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CASE CAPSULE
30 years old male, farmer by occupation
presented with chief complaints of
 Mass over Right lower eyelid since 3 months
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
• 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
Past history :
 No history of any major systemic illness
 No history of any previous ocular disease or medications
used in the past
Personal history :
 Patient is chronic tobacco chewer since 7 years
 Sleep, Appetite, Bowel and bladder habits are normal
Family history : Not contributory.
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
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
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
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
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
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.
Palpation
 Normal temperature
 Non tender
 Non reducing
 Cystic mass
 No thrills or pulsations felt.
 Transillumination test: positive
 Ascultation:
 No Bruits were heard
Provisional diagnosis
THANK
YOU

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CASE CAPSULE CORNEAL ULCER.pptx

  • 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
  • 16.