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