CASE PRESENTATION BY DR.HASSAN ASGHAR,EYE UNIT 2 MAYO HOSPITAL,LAHORE

1. CASE PRESENTATION
DR.HASSAN ASGHAR
PGR 3RD YEAR MS OPTHALMOLOGY
OPTHALMOLLOGY UNIT II
KING EDWARD MEDICAL UNIVERSITY
MAYO HOSPITAL LAHORE
SUPERVISOR
DR.NASIR CHAUDHRY
Associate professor
HEAD OF DEPARTMENT
OPTHALMOLLOGY UNIT II
KING EDWARD MEDICAL UNNIVERSITY
MAYO HOSPUTAL LAHORE

2. Patinet Biodata
Name nasir mehmood
Age 40 years
Sex male
Ward Eye unit II, 6th floor male
bay
Mode of admission opd

3. Presenting complains
 Loss of vision right eye (decrease of vision right eye from 1 month and
complete loss of vison from 4 days
 Right eye pain, proptosis and periorbital swelling from 1 month gradual
onset
 Restreiction of extraocular movements having no movement in any
directionof gaze

4. History of present illness
My patient diabetic 1 year (not taking any treatment) and Hypertensive(found after he
reported us)
Was in usual state of health 1 month ago when he develop swelling /abscess in
superotemporal portion of orbit which was small in size lead to proptosis of right eye with
decrease of vision and pain .patient having severe pain from 10 days and loss of vision to
no perception of light from 4 days associated with severe pain,proptosis conjunctiva
congestion ,chemosis and restriction of extraocular movements of eye ,having nop
movement in any direction of gaze

5. Past ocular History
No any medical and surgical ocular history before
Personal History
History of diabetes from 1 year but not taking any treatment
Hypertensive(found when he reported us.call to medicine department attended for evaluation
and management
No history of Hepatitis B and C
Positive history of Tuberculosis 20 year ago treatment done,now cured
Positive history of dust allergy and asthma
No any history of joint pain,arthritis and other systemic pathology

6. Family History
Elder sister having diabetes mellitus positive history
No relevant history of proptosis in family
Medication /drug history
Patinet was not taking any medication for diabetes mellitus .after he reported us call to
medicine department attended insulin Mixtard 6 units bd dose adjusted patient was also
unaware about hypertensive status consultation with medicine departmenet done and
antihypertensive medications Tab Extor 60/160 given per oral once daily
Patient was taking pain killer medication dicloran tablets before reported in our opd

7. OCULAR
EXAMINATION
Right EYE LEFT EYE
VISUAL acuity NPL 6/12
EXOPTHALMOMETRY RIGHT EYE PROPTOSIS
27
LEFT EYE MEASUREMENT
17
Facial symmetry HISTORY OF FACIAL PASLY NOW
NORMAL
NORMAL
EXTRAOCULAR MOVEMENTS RESTRICTED EXTRAOCULAR
MOVEMNETS IN ALL DIRECTION
OF GAZE,FIX EYE BALL
NORMAL EXTRAOCULAR
MMOVEMNETS IN ALL
OF GAZE
conjuctiva SEVERE CHEMOSIS AND
CONGESTION
CLEAR
cornea CLEAR CLEAR
PUPIL RELATIVE AFFERENT PUPIILARY
DEFECT POSITIVE
ROUND ,REACTIVE AND

8. RIGHT LEFT
IRIS NORMAL COLOUR AND
PATTERN
NORMAL COLOUR AANND
PATTERN
LENSE CLEAR CLEAR
CLEAR DISC MARGINS
DISC PALLOR
ROTH SPOTS NOTED INFERIOR
ANND TEMPORAAL TO DISC
DILATED TORTUOS VESSELS
RETINA
CLEAR DISC MARGINS
CDR 0.4
NEURORETINAL RIM
CHOROIDAL FOLDS VISBLE CHOROID NO ANY PATHOLGY NOTED

9. RIGHT EYE
PROPTOSIS RIGHT EYE
UPER AND LOWER LID SWELING

10. RIGHT EYE OF PATIIENT SHOWING
PROPTOSIS MEASSUREMENT WAS 27
mm on first day of admission
exopthalmometre
Lids: right upper and llower llid swelling
Cornea clear
Conjuctiva congestion and chemosis
and protrusion
Pupil :relative afferent pupillary defect
EOM: FIX no movement ina ny direction
of gaze

11. Investigations
MRI BRAIN AND ORBIT WITHOUT CONNTTRAST
 Features are suggestive of orbital cellulitis with localize abscess
 FINDINGS RIGHT EYE SHOWS PROPTOSIS AS BULGING OUTWAR MEASURING 2.4CM FROM
LINE DRAWN FROM ZYGOMATIC ARCH
 RIGHT SIDE ED PRESETAL AND PERIORBITAL CELLULIITIS SEEN ALONG RIGHT CHEEK WITH
BLIRRING OF FFAT PLANES
 RETRO ORBITAL FAT STRANDING AND EDEMATOUS SEEN
 RIGHT SIDE MEDIAL RECTUS IS SWOLEN ANND EDEMATOUS ALONG WHOLE MUSCLE BELLY
 SMALL WALLED COLLECTION MEASURING 1*0.5cm in medial compartment of retroorbital area
causing extrinsic compression on optic nerve

12. DIFFERENTIAL DIAGNOSIS
 ORBITAL CELLULITIS
 CAVERNOUS SINUS THROMBOSIS

13.  Right parotid gland is also swollen
 Cavernous sinuus ,ophthalmic veins and intra cavernous portion of bilateral carotid arteries is
unremarkable
 Normal sella turciaca,pituary gland ,infundibular stalk,optic chiiasma and
hupothalmaus.normal tectal plate and pineal gland

15. MANAGEMENT
VISUAL ACUITY , Slit lamp Examination detail fundus examination and
exopthalmometry done all examinations finding noted
exopthalmometrey donemeasurements was 27 mm on first day of admission
 CALL to medicine attended for diabetes and hyperstesnion control
 Vitals monitoring blood sugra level and temperature being noted 6 hourly

16. medications
 INJECTION ceftriazone 1 gram IV BD
 INJECTION FLAGYL 500MG IV TDS
 INJECTION GENTAMYCIN 80MG BD
 TABLET SYNFLEX 1PO BD
 CAPSULE ICON 100mg per oral OD
 EYE DROP CODORZAL 1 DROP BD
 EYE DROP ALPHAGAN 1 DDROP BD
 EYE DROP MEGAMOX 1 DROP 2 HOURLY
 TAB ACETAZOLAMIDE 250MG 1 PER ORAL QID
 TAB NEO K 1 PER ORAL OD
 Inj dicloran IM sos

17. Call to medicine department attended for diabetes and hypertension medications
Advised
Insuline mixtard30 6 units subcutaneous BD
TAB EXTOR (60/160) I tab per oral OD
Again call for shifting to medicine ward sent due to active fever ,vomiting and non resolving
of symptoms and suspicion of coronus sinus thrombosis
Patient shifted to medicine ward

18. Management in medicine ward
 All topical medications continued
 Injection ceftriazone 1gram IV Bd
 Injection flagyl 500 mg IV TDs
 Injection Gentamicin 90 mg Tds
 Systemic antipyretic medication provas infusion given BD
 Injection Amphotericin B 5 microgram IV once a day given
 Injection normal saline 1000 ml IV OD started
 Cap icon 100 mg OD
 Tab brufen 400 mg TDs
 Injection nalbin given for severity of pain management
 Culture and sensitivity sent .labs awaited

19. Thanks