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Case presentation on the topic BRVO.pptx
- 1. CASE PRESENTATION Dr. RahulGupta 2nd year Resident Department of ophthalmology 18th September, 2024
- 2. • Name: BelBahadur Shrestha • Age : 65 years • Sex : Male • Occupation : Teacher • Address : Chautara, Sirubari-6, Sindhupalchowk • Contact: 9818251376 • Mode of presentation: OPD • Date of Presentation : 2024/06/27
- 3. CHIEF COMPLAINS Sudden Blurringof Vision of Left Eye x 4 days
- 4. HISTORY OF PRESENTINGILLNESS • The patient was apparently well 4 days back when he developed sudden blurring of vision in his left eye, which was acute in onset, gradually progressive in nature. • It was not associated with pain, Itching, redness, discharge. • There was no complain of watering, photophobia, • There was no complain of glare, coloured halos, • There was no complain of distorted vision, flashes or black shadows • There was no history pain on ocular movement. • There was no complain of headache, trauma, fever.
- 5. PAST HISTORY PAST OCULARHISTORY: • No similar ocular illness in the past. • No any ocular surgery in past. • No history of use of glasses. PAST SYSTEMIC HISTORY: • Patient is a known case of Ischemic Cardiovascular disease 8 years backs under medication. • He is also known case of Hypertension under medication since 8 years. • He is also known case of Hypothyroidism under medication since 8 years. • No any surgical history.
- 6. TREATMENT HISTORY • Heis under Tab. Atorvastatin(statins) 10mg x PO x OD since 8years • He is under Tab. Aspirin 75mg x PO x OD for Ischemic condition since 8 years. • He also takes Tab. Telmisartan to control HTN since 8 years • He is also under Tab. Hydrochlorthiazide 12.5 mg x PO x OD • He is under Tab. Thyronorm 50 mg PO x OD for hypothyroidism since 8 years.
- 7. PERSONAL HISTORY – NonVegetarian, – History of alcohol consumption since long time and left 6 month back – Long history of smoking left 8 years back, smoked for 40years, 4-6 sticks per day. – Regular bowel and bladder habit – Good appetite FAMILY HISTORY No similar history in the family SOCIO-ECONOMIC HISTORY Retired teacher
- 8. DRUG AND ALLERGYHISTORY: • No any known allergic history to drugs or food.
- 9.
- 10. GENERAL EXAMINATION Physical examination •conscious and oriented to time, place and person • Ill-looking, Average built, anxious Vitals Temp : Afebrile Pulse : 84/min Respiratory rate : 22/min Blood pressure : 140/90mm of Hg at right arm in sitting position Pallor/Icterus/Lymphadenopathy/Clubbing/Edema/ Cyanosis/dehydration : Absent
- 11. SYSTEMIC EXAMINATION Respiratory system– B/L vesicular breath sound Cardiovascular system - S1 & S2 audible; no murmur Nervous system: sensory and motor system intact Gastrointestinal system: Normal bowel sound, No organomegaly
- 12. Ocular Examination 1. Visualacuity (VA) 2. Near vision: Add +2.75 DS, N(6) 2. Refraction -0.75 X 900 -1.50 X 900 (NIG) Right eye Feature Left eye 6/9 VA( unaided) 6/36 6/9 VA (with pinhole) 6/24 6/9 BCVA 6/24 -0.75 -1.50 0 0
- 13. External Ocular Examination HEADPOSTURE NO HEAD TILT, CHIN LIFT, OR FACE TURN, NO TORTICOLLIS FACIAL SYMETRY BILATERAL SYMMETRICAL Orbit No Proptosis/ enopthalmos
- 14. RIGHT EYE LEFTEYE FULL RANGE IN ALL THE DIRECTION OF GAZE EOM FULL RANGE IN ALL THE DIRECTION OF GAZE 10cm CONVERGENCE 10cm DIVERGENCE EOM- Full in all range No pain No restriction in all gazes No diplopia in any gazes
- 15. RIGHT EYE LEFTEYE HIRSCHBERG TEST 0 0 COVER TEST NO ANY CORRECTIVE MOVEMENT NO ANY CORRECTIVE MOVEMENT UNCOVER TEST NO ANY CORRECTIVE MOVEMENT NO ANY CORRECTIVE MOVEMENT COVER/ UNCOVER TEST NO ANY CORRECTIVE MOVEMENT NO ANY CORRECTIVE MOVEMENT Impression: Orthophoria
- 16. OCULAR EXAMINATION EYEBROWS RIGHTEYE LEFT EYE SYMMETRY Symetrically placed, Curved and with convexity upward, Comma- shaped. Symetrically placed, Curved and with convexity upward, comma shaped. POSITION Across superior orbital margin Across superior orbital margin CILIA Evenly distributed brow hairs with few graying. Evenly distributed brow hairs with few graying. PAF HORIZONTAL 30mm 30mm VERTICAL 10mm 10mm LID CREASE HEIGHT 4mm 4mm
- 17. RIGHT EYE EYELIDSLEFT EYE LOWER LID- TOUCHES THE LIMBUS UPPER LID-COVERS 2 MM OF CORNEA POSITION LOWER LID- TOUCHES THE LIMBUS UPPER LID-COVERS 2 MM OF CORNEA Lateral Canthi is Acute, and medial canthus is rounded. CANTHI Lateral Canthi is Acute, and medial canthus is rounded. Upper lids follows the eyeball in downward movement. MOVEMENT IF LIDS Upper lids follows the eyeball in downward movement. 14/min BLINKING 14min 2mm flat, no inward or outward rolling. No swellings, pus point LID MARGIN 2mm flat, no inward or outward rolling. No swellings, pus point DERMATOCHALASIS (present) DERMATOCHALASIS (present) 2-3 rows upper lid around 2 rows in lower lid. No misdirected lashes EYE LASHES 2-3 rows upper lid around 2 rows in lower lid. No misdirected lashes
- 18. RIGHT EYE LEFTEYE • SWELLING,TENTDERNESS (-) • NORMAL • 6.5mm FROM INNER CANTHUS • 6mm FROM INNER CNATHUS • NO SWELLING, ERYTHEMA • INDURATION,PUS POINTS or TENDERNESS • TEMPERATURE- NORMAL • NEGATIVE • CONVEX: 1 MM FROM LOWER LID MARGIN LACRIMAL APPARATUS LACRIMAL GLAND LACRIMAL PUNCTA LOWER UPPER LACRIMAL SAC AREA ROPLAS TEST TEAR MENISCUS HEIGHT • SWELLING,TENTDERNESS (-) • NORMAL • 6.5mm FROM INNER CANTHUS • 6mm FROM INNER CNATHUS • NO SWELLING, ERYTHEMA • INDURATION,PUS POINTS or TENDERNESS • TEMPERATURE- NORMAL • NEGATIVE • CONVEX: 1 MM FROM LOWER LID MARGIN
- 19. RIGHT EYE CONJUNCTIVALEFT EYE • lustorous • Grade 1 Pterygium present nasally • No congestion/chemosis/ • cysts/blebs/nodules/FB • Yellowish white patch, near the • limbus • No papillae/ concretions/ FB/ nodules/ discharge • No follicles/ concretions/ congestion/ nodules/ FB/ abnormal attachments to bulbar conjunctiva/ discharge BULBAR UPPER TARSAL LOWER TARSAL AND FORNIX Lusturous • No congestion /chemosis/degenerative changes/cysts/blebs/nodules/FB • No papillae/ concretions/ FB/ nodules/ discharge • No follicles/ concretions/ congestion/ nodules/ FB/ abnormal attachments to bulbar conjunctiva/ discharge
- 20. RIGHT EYE 2LEFT EYE No dilated episclersal vessels SCLERA No dilated episclersal vessels SIZE: Horizontal -11.7mm, vertical- 11mm. SHAPE : watch glass with uniform curve. SURFACE: Uniformly Smooth and regular TRANSPARENCY: Clear with no scar CORNEA SIZE: Horizontal -11.7mm, vertical- 11mm. SHAPE : watch glass with uniform curve. SURFACE: Uniformly Smooth and regular TRANSPARENCY: Clear with no scar QUIET, NORMAL DEPTH(Van Herick grade IV) ANTERIOR CHAMBER QUIET, NORMAL DEPTH(Van Herick grade IV) • Brown In color with normal pattern distribution of crypts and collarette. • No Neovascularization IRIS • Brown In color with normal distribution of crypts and collarette • No Neovascularization.
- 21. RIGHT EYE LEFTEYE ROUND REGULAR REACTIVE PUPIL ROUND REGULAR REACTIVE SINGLE NUMBER SINGLE DLR: Present CLR:Present RAPD: Negative Light Reflex DLR: Present CLR:Present RAPD: Negative • Normal position, No subluxation or dislocation. • Nuclear Sclerosis Grade 1 LENS • Normal position, No subluxation or dislocation. • Nuclear sclerosis grade1 present • 15mmHg IOP • 16mmHg
- 22. RIGHT EYE POSTERIORSEGEMENT LEFT EYE • Normal transparent vitreous. • No floating strands, cells, blood or membrane visualized. VITREOUS • Normal Transparent vitreous • No floating strands, cells, blood or membrane visualized.
- 23. Fundus Examination Right EyeFundus: • Optic disc: Pale pinkish color, well defined margin, circular shape, area of 1.5mm size, with cup disc ratio of : 0.3:1. • There is presence of Peripapillary atrophy • Artery to Vein Ratio: 2:3 with focal attenuation of artery seen. • MACULA: Healthy • FOVEAL REFLEX: Present • IMP: Grade I Hypertensive Retinopathy
- 24. Left Eye Fundus: Pictureis of 27th june, 2024 from fundus camera. – Optic disc: Pale pinkish color, well defined margin, circular shape, area of 1.5mm size, with cup disc ratio of : 0.3:1. – There is presence of Peripapillary atrophy healthy NRR. – Vessels arise from the centre of disc , branching dichotomously with an AV ratio of 2:3 with Attenuation of artery present – Superior retinal vessels appear dilated and tortuous with multiple flame shaped and dot blot haemorrhages along the superior arcade involving superior- temporal sectoral region. – Macula-is Normal situated, depigmentation can be visualized with loss of foveal reflex with splinter hemorrhage in superior parafoveal region. – Retinal thickening seen at the macula. – White fluffy ill defined lesions as cotton wool spots are also seen along the superior arcade – Yellowish well circumscribed deposits seen near macula as hard exudates - Periphery appears normal
- 25. DIFFERENTIAL DIAGNOSIS • BranchRetinal Vein Occlusion • Central Retinal Vein Occlusion • Optic Neuritis • Central Serous Choroi-Retinopathy • Vitreous Hemorrhage • Central Retinal Artery Occlusion
- 26. INVESTIGATION 1.Blood Investigation donewith reports assessed on 28th june, 2024 • Glucose, Fasting =118.0 mg/dl (High) • Glucose, Post-prandial = 137.0 mg/dl (high) • Total Cholesterol = 181.0 mg/dl (normal) • Triacyglycerol(TAG) = 1.02 mg/dl (normal) • HDL= 50.0 mg/dl (normal) • LDL = 111.0 mg/dl (normal) • Sodium = 145 mEq/L (normal) • Potassium = 4.3 mEq/L (normal) • Urea = 29.0 mg/dl (normal) • Creatinine = 1.0 mg/dl (normal)
- 27. Thyroid Function test •fT3 = 3.08 pg/ml (normal) • fT4 = 1.05 ng/dl (normal) • TSH = 3.09 mIU/L (normal)
- 28. 2. On Cardiacevaluation. • ECG= Borderline within Normal • ECHO = Mild Tricuspid Regurgitation, Grade 1 LV Diastolic Dysfunction with Normal LV Systolic Function(LVEF=60%) which is within normal limit. • Carotid and vertebral artery Doppler = Atherosclerotic changes seen, Hypoechoic plaque in anterior wall of CCA causing stenosis about 41%, calcified plaque in left CCA, calcified plaque in anterior and posterior wall of right carotid bulb noted.
- 29. On performing OCTmacula of left fundus on 27th june Collection of fluid with cyst like change around fovea region at Neurosensory retinal layers around Outer plexiform and inner nuclear layer of left macular OCT can be seen.
- 30. Provisional Diagnosis Right EyeGrade I Hypertensive Retinopathy with Left Eye Superotemporal Branch Retinal Vein Occlusion with Cystoid Macular Edema with Both eye Age related Cataract (NS1) with Simple Myopic Astigmatism with Presbyopia with Hypertension, Hypothyroidism and Ischemic Coronary Artery Disease.
- 31. MANAGEMENT • Patient Consultedat Cardio-medicine department to control fluctuating high blood pressure. • He was planned for Intra-vitreal Injection Anti-VEGF Bevacizumab(Avastin) at TIO, after cardio-medicine clearance. • After Cardio-medicine consultation, patient was planned for Holter monitoring for fluctuating high blood pressure and for Anti-hypertensive dose adjustment. • He was planned to refer TIO for 1st dose of Avastin injection with following medication, 1. Gtt. Ketorolac(Acular LS) x 1 drop x BE x TDS x 1 month 2. Regular medication continued. Follow up done in Cardio-medicine.
- 32. Regular Medications • Tab.Aspirin 75 mg x PO x OD x continued • Tab. Atorvastatin 10mg x PO x OD x continued • Tab. Telmisartan 80mg x PO x OD x continued • Tab. Hydrochlorthiazide 12.5mg x PO x OD x continued • Tab. Thyronorm 50mcg x PO x OD x continued
- 33. During 1st Followup on 26th July, 2024 1. Complain: 1. Marked decreased vision of Left Eye associated with mild vision distortion 2. Visual Acuity: Right eye Feature Left eye 6/9 VA( unaided ) 6/60 6/9 VA (with pinhole) 6/60 6/9 BCVA Not Improved 3. Refraction -0.75 X 900 -1.50 X 900 (NIG) -0.75 -1.50 0 0
- 34. History and Investigation: 1.Anterior Segment= Nuclera Sclerosis 1 2. Posterior segment = RE: Grade I Hypertensive Retinopathy LE: • CDR: 0.3:1 • AVR: 1:3 • Superior retinal vessels appear dilated and tortuous with multiple flame shaped and dot blot haemorrhages along the superior arcade involving superior- temporal sectoral region. Presence of Sclerotic vessels. • Foveal Reflex : Absent
- 35. Amsler grid • Metamorphopsiapresent • No Scotoma appreciated.
- 36. Macular OCT doneat TIO Collection of fluid with in multiple cyst like Edema around fovea region at Neurosensory retinal layers around Outer plexiform and inner nuclear layer extending more than macular area with Retinal detachment(?) of left macular OCT can be seen. Note: More severe Fluid collection is seen compared to Previous OCT.
- 37. ADVICE: • Cardio-medicine clearancedone for Inj. Avastin. • Anti-Hypertensive medication dose adjustment done. • Patient planned for Inj. Avastin on 2nd August at TIO.
- 38. Medications: He was sentwith following medication: 1. Tab. Cresar AM(Amlodipine+Telmisartan) 5/80mg x PO x OD x Continue 2. Tab. Atorvastatin 20 mg x PO x OD x Continue 3. Tab. Aspirin 75 mg x PO x OD x continued 4. Tab. Hydrochlorthiazide 12.5mg x PO x OD x continued 5. Tab. Thyronorm 50mcg x PO x OD x continued 6. Gtt. Ketorolac(Acular LS) x 1 drop x BE x TDS x 2 weeks Councelling done to follow up After Inj. Avastin
- 39. During 2nd Followup on 5th September, 2024 1. Complain: • Decrease in left eye vision • No any other fresh complain 2. Visual Acuity: Right eye Feature Left eye 6/9 VA( unaided ) 6/24P 6/9 VA (with pinhole) 6/24 6/6P BCVA Not Improved 3. Refraction -0.75 X 900 -1.50 X 900 (NIG) -0.50 -1.50 0 0
- 40. History and Examination 1.Anterior Segment : BE Nuclear Sclerosis grade I 2. Posterior Segment:- Right Fundus: • CDR:0.3:1 • AVR: 1:3 • Macula: Within normal limit • Foveal Reflex: Present • Attenuation of vessels = Present • IMP : NS -1 with Grade 1 Hypertensive Retinopathy
- 41. Left Eye Fundus Note:Patient fundus Picture taken after 1st dose of Inj. Avastin
- 42.
- 43. Investigation: OCT ofLE Resolving Macular Edema is noted After 1st dose of Inj. Avastin
- 44. Advice: • Patient advicefor 2nd dose of Inj. Avastin at TIO. • He was councelling done to Continue other medications • To control high blood pressure and high blood sugar. Patient adviced to follow up to OPD after 2nd dose of Avastin.
- 45. During 3rd Followup on 16th September, 2024 1. Complain: • Decrease in left eye vision • No any other fresh complain 2. Visual Acuity: Right eye Feature Left eye 6/9 VA( unaided ) 6/24P 6/9 VA (with pinhole) 6/24 6/6P BCVA Not Improved 3. Refraction -0.75 X 900 -1.50 X 900 (NIG) -0.50 -1.50 0 0
- 46. History • Patient Presentedto OPD for follow up after 2nd Dose of Inj. Avastin. On Slitlamp Examination: • Anterior Segment: Normal • Posterior Segment: No obvious changes appreciated from previous followup. • Patient adviced for OCT LE.
- 47. OCT Macula takenon 16th sep, 2024. Resolved Macular edema of LE
- 48. Advice: • Patient advicefor TIO follow up as per need of Inj. Avastin. • He was councelling done to Continue other medications • To control high blood pressure and high blood sugar. Patient adviced to follow up at DH-OPD sos.
- 49. Scientific Research Articlepublished on 27th January, 2023
Editor's Notes
- #3 Orbital cellulitis Orbital abscess
- #4 There was no any associating or aggravating factor.
- #5 No history of Tuberculosis, Diabetes.
- #10 96 drg fahrenheit
- #12 Visual acuity charts : Snellens Chart, Landolt C chart, Allens picture chaer. etc Near Chart: jaegers chart, Romans near vision chart Snellen’s Near vision chart.
- #13 Eye ball Examination: The two eyeballs are symmetrically placed in the orbits in such a way that line joining the central points of superior and inferior orbital margins just touches cornea. Head Posture: In paralytic squint head posture is abnormal. In complete ptosis chin is elevated to uncover pupil area. Head is turned in the direction of paralysed muscle to avoid diplopia. Forehead examination: Increased wrinkling due to overaction of frontalis muscle in patient of ptosis. Complete loss of wrinkling in one half forehead with lower motor neural palsy. Facial symetry may be affected in facial or bells palsy.
- #14 EOM EXAMINATION: Uniocular movement: aka duction, these are: there was full range of movement in adduction, abduction, supraduction and infraduction. Adduction: medial roation along vertical axis, Abduction: lateral rotation along vertical axis, Infraduction: downward movement(depression) along horizontal axis, Supraduction: upward movement(elevation) along horizontal axis, Incycloduction(Intorsion): rotatory movement along AP axis in which superior pole of cornea moces medially, Excycloduction(Extortion): rotatory movement along AP axis in which superior pole of cornea moves laterally. Binocular movement: Version aka conjugate movement of both eyes in same direction : On binocular versions examination, there was full range of movement in Levoversion, Levoelevation, Levodepression and Dextroversion, Dextro elevation, dextro depression. Dextroversion: movement of both eyes to right, Levoversion: movement of both eyes to left. Vergence aka disjugate movement are symmetric movement of eyes: On binocular vergence evaluation, Convergence: simultaneous inward movement of eyes. Divergence: simultaneous outward movement of eyes.
- #15 the Hirschberg test, also Hirschberg corneal reflex test, is a screening test that can be used to assess whether a person has strabismus (ocular misalignment). Cover and uncover is done for tropias altranate cover test done for phorias
- #16 Note: The two eyebrows are horizontaly placed over superciliary ridge of the frontal bone seperated by glabella. The Level of eyebrows may be changed in patient with ptosis due to overaction of frontalis muscle, where ptotic eye have raised eyebrow. Cilia of lateral 1/3 may be absent(madarosis) in pt. with leprosy or myxedema. In Brow ptosis there is downward pulling of eyebrows. Abnormality of PAH: 1. Ankyloblepharon is usually seen in adhesion of lids following burns, ulcerative blepharitis. 2. Blepharophimosis: congenital anamoly in which all around narrowing of Palpebral fissure.
- #17 IN primary position if gaze the upper eyelid covers around 2 mm and lower eye lid just touches the cornea. Canthus: In Both eyes the lateral canthus forms acute angle of 60 degrees (2mm above medial canthus) and medial canthus is rounded. the lateral canthus is slightly positioned upward compared to medial canthus. LID MARGIN : In both the eyes the opposing lid margins are nearly flat 2mm in width, the lacrimal papillae with lacrimal punta present. The lacrimal portion of lid margin is rounded and devoid of lashes. The ciliary portion consist of rounded ant. border and sharp border placed against globe. distance of punta ( upper punta is 6mm and lower punta is 6.5 mm from medial canthus). with presence of horizontal linear gray line. EYE LASHES: arrenged in 2-3 rows in upperlid, directed forward upward backward. In lower lid forward downward and backward In ptosis upper lid covers more than 1/6th (2mm) cornea. Upper limbus is visible due to lid retraction seen in thyrotoxicosis and sympathetic overactivity. Movement of lids: upper lid follows eyeball in downward movement but lags behind in case of TED. blinking is decreased in trigeminal anaesthesia and absent in 7th nerve palsy.
- #18 Lacrimal Apparatus: While Examination of lacrimal apparatus, On inspection and palpation of lacrimal sac region there was no redness, swelling of fistula. While examining lacrimal punta, there was no defect such as eversion, stenosis, abscence or discharge. ROPLAS: Regurgitation on pressure over lacrimal sac. positve in Dacrosystitis and NLDO.
- #20 Positions of Eye ball : Eye balls symetrically placed in orbit and the lines joining the central points superior and inferior orbital margin just touches the cornea. Visual axis of eyeball: both eyes are simultaneously directed at the same object which is maintained at all direction of gaze. deviation in visual axis is called squint. Conjunctiva: Bulbar conjucntiva was normal with a fine network of vessels is seen with no any sign of conjunctival or circumcilliary congestion or chemosis. On examining Palpebral conjunctiva, there was no discharge, discoloration, papillae or follicles present. Sclera: bluish discoloration seen in isolated anomaly or in osteitis deformans, Marfans syndrome, Pseudoxanthoma elasticum. Inflamation of sclera: Episcleritis: Superficial localised pink or purple circumscribed flat nodule. Scleritis: deep, dusky patch associated with marked inflammation and ciliary congestion. 5. Cornea: Ant. surface elliptical with horizontal diameter of 11.7mm and vertical diameter of 11mm. SURFACE smothness of cornea can be examined by use of Placido Keratoscopic disc(disc painted with alternating black and white circles). SHEEN= Normal cornea is a bright shining structure. Sheen of corneal surface is lost in dry eye conditions. While Examining Corneal Endothelium: Specular microscopy clear morphological study of endothelial cells including cell density of endothelium is around 3000 cells/mm2 in young adults, which decreases with advancing age.
- #21 PUPIL: Single pupil in each eye placed slightly nasally around with 3 mm in size and round regular and reactive to light. On direct light reflex constriction of pupil of ipsilateral eye on both eyes. On consentual light reflex constriction of pupil on contralateral eye and on swinging light reflex RAPD was absent. There was no Synaeciae. LENS : Position of lens normally positioned in the patellar fossa. Normal thickness 3-4 mm of lens.( IOL thickness around 1mm). Shape of lens= Normal lens is a biconvex structure, which is nicely demonstrated in an optical section of the lens on slit-lamp examination. COLOR: In nuclear cataract lens may look amber, brown or black in colour
- #23 Disc- pink colored, round regular, well defined , NRR heatly , following ISNT rule, C:D – 0.3:1:0.3 A:V- 2:3, vessels originating from centre of disc to periphery forming SN, ST, IN, IT vessels Macula-is Normal situated at the posterior pole with its centre (foveola) being about 2 disc diameters lateral to temporal margin of disc and macula is slightly darker than the surrounding retina which is healthy with center presence of foveal reflex.
- #29 CME: It refers to collection of fluid in the outer plexiform (Henles layer) and inner nuclear layer of the retina, centred around the foveola. causes: DR, CRVO, BRVO, Surgeries, Ocular laser therapy, Type A personality, HR, Posterior Uveitis. Pathogenesis: CME develops due to leakage of fluid following breakdown of inner blood-retinal barrier (i.e., leakage from the retinal capillaries) and accumulating in the outer plexiform and inner nuclear layer of retina with the formation of cyst-like changes as depicted on OCT macular scan
- #31 Note: His Blood suger level was high but is not a diagnosed case of DM and he was not under any anti-diabetic medication. So, for that reason as well the patient was adviced for medicine consultation.
- #35 Note: The patient could’nt appreciate the corner of the chart and there was widenning of the colloms and narrowing at certain areas. Metamorphopsia is a type of distorted vision in which a grid of straight lines appears wavy or partially blank. In addition, metamorphopsia can result in misperceptions of an object's size, shape, or distance to the viewer. People can first notice they suffer from the condition when looking at mini blinds in their home. Causes of Metamorphopsia are: ARMD, Macular hole, PVD, Vitreomacular traction.
- #37 Patient visited At TIO on July 18th, 2024 and was asked to came on August 2nd, 2024 for Inj. Avastin.
- #41 Optic disc: Pale pinkish color, well defined margin, circular shape, area of 1.5mm size, with cup disc ratio of : 0.3:1.There is presence of Peripapillary atrophy healthy NRR. Vessels arise from the centre of disc , branching dichotomously with an AV ratio of 1:3 with Attenuation of artery present Superior retinal vessels appear dilated and tortuous with multiple flame shaped and dot blot haemorrhages along the superior arcade involving superior- temporal sectoral region. Macula- loss of foveal reflex with splinter hemorrhage in superior parafoveal region.Retinal thickening seen at the macula. In extra Macular region multiple White fluffy ill defined lesions as cotton wool spots are also seen along the superior arcade Yellowish well circumscribed deposits seen near macula as hard exudates . Presence of Old Sclerotic vessels noted. - Periphery appears normal
- #42 RE FUNDUS: Optic disc is Pink, round, with sharp margin with CDR 0.3:1, Round cup, Healthy (follows ISNT rule). Retinal vessels branching dicotomously with focal arteriolar attenuation. Foveal reflex present. RE Fundus shows Grade 1 hypertensive Retinopathy. In LE FUNDUS: Optic disc is pink round with regular margin with CDR 0.3:1. Round cup and healthy which follows ISNT rule. Retinal Vessels arise from the centre of disc , branching dichotomously with an AV ratio of 2:3 with Attenuation of artery present Superior retinal vessels appear dilated and tortuous with multiple flame shaped and dot blot haemorrhages along the superior arcade involving superior- temporal sectoral region. Macula-is depigmented with loss of foveal reflex with splinter hemorrhage in superior parafoveal region. green circle signifies White fluffy ill defined lesions as cotton wool spots are also seen along the superior arcade Yellowish dot signifies deposits seen near macula as hard exudates and green vessels along temporally signifies old sclerotic vessel. RE fundus diagram shows ST-BRVO.
- #49 This article likely explores advancements in the treatment of branch retinal vein occlusion (BRVO) with macular edema using aflibercept.Aflibercept, a (VEGF) inhibitor, is commonly used to treat macular edema secondary to BRVO. The "individualized" aspect of the protocol suggests that the authors are focusing on tailoring the treatment regimen to better fit individual patient needs rather than using a one-size-fits-all approach. This article Individualized outlines Dosing and Scheduling protocol where dosing intervals are adjusted based on the patient's response to treatment, rather than sticking to a fixed schedule. This could mean more frequent injections for those who show less improvement or longer intervals for those who respond well. This type of personalized treatment strategy aims to enhance the effectiveness of aflibercept therapy while minimizing unnecessary treatment burden for patients. This novel protocol was found to be useful and effective and was not inferior to routine protocols evaluated in previous RCTs, thus this article emphasizes to consider individualized protocols treatment of macular edema assiciated with BRVO.