CLINICAL CASE

PRESENTATION

Moderator: Dr. Umesh HarakuniPresentor: Dr. Arushi Prakash

08/07/’14

PATIENT PARTICULARSNAME: A.P.Hospital In Patient No: 606236AGE: 50 yearsSEX: MaleRELIGION: HinduADDRESS: BelgaumOCCUPATION: Milk Seller

CHIEF COMPLAINTS•Progressively diminished vision in both

eyes since childhood•Loss of vision in Left Eye since 5 years •Sudden loss of vision in Right eye 20 days

ago

HISTORY OF PRESENT ILLNESS• Patient presented to KLES with complaints- • Ever since he was a small boy he had a faulty

vision as compared to his peers• Had diffculty in seeing blackboard• At the age of 10, he went to an

ophthalmologist who prescribed him glasses of number.

• Could see very clearly with those glasses

7

25

• As he grew older the number progressively increased and at last refraction 10 years ago was

• With each subsequent refraction vision kept on progressively deteriorating

• Since childhood patient has photophobia and experiences a little pain around eyes when direct light is put to his eye

• He has difficulty in judging depth and distances• Since past 6-7 years patient has difficulty in seeing

at night.

•5 years ago patient started developing increased diminution of vision in Left eye and within a period of one month he could no more than appreciate light from the light eye

•In the past 2-3 years he developed some black and blue spots in front of his right eye, which moved as he moved his eyes and persisted on closing the eyes also . Number of spots progressively increased.

•Since 25 days the patient started seeing lighting flashes infront of right eye even when it was dark at night and there was no light in the room.

•20 days back, the patient had gone to sell milk in the morning, and could see properly, as he was collecting money in the afternoon, he experienced sudden darkness infront of his eyes and could not count money.

•This loss of vision was so drastic that he did not even know how to go home

•After further 10 days of this sudden onset diminution of vision, the patient went to Ramkrishna Mission Ashram and was referred to KLESH for further evaluation

•No history of-Redness of eyesTufts of hair or cobwebs infront of eyeSudden shower of red spots in front of eyeExcessive lacrimationDiplopiaOcular pain or headacheRecent trauma to the eye or head

Physical straining or stressOcular surgery (cataract, squint, removal

of any growth)

PAST HISTORY• No history of similar complaints in the past• 10 years ago, while walking down the stairs

carrying a heavy weight object the patient fell and sustained injury to the left side of his head, above the left eye and on the chin for which sutures had to be put on the chin. Patient says he experienced no immediate deterioration of vision from this incident.

• While working night shifts in a plastic factory some 25 years ago, the patient often experienced night time chills which he attributes to an allergy to some material in the factory and which later stopped.

PAST HISTORY• History of easy fatigability since past 6 months

which has been progressively increasing

No history of –• Prolonged illness• Chronic Cough• Breathlessness• Diabetes• Hypertension• Haemoptysis• Malena

Joint painsChronic drug intakePrevious hospital admission

PERSONAL HISTORY•Diet - Vegetarain•Appetite – Markedly reduced•Sleep pattern - Disturbed•Bowel/Bladder habits - Unaltered•Addictions- Non smoker/ non drinker

No history of use of any recreational drugs

FAMILY HISTORY

FAMILY HISTORY•Patient was born of a consaginous marriage•Has 4 siblings and is third order child•Neither parents nor any of the siblings had

a similar complaint•Younger brother was prescribed glasses at

the age of 16 years, which after few subsequent refractions are now of number since few years

•None of the parents or the other three siblings had any history of spectacle use

10

FAMILY HISTORY•Patient’s father died at the age of 90 of

natural causes•Patient’s mother is 80 years old and suffers

from only age related degenerative changes•All of the patient’s siblings are alive and

healthy•He has a 10 year old son who goes to

school, does not wear glasses and has no ocular complaints.

GENERAL PHYSICAL EXAMINATION•Patient is a middle aged male,

moderately built poorly nourished man.•He is conscious, cooperative and well

oriented to time, place and person.

•Temperature – Afebrile to touch•Pulse - 70 beats/min•Respiratory Rate - 22 cycles/min•Blood Pressure – 110/70mmHg (in right

arm supine position)

•Pallor ++•Cheilosis +•Loss of papillae on tongue•Poor dental hygiene•Koilonychia +

•He exhibits no evidence of •Icterus•Clubbing•Cyanosis•Lymphadenopathy•Edema

SYSTEMIC EXAMINATION•Cardiovascular systemOn inspection- Distended neck veins present

On Palpation- Apical impulse cannot be palpated

Ausculation- Normal S1 and S2 heard in the mitral, tricuspid and aortic areas with no evidence of any murmurs

SYSTEMIC EXAMINATION In Pulmonary area a soft extrasystolic

murmur is present, best heard in sitting posture with breath held in expiration

SYSTEMIC EXAMINATION•Respiratory system

Bilaterally equal air entry on both sides.Normal vesicular sounds heard on auscultation.No adventitious sounds heard.

SYSTEMIC EXAMINATION•Per Abdomen

All 4 quadrants on palpation are soft, non tender.No evidence of organomegaly present.Normal bowel sounds heard.

SYSTEMIC EXAMINATION•Central Nervous System

Higher mental functions intact.No focal neurological deficit.

Ocular examination :• Head posture is erect • Facial symmetry maintained• Ocular posture – 30° of exotropia in left eye• Extraocular movements :

• Oculus dexter Oculus uterque Oculus sinister

N

N

N

N

N N

N N

N N

N

N

N

N

Oculus Dexter

Oculus Sinister 

Visual acuity

• Colour Vision could not be assesed

Right eye Left eye

UCVA HMCFPL +ve PR accurate

PL +vePR innacurate

With pinhole No improvement No improvement

Near Vision <N36 <N36

Retinoscopy : (with Tropicamide dilatation at 1m

distance ) -24.0 No

glow

• -24.0

Oculus Dexter Oculus sinister

•Patient does not acccept any subjective correction.

INTRAOCULAR PRESSURE (with Schiotz)

RIGHT EYE LEFT EYE12.2 mmHg Unrecordably

low

Visual Fields• Could not be assessed

Oculus Dexter

OD

A Scan

05/02/23

RIGHT EYE LEFT EYEK1 44.50 D 43.75 DK2 45.00 D 44.50 DAxial Length 27.08 mm 25.08 mmAC average 3.61 2.70PCIOL +10.00 D +15.50 D

B- Scan Ultrasonography

OD

OS

05/02/23

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Investigations•Hb – 04.8 gm%•TLC – 8,400 cells/cmm•DLC – N 69, L 26, E 03, M 02•ESR – 66 mm at the end of 1hour•PCV – 16.3 %•Platelet count – 5.4 lakhs/cmm•Absolute Eosinophilic Count- 225•Reticulocyte Count- 0.1

•RBC count- 3.19 million/ cmm•Peripheral smear- Microcytic hypochromic

anaemia, anicocytosis, pencil cells, tear drop cells and polychromatophils with thrombocytosis

•Blood Group – A positive

05/02/23

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• Mini renalSerum Urea – 23mg/dlSerum Creatinine – 0.6 mg/dl

05/02/23

39

•Liver Function Tests▫Total bilirubin - 0.8 mg/dl▫Direct bilirubin - 0.2 mg/dl▫Total protein - 6.6 g/dl▫Serum Albumin – 3.3 g/dl▫A:G Ratio – 1.0▫SGOT – 28 IU/L▫SGPT – 10 U/L

OCULAR DIAGNOSIS•Pathological Myopia

withRight Eye Rhegmatogenous Retinal Detachment with Choroidal Detachment

and Left Eye Senile Mature Cataract with Total Retinal Detachement