Retinal ditachment case discussion

1. CASE PRESENTATION (RD)
OPTOM FASLU MUHAMMED

2. PATIENT DETAILS
 Name: Mr.Ali
 Age: 54yrs
 Sex: Male
 Address: Marangery

3. CHIEF COMPLAINTS
 C/o floaters and flashes of light in the
RE,decreased vision in the RE since 1 ½ months

4. HISTORY OF PRESENT ILLNESS
 c/o floaters in the RE since 1 ½ months,increasing
the frequency since 2 wks and darken the colour of
dots
 Increasing the size and numbers of floaters during
eye movements
 h/o flash of light –only 1 attack 2 wks back
 Decreased vision -gradual painless loss
 No h/o redness,discharge and photophobia
 No h/o coloured halos

5. PAST OCULAR HISTORY
o H/o using spectacles for reading since 5yrs
o Last changed-2 months back
o h/o same complaits 2 yrs back-dilated examination
done.NAD
o No h/o ocular trauma or ocular surgery

6. MEDICAL & SURGICAL HISTORY
 No h/o diabetis mellitus,hypertension and other
systemic illness
 No relevent surgical history

7. FAMILY HISTROY
 No similar history in the family

8. OCULAR EXAMINATION
 Head Position –Normal
 Facial Symmetry- Normal
 Ocular Movements -Normal

9. VISUAL ACUITY
BY SNELLEN’S
CHART
RE LE
UCVA 6/9p,N10 6/6,N12
Vn with PG 6/9p,N6 6/6,N6
Pinhole 6/6p 6/6
BCVA 6/6p with-
0.50DC@90
N6,add 2.00ds
6/6 ,N6,add 2.00ds
IOP BY NCT @11am 14 mmHg 17mmHg

10. ANTERIOR SEGMENT EXAMINATION
RE LE
Lids and
adenexa
Normal Normal
Conjunctiva Normal Normal
Iris Normal pattern Normal pattern
Cornea Clear Clear
AC Normal depth,clear Normal depth, clear
Pupil Round regular reacting to light Round,regular,reacting to light
Lens Clear Clear
sclera Normal Normal

11. POSTERIOR SEGMENT EXAMINATION WITH 90D
LENS

12. RE LE
Media (vitreous) Normal glow altered Clear
Optic Disc C/D Ratio-0.3,NRR-
healthy
Margins –well defined
Colour -nl
Vessels over the disc-
normal
AV Ratio-2:3
C/D Ratio-0.3,NRR-
healthy
Margins –well defined
Colour -nl
Vessels over the disc-
normal
AV Ratio-2:3
Macula Hazly normal Normal , FR+
Peripheral retina up to
the equator
Giant retinal tear
superotemporal region
with superotemporal
detatchment of
retina,slightly opaque
and corrugated
appearance,vessels
darkened
Inferior horse shoe tear.
Normal

14. PROVISIONAL DIAGNOSIS
 Superotemporal GRT with retinal detatchment in
the RE,most probably rhegmatogenous RD

15. TREATMENT
 PARS PLANA VITRECTOMY
 PHACO IOL
 PFCL
 ENDOLASER
 SILICONE OIL INJECTION