Case presentation 2

Case of PAthological Myopia with RD

1. CLINICAL
CASE PRESENTATION
Moderator: Dr. Umesh Harakuni
Presentor: Dr. Arushi Prakash
08/07/’1
4

2. PATIENT PARTICULARS
NAME: A.P.
Hospital In Patient No: 606236
AGE: 50 years
SEX: Male
RELIGION: Hindu
ADDRESS: Belgaum
OCCUPATION: Milk Seller

3. 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

4. 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

5. 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.

6. •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.

7. •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

8. •No history of-
Redness of eyes
Tufts of hair or cobwebs infront of eye
Sudden shower of red spots in front of eye
Excessive lacrimation
Diplopia
Ocular pain or headache
Recent trauma to the eye or head

9. Physical straining or stress
Ocular surgery (cataract, squint, removal of any
growth)

10. 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.

11. 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

12. Joint pains
Chronic drug intake
Previous hospital admission

13. 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

14. FAMILY HISTORY

15. 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

16. 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.

17. 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)

18. •Pallor ++
•Cheilosis +
•Loss of papillae on tongue
•Poor dental hygiene
•Koilonychia +
•He exhibits no evidence of
•Icterus
•Clubbing
•Cyanosis
•Lymphadenopathy
•Edema

19. SYSTEMIC EXAMINATION
•Cardiovascular system
On 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

20. SYSTEMIC EXAMINATION
In Pulmonary area a soft extrasystolic murmur is
present, best heard in sitting posture with breath
held in expiration

21. SYSTEMIC EXAMINATION
•Respiratory system
Bilaterally equal air entry on both sides.
Normal vesicular sounds heard on auscultation.
No adventitious sounds heard.

22. SYSTEMIC EXAMINATION
•Per Abdomen
All 4 quadrants on palpation are soft, non
tender.
No evidence of organomegaly present.
Normal bowel sounds heard.

23. SYSTEMIC EXAMINATION
•Central Nervous System
Higher mental functions intact.
No focal neurological deficit.

24. 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

25. Oculus Dexter

26. Oculus Sinister 

27. Visual acuity
•Colour Vision could not be assesed
Right eye Left eye
UCVA HMCF
PL +ve
PR accurate
PL +ve
PR innacurate
With pinhole No improvement No
improvement
Near Vision <N36 <N36

28. Retinoscopy : (with Tropicamide dilatation at 1m distance )
-24.0 No glow
• -24.0

Oculus Dexter Oculus sinister

29. •Patient does not acccept any subjective
correction.

30. INTRAOCULAR PRESSURE (with Schiotz)
RIGHT EYE LEFT EYE
12.2 mmHg Unrecordably low
Visual Fields
•Could not be assessed

31. Oculus Dexter

32. OD

33. A Scan
08/22/15
RIGHT EYE LEFT EYE
K1 44.50 D 43.75 D
K2 45.00 D 44.50 D
Axial Length 27.08 mm 25.08 mm
AC average 3.61 2.70
PCIOL +10.00 D +15.50 D

34. B- Scan Ultrasonography
OD

35. OS

36. 08/22/15
36
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

37. •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

38. 08/22/15
38
• Mini renal
Serum Urea – 23mg/dl
Serum Creatinine – 0.6 mg/dl

39. 08/22/15
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

40. OCULAR DIAGNOSIS
•Pathological Myopia
with
Right Eye Rhegmatogenous Retinal
Detachment with Choroidal Detachment
and
Left Eye Senile Mature Cataract with Total
Retinal Detachement