OPHTHALMOLOGY CASE
PRESENTATION
PRIYA ASHOK MENON
7TH TERM
RAMAIAH MEDICAL COLLEGE
PATIENT PARTICULARS
▸ Name : Mrs X
▸ Age : 65 years
▸ Homemaker
▸ Upper class by Modified Kuppuswamy Classification
▸ Residence : Whitefield, Bangalore
▸ Date of examination : 22.2.2020
CHIEF COMPLAINTS
▸ Diminution of vision in both eyes since 8 months, right eye more than left eye.
HISTORY OF PRESENTING ILLNESS
▸ Patient was apparently alright 8 months back, when she developed diminution
of vision in both eyes, right eye more than the left eye. It was insidious in onset
and gradually progressed to the current state. It was not associated with pain.
▸ Diminution of vision was same for both distance and near vision and was more
in bright light.
▸ It was associated with glare.
▸ She also mentioned that initially she was able to differentiate colors well but
now she finds colors dull.
▸ It was not associated with Redness;
▸ Watering;
▸ Discharge;
▸ Headache;
▸ Double Vision;
▸ Colored halos;
▸ Frequent changing of glasses;
OCULAR HISTORY
▸ She uses glasses since 20 years.
▸ No history of ocular surgeries
▸ No history of trauma
▸ No history of using eye drops in the past
PAST HISTORY
▸ Patient is a known diabetic since 15 years and hypertension since 10 years and
is on medication for the same.
▸ No history of Asthma, COPD, Ischemic heart disease.
FAMILY HISTORY
▸ No significant family history
PERSONAL HISTORY
▸ Mixed diet, predominantly non vegetarian.
▸ Normal Apetite
▸ Regular Bowel and Bladder Movements
▸ Normal Sleep
▸ No ill habits
GENERAL PHYSICAL EXAMINATION
▸ Patient was examined under adequate light.
▸ She was well oriented to time place and person.
2
▸ Height : 153 cm Weight : 65kg BMI : 27.7Kg/m
▸ Vitals :
Temperature : 98F
Pulse : 82 beats per minute
Blood Pressure : 140/ 80 mm Hg ; Right Arm Sitting Position
Respiratory Rate : 16 per minute
No Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema.
OCULAR EXAMINATION
▸ Head Posture Straight and erect.
▸ Both sides of the face are symmetric in appearance
▸ Ocular Symmetry : Symmetrical
Right Eye Left Eye
Visual Acuity
Counting fingers more than 6 m Counting fingers more than 6 m
(Bedside)
Eye Brows Normal Normal
Eyelids Normal Normal
Normal
Eyelashes Normal
Conjunctiva Normal Normal
Normal in size
Cornea Shape Normal in size
Transparency Shape
Sheen Transparency
Sheen
Right Eye Left Eye
Corneal Sensations
Sclera Normal Normal
Anterior chamber Normal depth and clear content Normal depth and clear content
Right Eye Left Eye
Iris Dark Brown in color Dark Brown in color
Normal pattern Normal pattern
Pupil 3mm round and circular 3mm round and circular
Direct Reflex Present briskly reactive Present briskly reactive
Indirect reflex Present briskly reactive Present briskly reactive
Near reflex Present Present
Right Eye Left Eye
Greyish white opacity seen Greyish white opacity seen
Lens
Iris shadow seen Iris shadow seen
Ocular Movements
Duction Free and full in all directions Free and full in all directions
Versions
Lacrimal Apparatus
Punctum Normal Normal
Skin over lacrimal sac Normal Normal
ROPLAS Negative Negative
Digital Tonometry Firm and Fluctuant Firm and Fluctuant
SUMMARY
▸ Mrs X, 65 yr old homemaker, came with complaint of painless diminution of
vision in both eyes since 8 months, Right eye more than left eye. It was same
for near and distance vision and was associated with glare .On examination,
the patient was found to have a grayish white opacity in the right and left
pupillary area and iris shadow was present.
PROVISIONAL DIAGNOSIS
▸ Bilateral Senile Immature Cataract.
