glaucoma case presentation

Glaucoma case by Dr. Milan Paudel

1. WELCOME TO THE PRESENTATION Department of Ophthalmology Presented by Intern Doctor: Milan Paudyal

2. Name: Anjuara Begum Age: 60 years Gender: Female Religion: Islam Occupation: Housewife Marrital status: Married Address: Chamersori ,Ponchogor DOA:02-04-2017 @ 11:45am DOE: 02-04-2017 @ 12:00pm Particulars of the patient

3. Pain and redness in the left eye for 3 days. Marked dimness of vision in the same eye for 3 days. Chief Complaints

4. According to the statement of the patient, she was reasonably alright 3 days back . Then she developed sudden severe eye ache, redness and watering on her left eye. She also experienced marked dimness of vision and haloes around light on left eye. It was associated with headache History of Present Illness:

5. and few episodes of vomiting. With these complaints she attended in a local hospital and was treated with topical eye drops and oral medications. But the symptoms did not improve significantly . So she came to our hospital for better management.

6. No history of use of spectacles . No history of ocular trauma or surgery. Ocular Medications: Timolol + Brimonidine ED – Twice daily Tab Acetazolamide (500mg) – TDS Past Ocular History

7. She is recently diagnosed as hypertensive but has no history of – DM Bronchial Asthma. Hyperlipidemia. Migraine . General Medical History

8. She has no significant general surgical history General Surgical History

9. She is taking antihypertensive ( Amlodipine + Omlesartan) after being diagnosed as hypertensive here. Drug History

10. No significant systemic, ocular or drug allergic history. Allergic History

11. She has habit of taking betel leaf for 15 years. Personal History

12. She has 3 sons and 1 daughter. All are in good health. No family history of Glaucoma. Family History

13. She comes from lower middle class family. Socio-economic History

14. Appearance: Ill looking Body built & nutritional status: Average Co-operation : Co- operative Anemia : absent Jaundice: Absent Cyanosis : Absent BP : 180/110 mm of Hg Pulse : 80 per min Respiratory rate : 14 breaths per min Temperature : 98 F Lymph nodes : Not Palpable General Examination

15. Visual Acuity RE LE Distant Vision Unaided 6/6 CF 3 Feet With pin-hole 6/6 Not improved With correction 6/6 Not Applicable Near Unaided N8 Not Applicable With correction N5;add +1.00DSph Not Applicable Ocular Examination

16. RE LE Colour Vision Trichromatic Could not be evaluated Field of Vision Normal on Confrontation test Could not be evaluated Ocular Motility Full in all gazes Full in all gazes Pupillary Light Reflex Brisk Non-reactive Ocular Examination

17. RE LE Lid Normal Normal Conjunctiva Normal Ciliary Congestion Cornea Normal Hazy Ant. Chamber Shallow Very Shallow Pupil Round, regular, reactive Vertically oval, mid dilated, non reactive Lens NS1 NS1 Ant. Chamber Angle Narrow Could not be evaluated Fundus Optic Disc Macula Background Retina Vessels CDR 0.3 Normal Normal Normal Was not visible Slit Lamp Ocular Examination

18. 17.3 mmHg Intraocular Pressure 69.3 mmHg Ocular Examination

19. Respiratory System : Gastro intestinal system. Nervous system: Renal System : All other systems reveal no abnormality except cardio vascular system as patient is hypertensive. Systemic Examination

20. Mrs Anjuara Begum, 40 years old, hypertensive female coming from Chamerswori, Ponchogor was admitted in this hospital with complaints of pain, redness and marked dimness of vision in her left eye for 3 days associated with headache and few episodes of vomiting. Salient Features:

21. She has no significant past ocular history . On general examination , she is ill looking, BP- 180/110 mm of Hg and other vital signs are normal . On ocular examination , VA of left eye is CF at 3feet unaided , colour vision and field of vision could not be evaluated . On slit lamp examination , left eye shows ciliary congestion ,

22. h azy cornea, very shallow anterior chamber, p upil vertically oval , mid dilated and non- reactive , lens shows NS1, anterior chamber angle could not be evaluated and fundus was not visible. IOP on left eye high ( 69.3mmHg) and normal (17.3mmHg ) on right eye.

23. Acute Congestive Glaucoma (left eye) Provisional Diagnosis

24. Phacomorphic Glaucoma Acute Anterior Uveitis Differential Diagnosis

25. UBM of anterior chamber angle. Investigations

26. CBC with ESR FBS & 2HABF Serum Creatinine Fasting Lipid Profile Systemic Investigation

27. Medical Therapy Surgery Counseling Follow Up Plan of Management

28. 17.3mm Hg IOP 69.3mm Hg On admission: Difluprednate eye drop Brimonidine + Timolol eye drop 2% Pilocarpine ED Tab. Potassium Chloride (600mg) Tab. Acetazolamide(500mg) 2% Pilocarpine ED Tab. Amlodipine + Omlesartan 5/40 mg

29. 12.2mm Hg IOP 35.8mm Hg Pre- operative day Tab.Levofloxacin (750mg) Tab.Acetazolamide (250mg) Tab.Potassium Chloride(600mg) Tab . Amlodipine + Omlesartan 5/40 mg Difluprednate eye drop Levofloxacin ED Brimonidine + Timolol ED 2% Pilocarpine ED

30. Surgical Treatment Trabeculectomy (Lt eye) & Surgical Peripheral iridectomy (Rt Eye)

31. 12.2mm Hg IOP 4.0mm Hg 6/6 VA 6/9 1 st POD Tab.Levofloxacin(750mg) Tab . Amlodipine + Omlesartan 5/40 mg 2 % Pilocarpine ED Difluprednate eye drop Levofloxacin ED

32. 8.5mm Hg IOP 4.9mm Hg 6/6 VA 6/6 2 nd POD Tab.Levofloxacin (750mg) Tab . Amlodipine + Omlesartan 5/40 mg Tab. Mecobalamin (0.5mg) 2 % Pilocarpine ED Difluprednate eye drop Levofloxacin ED

33. 12.2mm Hg IOP 7.8mm Hg 3 rd POD Tab.Levofloxacin (750mg) Tab . Amlodipine + Omlesartan 5/40 mg Tab. Mecobalamin (0.5mg) 2 % Pilocarpine ED Difluprednate eye drop Levofloxacin ED

34. 12.2mm Hg IOP 17.3mm Hg 6/6 VA 6/6 On Discharge Tab.Levofloxacin(750mg) Tab . Amlodipine + Omlesartan 5/40 mg Tab. Mecobalamin(0.5mg) 2 % Pilocarpine ED Difluprednate eye drop Levofloxacin ED