2. • 61 year old male, Hindu by religion,
• Farmer by occupation, Resident of Antora, Wardha.
• Came to eye OPD with Chief complaints of:
Diminution of vision in left eye since 1 year.
3. HISTORY OF PRESENT ILLNESS
• Patient was apparently alright 1 year back when he
started noticing diminution of vision in left eye
which was
• Insidious in onset
• Gradually Progressive in nature
• Not associated with pain
4. NEGATIVE HISTORY
• No h/o any use of topical drugs in the eye
• No h/o discharge
• No h/o Malaria, HS keratitis.
5. • Past medical history:
No h/o hypertension and diabetes mellitus.
•Past ophthalmic history:
Patient gives a history of trauma to both eyes 10
years back by falling on gravel. After which he had
redness, watering and pain in both eyes and
developed whitish opacity in a month. He had not
taken any treatment for the same.
7. GENERAL EXAMINATION
• Conscious, cooperative & well oriented to time, place and
person
• Average built
• Afebrile
• Pulse -70 beats/min
• Blood pressure- 110/80 mm of Hg
• No pallor, icterus, cyanosis, clubbing, lymphadenopathy and
oedema feet
9. Right eye Left eye
Vision
• Distance
With pinhole
6/60
No Improvement
6/36
No Improvement
Eyelids
• Position
• Movement
• Lid margin
• Eye lashes
NORMAL NORMAL
Conjunctiva
• Bulbar
• Palpebral
• Limbal
NORMAL NORMAL
• Ocular examination:
Head posture – straight
Forehead - senile wrinkles
Eyebrows - normal
10. Right eye Left eye
Cornea
• Size
• Shape
• Surface
• Transparency
• Sensations
• Vascularisation
Could not be assessed
Could not be assessed
Smooth
Maculo-leucomatous opacity from 3-9 o clock
Absent
Present
Normal
Normal
Smooth
Adherent leucoma at 3 o clock
Present
Present
11. Right eye Left eye
Anterior chamber
• Depth
• Contents
Deep
No abnormal contents
Irregular
No abnormal contents
Iris
• Colour
• Pattern
Normal
Normal
Normal
Normal
Pupil
• Number
• Size
• Shape
• Position
• Pupillary margin
• Pupillary reflex
Single
4-5 mm
Vertically oval
Central
Normal
Shimmering
Single
3-4 mm
Normal
Central
Normal
Greyish white
12. Right eye Left eye
Pupillary reaction
• Direct
• Consensual
Could not be elicited Normal
Could not be elicited
Lens
•Position
•Shape
•Color
Normal
Normal
Glassy
(PC IOL)
Normal
Normal
Greyish white
Intraocular pressure
(NCT)
13 mm of Hg 16 mm of Hg
Lacrimal apparatus
• Punta
• Sac area
• Regurgitation test
• Syringing
Normal
Normal
Negative
Patent
Normal
Normal
Negative
Patent
Ocular movements
• Uniocular
• Binocular
Free and Full in all directions
of gaze
Free and Full in all directions
of gaze
13. SLIT LAMP EXAMINATION
Right Eye:
• Maculo-leucomatous opacity from 3 to 9 o clock
• Corneal thinning inferiorly
• Corneal vascularization (superficial)
• Conjunctivalization of cornea 360 degree
• Vertically oval pupil
• Deep AC
15. Left eye
• Corneal degeneration
• Adherent leucoma at 3 o’clock with vascularization (superficial)
• Nebulo macular opacity from 10 to 2 o’clock para centrally
• Irregular AC
17. PROVISIONAL DIAGNOSIS
• Right eye- Maculo-leucomatous opacity from 3-9 o clock
with Pseudophakia
• Left eye- Adherent leucoma at 3 o clock with Immature
senile cataract
18. THANK YOU !
NEXT PG ACTIVITY: 11/10/2021
CASE PRESENTATION ON RETINAL
VEIN OCCLUSION
PRESENTER: DR ABHISHEK
MODERATOR: DR SUNE SIR
CONDUCTOR: DR PRANAY SIR