Upon further history, the patient reports taking ibuprofen frequently over the past 2 weeks for a shoulder injury sustained during boxing.
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:
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.
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Ophtho On Call Case 9 Index
Ophtho On Call Case 9: Introduction