Ophtho On Call Case 10: Physical Exam

Ophtho On Call Case 10 Index

  Physical Exam: 

General appearance: Pt appears stated age, appears uncomfortable
Vitals: Temp: 37C, BP: 118/85, HR 58, RR 13, O2 Sat: 98% on room air 
Best Corrected Visual Acuity (BCVA): OD 20/20, OS 20/20
Pupils: OU equal round and reactive, no rAPD OU  
EOM: OD full, OS restricted supraduction

Confrontation Visual Fields (CVF): Full OU
Intraocular pressures (Tonopen in ED): OD 13 mmHg, OS 9 mmHg

External examination of the patient attempting upgaze is shown below:

orbital fx aao

Above Image Credit: © 2022 American Academy of Ophthalmology  

External slit lamp exam:
Eyelids: OS flat, OS periorbital ecchymosis and eyelid edema/swelling, decreased sensation over left cheek 
Conjunctiva: OD  white and quiet, OS tr injection
Cornea: OU clear 
Anterior Chamber: OD deep and quiet, OS deep with 1+cells
Iris: OU round and reactive
Lens: Clear OU

Dilated fundus exam of the both eyes is within normal limits (no retinal tears/breaks or vitreous hemorrhage). 

What’s at the top of your differential now?
Traumatic hyphema
Traumatic iritis
Globe rupture
Subconjunctival hemorrhage
Retrobulbar hematoma
Orbital fracture

What additional testing do you want to order?
MRI brain and orbits
CT head and orbits
Maxillofacial X-ray

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Ophtho On Call Case 10 Index
Ophtho On Call Case 10: Introduction