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:
[/quiz]
Click here for more information!
Ophtho On Call Case 5 Index
Ophtho On Call Case 5: Introduction