Case presentation

Entropion with Pterygium with ARC

1. Case Presentation DR. MALIHA NAWAR RESIDENT, PHASE-A(YEAR-2) COMMUNITY OPHTHALMOLOGY BANGABANDHU SHEIKH MUJIB MEDICAL UNIVERSITY

2. Particulars of the patient Name: Abdul Bari Age: 60 years Sex: Male Occupation: Farmer Address: Potuakhali Religion: Islam Date of examination: 17/11/21 2

3. Chief complaints : Blurring of vision in both eyes for 1 year. Watering from both eyes for 8 months. Eye ache during blinking, photophobia and gritty sensation in both eyes for 8 months.

4. History of present illness: According to the statement of the patient, he was reasonably well about 1 year back. Then he developed gradual blurring of distant vision in both eyes. But for the last 8 months, his vision was more deteriorated in right than left eye. He had history of occasional watering from both eyes. Gradual blurring of vision was associated with photophobia, eye ache and gritty sensation.

5. History of present illness: But wasn’t associated with redness, discharge, headache, or seeing color halos. He is normotensive, non diabetic and non asthmatic. With these above complaints he came to BSMMU, Department of Community Ophthalmology through OPD for better management. 5

6. History of past illness: No history of trauma, surgery or any significant systemic illness in the past. 6

7. Family History: None of his family member is suffering from same type of problem All of them are healthy. 7

8. Drug History: Tab. Pantobex (20mg)-1+0+1(Pantoprazole) Tab. Atova (10mg)-0+0+1(Atorvastatin) Tab.Ecospirin (75mg)-0+1+0(Aspirin) 8

9. Personal History: He is non smoker, non alcoholic but chews betel leaf & nuts. He maintains personal hygiene.

10. Socio-economic History: Belongs to a low socio-economic family. Lives in a tin-shade house, drinks tube well water and use sanitary latrine. 10

11. Immunization History: He is well immunized according to EPI schedule. 11

12. General examinations: Appearance- Normal Co operation-Co-operative Body built- Average Nutrition-Good Decubitus- On choice Anaemia - Absent Jaundice-Absent Cyanosis- Absent Oedema-Absent 12

13. General examinations: Dehydration-Absent Clubbing-Absent Neck vein-Not engorged Lymph node –Not enlarged Thyroid gland-Not enlarged Pulse -76 beats/minute BP-120/80 mm of Hg Respiratory rate- 16 breaths/min Temperature-98.6 degree F 13

14. Ocular examination: Ocular Examination Right eye Left eye Visual acuity-distant vision 6/18 6/12 with pinhole 6/9 6/9 near Vision N10 N10 BCVA 6/9 (-2.00 DCYL@15 ˚ ) N6 with +2.50D Sph 6/9 (-0.50 DCYL@120 ˚ ) N6 with +2.50D Sph Pupillary light reflex- Direct Consensual Brisk Present Brisk Present Hirschberg reflex Central Central RAPD Absent Absent Ocular motility Full in all gaze Full in all gaze Color Vision Trichromatic Trichromatic

15. Slit lamp findings: Right eye Left eye Eye lids Inward turning of the eyelid margin Normal Eye lashed Normal Normal Conjunctiva Mildly congested, a triangular fibrovascular band with overlying blood vessels which extend from medial canthus up to the cornea at 3 O’clock position. 9 O’ clock position. Mildly congested, a triangular fibrovascular band with overlying dilated blood vessels which from medial canthus up to the cornea at 3 o’clock position. 9 o’clock position. Cornea A triangular slightly pinkish band at 3 o’clock position which invade cornea. Approximate diameter, measuring about 7 mm in height at apex, breadth 5.5 mm at limbus. Transparent

16. Slit lamp findings: Right eye Left eye Anterior Chamber Normal in depth both in centre and periphery Normal in depth both in centre and periphery Iris Normal in color and pattern Normal in color and pattern Pupil Round regular and Reacting to light Round regular and Reacting to light Lens Lental opacity present ( Nuclear sclerosis grade – I+cortical ) cataract Lental opacity present ( Nuclear sclerosis grade – I+cortical ) cataract IOP(by GAT at 17/11/2021 @ 1.06pm) 11mm of Hg 13 mm of Hg

17. Fundus examination: Fundus examination ( Direct ophthalmoscopy) Right eye Left eye Media Hazy Hazy Optic disc-Color Pink Pink Margin Well defined Well defined Shape Circular Circular CD ratio 0.5 0.5 Blood vessels Myopic cresent Normal in number and distribution Background fundus Tesselleted Tesselleted Macula Healthy, Foveal reflex present Healthy, Foveal reflex present

18. right eye: (naked eye view) 18

19. left eye: (naked eye view)

20. Diffuse illumination view of right eye 20

21. Diffuse illumination view of left eye 21

22. Oblique focal illumination view of right eye 22

23. Oblique focal illumination view of left eye 23

24. Retro illumination view of right eye 24

25. Retro illumination view of left eye 25

26. Special ocular examination: Sac patency test- On right side- Fluid easily pass into the nose and naso-pharynx.Lacrimal drainage system is patent. On left side- Fluid easily pass into the nose and naso-pharynx.Lacrimal drainage system is patent.

27. Examination of the cardiovascular system: Inspection – Shape of the chest-normal. Arterial pulse- 76 beats/min Blood pressure- 120/80 mm of Hg 20XX 27

28. Examination of the cardiovascular system: Palpation- Apex beat-present in left 5 th intercostal space just medial to the mid clavicular line.There was no thrill. Percussion-area of superficial cardiac dullness normal. Auscultation- The first and second heart sounds were audible . There is no added sound. 28

29. Examination of the Respiratory System: Inspection-Nasal cavity-normal Nasopharynx-NAD Oral cavity-NAD Oropharynx-NAD Respiratory rate-16 breaths/min Shape of the chest-normal ,bilaterally symmetrical Palpation-position of the trachea central. Percussion-resonant Auscultation-vesicular breath sound 29

30. Alimentary system: Inspection : Size and Shape – Normal Position of the Umbilicus – central Palpation : Temperature is normal. There is no tenderness, rigidity or swelling. Percussion : Tympanitic Auscultation : Bowel sound present. 30

31. Musculoskeletal system: Gait: Normal Arms: Normal Limbs: Normal Spine: Normal 31

32. Examination of the Nervous System: Higher cerebral function- intact Patient is conscious and oriented , gait normal. All cranial nerves-intact Motor function-There is no muscle wasting ,bulk and tone of muscle is normal in both upper and lower limbs . Reflexes- are intact and normal. Sensory function-Temperature ,touch , pain and vibration and position sense intact. Cerebellar function- intact Signs of meningeal irritation -absent 32 This Photo by Unknown Author is licensed under CC BY-SA

33. SALIENT FEATURES: Mr. Abdul Bari,60yrs old male presented to BSMMU Community Ophthalmology OPD with complaints of gradual blurring of vision in both eyes for 1year. But for last 8 months,his vision was deteriorated more in right than left eye. He had history of occasional watering from both eyes. Gradual blurring of vision was associated with photophobia, eye ache and gritty sensation for same duration. All his vital parameters are normal. 33

34. SALIENT FEATURES: His ocular examination revealed VA R/E 6/18 with Pinhole 6/9 , VA L/E 6/12 with Pinhole 6/9. B/E near vision N10.BCVA 6/9(-2.00 DCYL@15˚)right eye and 6/9(-0.50DCYL@120˚)left eye. N6 with addition + 2.50 D spherical. Slit-lamp examination showed inward turning of the right eyelid margin. Conjunctiva m ildly congested, a triangular fibrovascular band with overlying blood vessel which extend from medial canthus up to the cornea at 3 o’clock position and 9 o ’ clock position both eyes. 34

35. SALIENT FEATURES: Over right eye, a triangular slightly pinkish band at 3 o’clock position which invade cornea ,a pproximate diameter, measuring about 7 mm in height at apex, breadth 5.5 mm at limbus. Lental opacity present( nuclear sclerosis grade-I+cortical cataract) in both eyes 35

36. Provisional diagnosis: Entropion(right eye) with Nasal and temporal Pterygium both eyes with Age related cataract of both eyes (NS grade-I + cortical cataract) 36

37. Differential diagnosis: Spastic Entropion of right eye with pterygium both eye with Age related Cataract Entropion of right eye with pseudo pterygium with traumatic cataract. Entropion of right eye with OSSN(Ocular Surface Squamous N eoplasia )with Age related cataract. 37

38. Investigations: RBS- 7.7 mmol/L ECG –RBBB(right bundle branch block) RT PCR for COVID-19 –Negative HbsAg - Negative Echocardiography-32% 38

39. Plan of management: Correction of entropion Followed by (after 6 weeks) excision of pterygium with conjunctival autograft of right eye then left eye under local anaesthesia Followed by Cataract Extraction with PC-IOL implantation under Local anaesthesia . 39

40. Thank you