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Branch retinal vein occlusion case presentation shine.pptx
- 2. • 44 year old male • Driver by occupation • Resident of Aluva
- 3. Presenting complaint C/o defective vision in the right eye since 2 months
- 4. HISTORY OF PRESENTING ILLNESS Patient complaints of defective vision in the right eye since 2 months It was sudden in onset and progressive in nature No c/o redness, pain, discharge No c/o watering, photophobia, headache No c/o glare, coloured halos, diplopia No c/o distorted vision, flashes or floaters No h/o trauma to the eye No h/o frequent change of glasses
- 5. PAST MEDICAL HISTORY Pt recently diagnosed diabetic and on treatment No h/o HTN, CAD, Stroke, Asthma
- 6. ► Diet : Mixed ► Appetite : normal ► Sleep : Normal ► Bowel and Bladder: Regular. ► Addictions: Non smoker, Non Alcoholic PERSONAL HISTORY
- 7. FAMILY HISTORY No relevant history
- 8. ► Patient is conscious , Oriented ► Moderately built and nourished. No pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy or pedal edema ► Vitals: Afebrile PR: 76/min. RR: 20 cpm BP :140/80 mm hg ►Systemic examination : NAD GENERAL EXAMINATION
- 9. OCULAR EXAMINATION Normal head posture No facial asymmetry Orthophoric Ocular movements : ductions , versions and vergence full in all directions
- 10. REFRACTION RIGHT EYE LEFT EYE UNAIDED VISUAL ACUITY 3/60 6/6 SUBJECTIVE REFRACTION 3/60 NIG Plano 6/6 NEAR VISION +1.25 D SPH ( N12) +1.25 D SPH ( N6 ) IOP @10:55 AM 18 mmhg 18 mmhg
- 11. RIGHT EYE LEFT EYE LIDS & ADNEXA Lid margin healthy, eyelashes normal in orientation and number, duct orifices normal Lid margin healthy, eyelashes normal in orientation and number, duct orifices normal CONJUNCTIVA and SCLERA Normal Normal CORNEA Epithelium, stroma and endothelium normal Epithelium, stroma and endothelium normal ANTERIOR CHAMBER Quiet, VH grade 3 Quiet, VH grade 3
- 12. RIGHT EYE LEFT EYE IRIS Normal in colour and pattern No NVI/iris atrophy Normal in colour and pattern No NVI/iris atrophy PUPIL 3 mm round regular and reacting 3 mm round ,regular, reacting LENS Clear Clear AVF Quiet Quiet
- 13. RIGHT EYE
- 14. RIGHT EYE Slit lamp 90D biomicroscopy Media clear Disc normal in size, shape and colour with well defined margins, CDR 0.4 with healthy NRR. Vessels arise from the centre of disc , branching dichotomously with an AV ratio of 2:3 Superior retinal vessels appear dilated and tortuous with multiple flame shaped and dot blot haemorrhages along the superior arcade White fluffy ill defined lesions s/o cotton wool spots are also seen along the superior arcade Retinal thickening seen at the macula , s/o macular edema Yellowish well circumscribed deposits seen near macula , s/o hard exudates Slit lamp biomicroscopy findings confirmed with indirect ophthalmoscopy and periphery appears normal
- 17. OD
- 18. LEFT EYE
- 19. LEFT EYE Slit lamp biomicroscopy with 90D lens Media clear Disc normal in size ,shape and colour, well defined margins, CDR 0.5 with healthy NRR Vessels arise from the centre of disc , branching dichotomously maintaining an AV ratio of 2:3 Macula appears normal & Foveal reflex dull Background retina appears normal Slit lamp biomicroscopy findings confirmed with indirect ophthalmoscopy and periphery appears normal
- 20. OS
- 21. SUMMARY A 44 year old known diabetic male patient came with c/o defective vision in right eye since 2 months. On examination RE vision was 3/60 and left eye was 6/6. Anterior segment examination was normal in both eyes. On fundus examination the Right eye showed numerous flame shaped superficial hemorrhages along the superotemporal vascular arcade with macular edema.Left eye fundus appears normal
- 22. PROVISIONAL DIAGNOSIS Right eye - Superotemporal Branch retinal vein occlusion with macular edema
- 23. OD
- 24. OS
- 25. THANK YOU