General appearance: Anxious, diaphoretic male, sitting upright
Vitals: Temp: 37C, BP: 120/80, HR: 100, RR 18,
Best Corrected Visual Acuity (BCVA): OD Hand motion OS 20/25
Pupils: OD hazvy view, OS round and reactive
EOM: OU full
Confrontation Visual Fields (CVF): OD unable, OS full
Intraocular pressures: OD 23 mmHg, OS 18 mmHg
External ocular exam:
Eyelids: OD matting of eyelashes with yellow discharge, OS flat
Conjunctiva: OD 3+conjunctival injection, OS white and quiet
Cornea: OD 1+stromal edema with haze, OS clear
Anterior Chamber: OD 4+cell and flare, 1 mm layered hypopyon inferiorly, OS deep and quiet
Iris: OD round, minimally reactive, OS round and reactive
Lens: OD IOL with overlying fibrinous material, OS PCIOL
An external photograph of the right eye is shown below:
Dilated fundus exam:
Upon attempting dilated exam in the right eye, there s no view. The left dilated fundus exam is WNL.
A B-scan of the right eye is performed and shown below:
Above Image Courtesy of Jeanette Du, MD
OD showed hyperechoic vitreous debris. The retina is flat and attached 360 degrees. No evidence of retained lens fragment.
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