CA1a Posterior Segment

Case #1
Part 2

History: 25 year Caucasian male presents to clinic for an eye examination. He has
no significant medical history and is not taking medications. He denies family
history of eye diseases.
His last eye examination was 2 weeks ago. He does not wear glasses or contact
lenses. He states he has perfect vision.

Chief complaint: Patient reports for a second opinion after having a recent eye
examination. He reports he was told he has a spot in the back of his eye. He does
not remember which one. He denies blurred vision, eye pain or irritation or
redness.

Gross observation: Patient is alert and oriented. See below picture

DVA sc OD: 20/20 NVA sc: OD 20/30

OS: 20/20 OS 20/30

EOMs: FROM OU
CVF (confrontation visual fields): FTFC OD, OS
Pupils: PERRL (-)APD

Anterior segment with SLE:

Lids/lashes: Clear OU
Conjunctiva: white and quiet OU
Cornea: Clear OU
Iris: Clear OU
Anterior Chamber: Deep and quiet OU, 4+ N/T OU
Lens: Clear OU

DILATED posterior segment with 90D and BIO:

Optic nerve: pink and distinct
C/d: OD 0.6 OS 0.55
Macula: clear, +FR OU
Vasculature: ¾ OU
Periphery: 1.5 DD pigmented lesion with defined borders and underlying drusen.
Located approximately 1 DD superior temporal to optic nerve. Not present with
red-free filter (-)vascularization, orange pigment. See photos below
OS: Clear, flat and intact

What is your diagnosis?

What is your treatment plan? Prognosis?
When would you like to see this patient again?
How would you educate the patient regarding the diagnosis?