Ophtho On Call Case 9: Additional History & Physical Exam

Ophtho On Call Case 3 Index

Additional History: 

Upon further history, the patient reports taking ibuprofen frequently over the past 2 weeks for a shoulder injury sustained during boxing. 

Physical Exam: 

General appearance: Pt appears stated age, appears is acute distress
Vitals: Temp: 37C, BP: 137/80, HR: 118, RR 20
Best Corrected Visual Acuity (BCVA): OD Count Fingers at 3 Feet, OS 20/20
Pupils: OD sluggish pupil with apparent iris sphincter tear, OS round and reactive, no rAPD OU (performed by reverse)
EOM: full OU 

Confrontation Visual Fields (CVF): Full OU
Intraocular pressures (Tonopen in ED): OD 28 mmHg, OS 14 mmHg

Slit lamp examination of the left eye is within normal limits. External examination of the right eye is show below:

Screen Shot 2022-07-04 at 10.15.54 PM

Above Image Credit: © 2022 American Academy of Ophthalmology  

External slit lamp exam:
Eyelids: OD periorbital ecchymosis and eyelid edema/swelling, OS flat
Conjunctiva: OD  2+conjunctival injection, OS white and quiet
Cornea: OD tr edema, OS clear
Anterior Chamber: OD deep with ~4 mm layered hyphema, 3+microhyphema, OS deep and quiet
Iris: OD sphincter tear nasally, OS round and reactive
Lens: Clear OU

Dilated fundus exam of the left eye is within normal limits. There is no view to the fundus of the right eye, so B-scan is performed and is flat without vitreous debris.

Additionally, orbital imaging was performed in the ED and there is no evidence of retrobulbar hematoma or orbital fracture.

What’s at the top of your differential now?
Traumatic hyphema
Traumatic iritis
Globe rupture
Subconjunctival hemorrhage
Acute angle closure glaucoma

What additional historical information is important to elicit prior to initiating therapy (check all that apply)?
History of allergy to steroids
History of sickle cell anemia
History of hypertension
Anticoagulant use 

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Ophtho On Call Case 9 Index
Ophtho On Call Case 9: Introduction