CASE PRESENTATION

DR RUKSANA
FIRST YEAR OPHTHALMOLOGY RESIDENT
• A 58 YEARS OLD MALE CAME WITH A COMPLAINT OF DIMINUTION
OF VISON IN BOTH EYES SINCE 6 MONTHS
HISTORY OF PRESENTING ILLNESS:-
• PATIENT PRESENTED WITH C/O DIMINUTION OF VISION IN THE BE
SINCE 6 MONTHS WHICH WAS INSIDIOUS IN ONSET , GRADUALLY
PROGRESSIVE IN NATURE.
• NO H/O PAIN, REDNESS, WATERING, DISCHARGE, PHOTOPHOBIA,
GLARE
• NO H/O TRAUMA
• No h/o of frequent change of glasses
• No h/o difficulty in adjusting to darkness
• No h/o excessive near work
• No h/o headache, nausea or vomiting
• No h/o colored halos
• No h/o of systemic steroid usage
• No h/o of perception of black spots in front of the eye
• No h/o of similar complaints in the past
• No h/o transient obscuration of vision.
• No h/o of sleep apnea
• PAST HISTORY-
NOT A K/C/O DM,HTN,TB,ASTHMA,EPILEPSY, CVA,CAD
• PERSONAL HISTORY-
DIET-MIXED
APPETITE-NORMAL
SLEEP-ADEQUATE
BOWEL AND BLADDER-NORMAL

• FAMILY HISTORY-NOT SIGNIFICANT

• DRUG HISTORY- NO H/O KNOWN DRUG ALLERGIES
• GENERAL EXAMINATION
PATIENT IS MODERATELY BUILT AND MODERATELY NOURISHED
PR-86/MIN,REGULAR IN RHYTHM,VOLUME,NORMAL IN CHARACTER
BP-130/80 MM HG
RR-18/MIN
• SYSTEMIC EXAMINATION
CVS-S1S2 HEARD
RS-B/L NVBS HEARD
CNS-NAD
P/A-SOFT
LOCAL EXAMINATION

• FACIAL SYMMETRY NORMAL

• HEAD POSTURE NORMAL

OCULAR EXAMINATION

RE LE

• VISUAL ACUITY 6/36 WITH PH 6/6 6/36 WITH PH 6/6

• COLOR VISION NORMAL NORMAL

• EYE BROWS

LEVEL NORMAL NORMAL

CILIA NORMAL NORMAL

• ORBIT

INSPECTION NORMAL NORMAL

PALPATION NORMAL NORMAL

EYE BALLS

POSITION NORMAL NORMAL

MOVEMENTS NORMAL NORMAL

• EYE LIDS RE LE
POSITION NORMAL NORMAL
MOVEMENTS NORMAL NORMAL
LID MARGIN NORMAL NORMAL
EYE LASHES NORMAL NORMAL
SKIN OVER THE LIDS NORMAL NORMAL
• PALPEBRAL APERTURE
WIDTH NORMAL NORMAL
HEIGHT NORMAL NORMAL
• LACRIMAL APPARATUS
PUNCTA NORMAL NORMAL
LACRIMAL SAC AREA NORMAL NORMAL
REGURGITATION TEST NORMAL NORMAL
• CONJUNCTIVA RE LE
BULBAR NORMAL NORMAL

PALPEBRAL NORMAL NORMAL

FORNICES NORMAL NORMAL
• LIMBUS NORMAL NORMAL

• CORNEA
SIZE NORMAL NORMAL
SHAPE NORMAL NORMAL

SURFACE REGULAR REGULAR

TRANSPARENCY CLEAR CLEAR
SENSATIONS INTACT INTACT
• ANTERIOR CHAMBER ND ND
• IRIS RE LE
COLOUR NORMAL NORMAL
TEXTURE
• PUPIL NSRL NSRL
• PUPILLARY REACTIONS
DIRECT PRESENT PRESENT
CONSENSUAL PRESENT PRESENT
• LENS CLEAR CLEAR
• EXTRA OCULAR MOVEMENTS RE LE

FULL AND FREE FULL AND FREE

• NCT 12MMHG 14MMHG

• FUNDUS

MEDIA CLEAR CLEAR

OPTIC DISC NORMAL NORMAL

C:D 0.5:1 0.3:1

NRR THINNING OF INFERIOR NRR NORMAL

VESSELS NORMAL NORMAL

FR PRESENT PRESENT

PERIPHERAL NORMAL NORMAL

RETINA
PROVISIONAL DIAGNOSIS
? PRIMARY OPEN ANGLE GLAUCOMA (BE)