Ophtho On Call Case 5: Additional History & Physical Exam

Ophtho On Call Case 5 Index

Additional History: 

Upon further questioning, the patient reveals that he noticed an increased number of black specks in his right eye several weeks ago but he never got around to making an appointment for it. He had difficulty reading the paper this morning because he could only read the left half of the page. He denies trauma or prior surgery. A review of his chart revealed high myopia with his most recent refraction measuring -6.00 diopters in both eyes.  

Physical Exam: 

General appearance: Well-groomed and in no apparent distress; appears stated age
Vitals: Temp: 37C, BP: 130/80, HR: 68, RR 17, 
Best Corrected Visual Acuity (BCVA): OD 20/50, OS 20/20
Pupils: Pupils equal and reactive to light OU, no rAPD OU
EOM: full OU 

Confrontation Visual Fields (CVF): OD- Restricted in inferonasal quadrant, OS full
Intraocular pressures (Tonopen in ED): OD 15 mmHg, OS 19 mmHg


External ocular exam:
Eyelids: flat OU, no ptosis OU
Conjunctiva: white and quiet OU
Cornea: Clear OU
Anterior Chamber: Deep and quiet OU
Iris: Round and reactive OU
Lens: 1+nuclear sclerosis OU


Dilated fundus exam:
Vitreous: OD +Shafer’s sign, OS vitreous syneresis
Optic nerves: C/D 0.3 OU, sharp and pink OU

Macula: Flat OU, no microaneurysms, dot-blot hemorrhages, hard exudates, or neovascularization
Vessels Attenuated OU
Periphery: OD see image below; OS flat, no breaks 360

An image of the peripheral retina in the right is shown below:

retinal tear

Above Image Credit

How would you describe the image above?
Giant Retinal tear with surrounding retinal detachment  
White without pressure
Presence of scleral buckle


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Ophtho On Call Case 5 Index
Ophtho On Call Case 5: Introduction