A long case presentation

1. Case Presentation
Dr. Rifat Binth Rezayee
Resident, Phase-B
Community Ophthalmology
BSMMU

2. Patient Particulars
 Name : Jobayer Islam
 Age : 7 years
 Sex : Male
 Father’s name : Robiul Islam
 Mother’s name : Salma Begum
 Religion : Islam
 Address : Shuagonj sadar, south cumilla
 Date of admission : 12th June ,2021
 Date of examination : 13th June ,2021

3. Swelling of left upper eyelid for three years.
Presenting Complaint

4. History of Present illness
According to the statement of patient’s mother , her son was
born with a tiny reddish spot in his left eyelid which was not
bothersome for a long period. When the child was about 3
years of age they noticed the spot had increased a bit. Then
they went to a local physician and got adviced to be on
follow up.
But the swelling progressively enlarged and became more
marked for the last four months. His mother also complained
that now her son could not open his eye due to the
progression .

5. History of Present illness (contd
 Swelling in left eyelid
 Progressive
 Purplish pink
 Soft
 Painless
 Nonpulsatile
 fluctuating
 increases during sleep

6. History of Present illness
 Headache
 Ocular surgery
 Radiotherapy
 Using spectacles
 Ocular patching
 No history-
 Visual disturbance
 Double vision
 Photophobia
 Trauma
 Fever
 Excessive lacrimation
 Grittiness ,itching

7. History of Present illness (contd)
 For these reasons they consulted with different
ophthalmologists in Cumilla , Chattogram and Dhaka.
 Finally patient has been referred to BSMMU for better
management.
 Patient is non asthmatic, non diabetic.

8. As noted before.
Past Ocular history

9. Nothing contributory
Past Medical history

10. Family history
 Master Jubayer is the first and only child of his non-
consanguinous parents.
 His parents did not suffer in such disease or other congenital
and ocular diseases.
 His parents are non diabetic ,non asthmatic ,not hypertensive
and are in sound health now.
 His mother was not exposed to any infectious diseases,
radiotherapy during pregnancy period but got essential anti
natal visit.

11.  He was delivered by caesarean section
 His pre and postnatal period was uneventful
according to his mother’s statement.
Natal history

12. Duely immunized according to EPI schedule.
Immunization history

13. Nothing contributory.
Drug history

14.  Patient belongs to lowermiddle socioeconomic background.
 Lives in brickbuilt house with proper sanitation.
 Drinks tubewell water.
Socioeconomic history

15.  Appearance : agitated,facial
asymmetry.
 Co operation - irritated
 Height : 0.92 m
 Weight : 22 kg
 Pulse : 88 beats/min
 Blood pressure : 100/60 mm Hg
 Temperature- 98°F
 Respiratory rate- 28 breaths/min
 Oedema / pretibial myxoedema-
absent
 Clubbing/koilonychia/
leuconychia – absent
 Anaemia/Jaundice
/cyanosis/palmar erythema-absent
 Dehydration – absent
 Lymphnode – not enlarged
 Neck vein – Not engorged
 Thyroid gland –not enlarged
General examination

16. Local examination
Inspection :
 Facial asymmetry with slight face turn due to
swelling in left lid causing drooping of that lid.
 Site- left upper eyelid
 Size- 30x18 mm
 Shape- oval
 Colour-dark purplish with visible vasculature
 surrounding skin- normal
 Visible pulsation- absent
 No scarring and ulceration
 Hair follicle- absent

17. Local examination
 Palpation :
 Temperature- increased than the
surrounding site.
 Tenderness- absent
 Surface –irregular
 Consistancy – soft and but not
blanches with pressure.
 Margin – Well delineated.
 Overlying skin- free
 Fixity- fixed with underlying lid
structure.
 Mobility-not mobile but fluctuant
 Slip sign- negative

18. Local examination
 Palpation :
• Transillumination test- negative
 Pulsation -absent
 Finger insuination -possible
 Compressibility- compressible
 Reducibility- reducible.
 Valsalva manoeuvre-negative
Regional lymphnode –not enlarged
 Auscultation – no bruit

21. Ocular examination
Right Eye Left Eye (everting the lid)
Visual acuity( Unaided) 6/6 6/6
Near Vision N6 N6
Colour vision Trichromatic Trichromatic
Pupillary light reaction
Direct Brisk Brisk
Consensual Present Present
RAPD Absent Absent
Hirschberg Reflex Central Central
Confrontation Test Normal in all quadrants Could not assesed reliably
Ocular Motility Full in all gazes Full in all gazes.
Corneal sensation Intact Intact

22. Lagophthalmos- Absent
Bells phenomenon- Good
 Marcus gunn jaw winking phenomenon - absent
4+5
mm
-4
mm
MRD
9 mm 0 mm
PFH

23. Slit lamp examination
Right Eye Left Eye(everting lid)
Eyelid Normal oval swelling ,drooping
of lid
Conjunctiva Not congested Not congested
Cornea Transparent Transparent
Anterior chamber Normal in depth and
contour
Normal in depth and
contour
Iris Normal in colour and
pattern
Normal in colour and
pattern
Pupil Round regular and
reacting to light
Round regular and
reacting to light
Lens Transparent Transparent
IOP 14 mm Hg(NCT at
14/6/21 at 1.30pm)
apparently normal by
palpation

24. Fundus Examination
Right eye Left eye
Media Clear
Optic disc Could not visualized as there
is a mass over the lid.
C:D 0.3
Blood Vessels Normal in count and
pattern
Macula Healthy
Foveal reflex Present
Peripheral Retina Normal

25. Systemic Examinations

26. Respiratory System
Inspection:
Size & Shape- Normal
Chest movement- bilaterally symmetrical
Palpation:
Position of trachea- Normal
Vocal fremitus- resonant
Chest expansibility- Normal & bilaterally symmetrical
Percussion :
Resonant
Auscultation:
Breath sound-Vesicular
Vocal resonant- normal
No added sound

27. Cardiavascular System
Inspection:
Apex beat- visible
Palpation:
Apex beat in left 5th ICS
Blood pressure-100/60 mmHg
Percussion:
Superficial cardiac dullness present
Auscultation:
S1+S2 audible
Murmur absent

28. Alimentary System
 Oral cavity:
Normal
 Abdomen proper:
 Inspection:
Size & shape-Normal
Position of umbilicus- centrally and everted
No scar mark or visible pulsation
 Palpation:
Superficial –normal
Deep- no tenderness and no organomegaly
 Percussion: Tympanic
 Auscultation:
Bowel sound present

29. Nervous System
 Higher cerebral function : Intact
 Level of consciousness- GCS score 15/15
 Motor function and reflexes- Intact
 Cranial nerves – Intact
 Sensory – Intact
 Cerebellar function- Intact

30. Musculoskeletal System
 Gait- Normal
 locomotor function – normal
 Spine-normal

31. Salient Feature
Master Jubayer of 7 years of age residing in Cumilla
presented with the complaint of left upper eyelid swelling for
three years which had been markedly progressive for last four
months. Swelling had been painless, soft & increases with
sleep but not with crying or straining.

32. Salient Feature
On examination, his BCVA in B/E is 6/6 & N5. Local
examination revealed an oval shaped swelling in left
upper eyelid measuring about 30x18 mm in diameter
causing mechanical severe ptosis. It was soft,
compressible, non tender, fixed with underlying structure,
not blanches with pressure, transillumination test-
negative, no regional lymphnode involvement.
Rest of ocular examination found normal in both eyes
though fundus examination could not be assessed reliably
in left eye .

33. Mechanical ptosis due to
Capillary haemangioma of
left upper eyelid
Provisional diagnosis

34. Arteriovenous
malformation
Lymphangioma
Differential Diagnosis

35. Investigations
 Heamatology (14/6/2021)
 Hb- 12.0g/dl
 ESR- 17 mm in 1st hour
 WBC- 11.5 x 10 /L
 RBC-5.42x 10 /L
 Plateletes-450x 10 /L
 Bleeding time-3 min 30 sec
 Clotting time-5 min 30 sec
 serum creatinine-0.64 mg/dl

36. CT scan of Orbit (Axial)

37. CT scan of Orbit (Axial)

38. Duplex study of left upper lid

39. Duplex study of left upper lid

40. Duplex study of left upper lid

41. Duplex study of left upper lid

42. CT Angiogram
ECA(left)
Oph.art(lt)
ICA(left)
NIDUS

43. CT Angiogram

44. CT Angiogram

45. Arteriovenous malformation
of
left upper eyelid
Clinical diagnosis

46. Multidisciplinary approach
Patient
Ophthalmology
Radiology
Vascular surgery
Oculoplasty

47. Management Plan
 Councelling
 Referral to Vascular surgeon
 Proposed Vascular intervention by
Endovascular chemo-embolization by angiogram of
feeding vessel or External carotid artery ligation
 Followed by Oculoplastic intervention.
 Follow up.