Plus lenses for near work (if indicated)
en when read- Vision therapy (accommodative facility training) - weekly in-office therapy with 5
ing for long days of home therapy
periods. Refrac- Patient Education:
tion shows low "Your eyes are over-focusing up close, which is causing fatigue and headaches."
hyperopia with "We may prescribe reading glasses or exercises to help relax your focus at near."
reduced accom- "Taking breaks and adjusting your reading habits can help improve symptoms."
modative facility. RTC: 4-6 weeks to assess symptom improvement and compliance with therapy OR
NPC and cover 1-2 weeks to initiate in-office vision therapy
test are normal.
What is the most
likely diagnosis?
4. A 4-year-old child Diagnosis: Accommodative Esotropia
presents with in-
termittent cross- Ancillary Tests:
ing of the Cycloplegic refraction (to determine full hyperopic correction)
eyes, especially AC/A ratio (usually high)
when looking at
Management:
near objects. Re-
Full-time hyperopic correction (prescribe full cycloplegic refraction)
fraction reveals
, NBEO PEPs Study Cases
+4.00D hyper- Bifocal addition (if significant near esotropia remains with correction)
opia OU. Cov-
er test at near Patient Education:
shows a large es- "Your child's eye crossing is caused by a strong focusing effort due to farsighted-
otropia that im- ness."
proves with full "Glasses will help relax the eyes and reduce the crossing."
hyperopic correc- "We'll monitor vision and binocular function to ensure normal development."
tion. What is the
RTC: 2-3 months
most likely diag-
nosis?
5. A 12-year-old re- Diagnosis: Accommodative Insufficiency
ports difficul- Ancillary Tests:
ty focusing at Accommodative amplitude (reduced for age)
near, frequent NRA/PRA (low PRA, normal NRA)
headaches, and FCC (high lag)
eye strain that Accommodative facility (difficulty with minus lenses)
worsens through Management:
the day. No eye Plus lenses for near work (if indicated)
turns. No refrac- Vision therapy (accommodative amplitude training)
tion found - does Patient Education:
not wear glasses "Your focusing system isn't as strong as it should be for near tasks."
or contact lenses. "We may use reading glasses or therapy to improve your ability to focus up close."
What is the most "Regular breaks and good reading posture can help reduce strain."
likely diagnosis?
RTC: 1-2 months to assess symptom improvement OR 1-2 weeks to initiate in-office
vision therapy.
, NBEO PEPs Study Cases
6. A 65-year-old Diagnosis: Acute Angle Closure
Alaskan native
female presents Ancillary Tests:
with sudden on- Gonioscopy (confirm angle closure)
set of severe eye
Management:
pain, headache,
blurred vision,
Attempt compression gonioscopy to break angle attack
and nausea. She
reports seeing Initial Medical Management (Lower IOP and Reduce Inflammation):
halos around IOP lowering agents:
lights. VA is re- 3 rounds of drops every 15 minutes in-office:
duced, IOP is 52 Beta-blocker (Timolol 0.5%) - 1 gtt
mmHg, and slit Alpha agonist (Brimonidine 0.1%) - 1 gtt
lamp exam re- CAI (Dorzolamide 2.0%) - 1 gtt
veals a mid-di- Topical steroid (Prednisolone acetate 1% q1h) to reduce inflammation
lated, non-reac- --- If IOP remains elevated after in-office drops then refer to ER for emergent IOP
tive pupil with lowering with IV medication
corneal edema.
What is the most Definitive Treatment:
likely diagnosis? Urgent referral for LPI (Laser Peripheral Iridotomy) once IOP is controlled
Patient Education:
"Your eye pressure is dangerously high due to a blockage in the drainage system
of your eye."
"We are using medications to lower your pressure and prevent permanent dam-
age."
"You will need a laser procedure to prevent this from happening again."
"If you ever experience sudden eye pain and vision loss in the other eye, seek
emergency care immediately."
RTC: 1-2 days / 4-6 weeks after LPI
1. 40-year-old fe- Diagnosis: Anterior Uveitis
male presents Ancillary Tests:
with unilateral First time - no testing needed
eye pain, pho- Management:
tophobia, and Prednisolone acetate 1% q1-2h while awake
blurred vision for Cyclopentolate 1% BID
three days. No Monitor IOP at follow-up
discharge. Slit Patient Education:
lamp shows 2+ "You have inflammation inside your eye, similar to arthritis in the eye."
cells and flare "We are treating this with steroid drops and a dilating drop to relieve discomfort."
in the anterior "This condition can sometimes come back, and if it does, we may need additional
chamber. No ker- testing."
atic precipitates. RTC: 2-5 days for IOP and response to treatment, then weekly until resolved
IOP is 12 mmHg.
What is the most
likely diagnosis?
2. A 32-year-old Diagnosis: Recurrent Anterior Uveitis (Likely Associated with a Systemic Condition)
male with a his- Ancillary Tests:
tory of anteri- HLA-B27 testing (if not already diagnosed)
or uveitis pre- Additional systemic workup (if indicated): ANA, RF, chest X-ray (sarcoidosis),
sents with eye syphilis testing (RPR, VDRL)
pain, photopho- Management:
bia, and blurred Prednisolone acetate 1% q1-2h, then taper
vision in his right Cyclopentolate 1% BID
eye. He reports Referral to rheumatology for autoimmune workup
similar episodes Patient Education:
in the past. Slit "Since this is not your first episode, we need to evaluate whether an underlying
lamp shows 2+ systemic condition is contributing to it."
anterior chamber "This may be linked to autoimmune diseases such as ankylosing spondylitis or
cells and ker- sarcoidosis."
atic precipitates. "Proper treatment and monitoring can prevent complications like glaucoma or
, NBEO PEPs Study Cases
What is the most vision loss."
likely diagnosis? RTC: 2-5 days for IOP and response to treatment, then weekly until resolved
3. A 16-year-old fe- Diagnosis: Accommodative Excess
male complains Ancillary Tests:
of headaches and Binocular accommodative facility (reduced with plus lenses)
blurred vision af- FCC (lead of accommodation)
ter prolonged NRA/PRA (low NRA, high PRA)
near work. Symp- Cycloplegic refraction (to rule out latent hyperopia)
toms improve Management:
when she takes Near vision correction if latent hyperopia is present
breaks but wors- Plus lenses for near work (if indicated)
en when read- Vision therapy (accommodative facility training) - weekly in-office therapy with 5
ing for long days of home therapy
periods. Refrac- Patient Education:
tion shows low "Your eyes are over-focusing up close, which is causing fatigue and headaches."
hyperopia with "We may prescribe reading glasses or exercises to help relax your focus at near."
reduced accom- "Taking breaks and adjusting your reading habits can help improve symptoms."
modative facility. RTC: 4-6 weeks to assess symptom improvement and compliance with therapy OR
NPC and cover 1-2 weeks to initiate in-office vision therapy
test are normal.
What is the most
likely diagnosis?
4. A 4-year-old child Diagnosis: Accommodative Esotropia
presents with in-
termittent cross- Ancillary Tests:
ing of the Cycloplegic refraction (to determine full hyperopic correction)
eyes, especially AC/A ratio (usually high)
when looking at
Management:
near objects. Re-
Full-time hyperopic correction (prescribe full cycloplegic refraction)
fraction reveals
, NBEO PEPs Study Cases
+4.00D hyper- Bifocal addition (if significant near esotropia remains with correction)
opia OU. Cov-
er test at near Patient Education:
shows a large es- "Your child's eye crossing is caused by a strong focusing effort due to farsighted-
otropia that im- ness."
proves with full "Glasses will help relax the eyes and reduce the crossing."
hyperopic correc- "We'll monitor vision and binocular function to ensure normal development."
tion. What is the
RTC: 2-3 months
most likely diag-
nosis?
5. A 12-year-old re- Diagnosis: Accommodative Insufficiency
ports difficul- Ancillary Tests:
ty focusing at Accommodative amplitude (reduced for age)
near, frequent NRA/PRA (low PRA, normal NRA)
headaches, and FCC (high lag)
eye strain that Accommodative facility (difficulty with minus lenses)
worsens through Management:
the day. No eye Plus lenses for near work (if indicated)
turns. No refrac- Vision therapy (accommodative amplitude training)
tion found - does Patient Education:
not wear glasses "Your focusing system isn't as strong as it should be for near tasks."
or contact lenses. "We may use reading glasses or therapy to improve your ability to focus up close."
What is the most "Regular breaks and good reading posture can help reduce strain."
likely diagnosis?
RTC: 1-2 months to assess symptom improvement OR 1-2 weeks to initiate in-office
vision therapy.
, NBEO PEPs Study Cases
6. A 65-year-old Diagnosis: Acute Angle Closure
Alaskan native
female presents Ancillary Tests:
with sudden on- Gonioscopy (confirm angle closure)
set of severe eye
Management:
pain, headache,
blurred vision,
Attempt compression gonioscopy to break angle attack
and nausea. She
reports seeing Initial Medical Management (Lower IOP and Reduce Inflammation):
halos around IOP lowering agents:
lights. VA is re- 3 rounds of drops every 15 minutes in-office:
duced, IOP is 52 Beta-blocker (Timolol 0.5%) - 1 gtt
mmHg, and slit Alpha agonist (Brimonidine 0.1%) - 1 gtt
lamp exam re- CAI (Dorzolamide 2.0%) - 1 gtt
veals a mid-di- Topical steroid (Prednisolone acetate 1% q1h) to reduce inflammation
lated, non-reac- --- If IOP remains elevated after in-office drops then refer to ER for emergent IOP
tive pupil with lowering with IV medication
corneal edema.
What is the most Definitive Treatment:
likely diagnosis? Urgent referral for LPI (Laser Peripheral Iridotomy) once IOP is controlled
Patient Education:
"Your eye pressure is dangerously high due to a blockage in the drainage system
of your eye."
"We are using medications to lower your pressure and prevent permanent dam-
age."
"You will need a laser procedure to prevent this from happening again."
"If you ever experience sudden eye pain and vision loss in the other eye, seek
emergency care immediately."
RTC: 1-2 days / 4-6 weeks after LPI
