2. 30 years old male, farmer by occupation
presented with chief complaints of
Mass over Right lower eyelid since 3 months
3. History Of Present Illness :
Patient was apparently alright 3 months back when he noticed
swelling over right lower eyelid margin which was painless,
gradually increasing in size.
Patient took treatment from a private hospital, details of which
are unclear.
During the treatment, there was trauma to right eye by a glass
particle which induced bleeding from the mass, followed by
ulceration and Scab formation
4. • No h/o defective vision
• No h/o pain/discharge/fever
• No h/o any surgery in the past
• No h/o similar swelling over any other part of body
• No h/o loss of weight
5. Past history :
No history of any major systemic illness
No history of any previous ocular disease or medications
used in the past
6. Personal history :
Patient is chronic tobacco chewer since 7 years
Sleep, Appetite, Bowel and bladder habits are normal
Family history : Not contributory.
7. Examination :
GENERAL EXAMINATION:
Patient is conscious, co-operative, oriented to time place
and person
Afebrile
Pulse- 88bpm
BP- 120/80 mm Hg
SYSTEMIC EXAMINATION:
Within normal limits
8. Ocular examination:
Facial Symmetry- Absent
Head posture- normal
Ocular position – normal
OD OS
EXTRAOCULAR
MOVEMENTS
Full ranged, free and
painless in all the gazes
Full ranged , free and
painless in all the gazes
VISUAL ACUITY 6/6 6/6
COLOUR VISION NORMAL NORMAL
9. OD OS
LID Mass of size 1.5cm x 1.5cm
arising from middle 1/3rd
of Lower Lid margin
causing mechanical
ectropion
NORMAL
CONJUCTIVA Normal NORMAL
Examination of Anterior Segment:
ANTERIOR CHAMER NORMAL DEPTH, CLEAR NORMAL DEPTH, CLEAR
IRIS BROWN , NORMAL
TEXTURE
BROWN , NORMAL
TEXTURE
10. EXAMINATION OF ANTERIOR SEGMENT:
OD OS
PUPIL
SIZE
SHAPE
POSITION
REACTION
3MM
CIRCULAR
CENTRAL
RTL
3MM
CIRCULAR
CENTRAL
RTL
IOP Digitally Normal Digitally Normal
LENS CLEAR CLEAR
11. EXAMINATION OF POSTERIOR SEGMENT:
Indirect Ophthalmoscope
OD OS
Fundus Media- clear
Disc- average size and shape,
NRR healthy, margins well
defined, CDR 0.3
Blood vessels- A:V = 2:3
Foveal reflex- present
Media- clear
Disc- average size and shape,
NRR healthy, margins well
defined, CDR 0.3
Blood vessels- A:V = 2:3
Foveal reflex- present
12. Examination of Lid Mass
Inspection:
Approx. 1.5cm x 1.5cm in size, oval, smooth, sessile, slightly pinkish
in colour at middle 1/3rd of lower lid margin with dilated blood vessels
on the surface with healing ulcer on the lateral aspect of the mass.
No oozing or discharge.
Mass is causing mechanical ectropion of lower lid.
13.
14. Palpation
Normal temperature
Non tender
Non reducing
Cystic mass
No thrills or pulsations felt.
Transillumination test: positive
Ascultation:
No Bruits were heard
