ophthalmology case posterior subcapsular cataract.pdf

Posterior subcapsular cataract case report hx investigation ophthalmic examination and surgery

1. OPHTHALMOLOGY
CASE
TCD 1
GROUP 1

2. PERSONAL HISTORY
•Mohsen AbdellatifAbdellatif, 64-year-old, worker in educational institute, married with 4
children youngest is 34-year-old.
•Non-smoker
•The patient was admitted on 23
rd
of September 2023 and examined by us 25
th
of
September .

3. COMPLAINT
Gradual diminution of vision over the last 6 months.

4. PRESENT HISTORY
Gradual progressive diminution of vision over the last 6
months and required to change myopic glasses with no
improvement.
No pain, discharge, lacrimation or photophobia
No visual fields defect, previous contact lens wear
No metamorphopsia or squint
No other system affection

5. PAST HISTORY
•No history of a similar condition.
•Patient is diabetic type 2 diagnosed 5 years ago with good compliance to Glimipridewith no
diabetic complications (stroke, diabetic foot, nephropathy) other than Diabetic Retinopathy.
•No hypertension or other systemic disease
•History of IVI once 2 years ago
•No history of trauma or surgeries

6. FAMILY HISTORY
•-No history of similar condition
•- No Parental consanguinity
•-No history of other medical disorders or hereditary diseases.

7. GENERAL
EXAMINATION
✓Cooperative patient, conscious and fully oriented.
✓no special decubitus or gait
✓Overweight built with good nutritional status (BMI 32)
✓no pallor , no cyanosis or jaundice
✓No rashes, purpura or petechiae
Vital signs:
➢BP: 140/80 pulse:88bpm RR:18 Temp:37
Head and neck examination:
• No lymph node enlargement
•No neck vein congestion or tracheal shift
Upper limb Examination:
•No tremors, cyanosis, clubbing or pigmentations
•No edema, bruises or scratch mark
Lower Limb Examination:
•No edema,ulcerations, varicose veins
•No other deformities, scars of previous operation or sinuses
Cardiac examination:
• No significant findings on inspection, palpation, percussion and
auscultation
Chest examination:
• No significant findings on inspection, palpation, percussion and
auscultation

8. OPHTHALMIC
EXAMINATION
Right eye Left eye
UDVA 6/24 6/60
External appearance Other Other
Other Dermatochalesis Dermatochalesis
Lid Normal Normal
Sclera Normal Normal
AC Normal Normal
Pupil Dilated under mydriaticDilated under mydryatic
Iris Normal Normal
Occular motility Full in all directions of gazeFull in all directions of gaze
Cornea Faint nebula Faint nebula
Conjunctiva normal Normal
Lens Senile immature cataractSenile immature cataract
Vitreons Floaters Floaters
Retina Diabetic nephropathy, non
proliferative
Diabetic nephropathy, non
proliferative
Optic disc Normal Normal

9. DIFFERENTIAL
DIAGNOSIS
•Causes of gradual painless diminution
of vision: retinopathy , optic nerve
atrophy, open angle glaucoma
•Senile immature cataract (diagnosis)

10. INVESTEGATIONS
•CBC , BG , HA1C, LFTs , RFTs
•Prothrombin time
•Perimetry for visual field assessment
•Colour vision for macula function
•Light projection for periphree of retina
•Pupillary light reaction
•A scan (biometry) & B scan

11. CBC

12. B Scan

13. TREATMENT
•Phacoemulsification with foldable IOL –left eye (+19.5D)

14. POST OPERATIVE CARE
•Vigamox eye drops, 6 times/day (moxifloxacin)
•Tobradex eye drops, 6 times/day (tobramycin)
•Polyfresh eye dropes, 4 times/day
•Tobradex eye ointment, once/day before bed
•Follow up in 1 week and check pupillary reflex and tension digitally post-
operative.