Physical Exam:
Vitals: Temp: 37.0C, BP: 110/72, HR 70, RR 16, BMI: 24 kg/m2
VA with correction: OD 20/20, OS 20/50
Pupils: equal and reactive OU, 3+rAPD OS
Intraocular pressures (IOP) by tonopen in ED: 16 mmHg OU
EOM: full OU, no nystagmus
Confrontation Visual Fields (CVF): OD visual fields intact to finger count, OS restricted superiorly
Red desaturation test: OD 100%, OS 60%
External ocular exam:
Eyelids: flat OU, no ptosis OU
Conjunctiva: white and quiet OU
Cornea: Clear OU
Anterior Chamber: Formed OU
Iris: flat OU
Lens: clear OU
Neuro Exam: Mental status exam is unremarkable. Cranial nerves are intact other than the left APD and decreased acuity. Motor, coordination, and gait exams are normal. There is mildly decreased sensation to pinprick in the right leg and foot. Reflexes are 2+ throughout except at the right patella which is 3+. Babinski sign is present on the right.
Fundoscopic exam of the right eye is within normal limits. Fundoscopic exam of the left eye shows the following:
Above Image Credit: © 2020 American Academy of Ophthalmology
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Neuro-oph Case 3 Index