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Ophthalmology Case Write Up
Ophthalmology Case Write Up
Name : Ms Z
Gender : Female
Race : Malay
Religion : Islam
Occupation : Housewife
Address : Klang
CHIEF COMPLAINT
Her son noticed that she has a squint.
HISTORY OF PRESENTING ILLNESS
Ms. Z, with underlying right eye cataract for 1 year, diabetes mellitus for 9
years, hypertension and dyslipidemia for 5 months, was apparently well until 5
days ago when his son noticed that she has a squint . He realized it when she
could not move her right eye to the right side when she was talking to him.
It was sudden and associated with pain at the right eyebrow region. The
eyebrow pain was non-radiating and continuous throughout the day until now.
She herself did not realized her inability to move her right eye to the right side
because she had lost her right eye vision completely due to cataract since October
2016.
As advised by her friend who is a doctor in Klinik Kesihatan, she went to see
the doctor in Hospital eye clinic on the following Monday. She was told that she
needed to be admitted for further evaluation.
She has been wearing multifocal eyeglasses for short and distant vision for
7 years and the last time she went for eye power check-up was 2 years ago.
Ms. Z has underlying cataract on her right eye for 1 year. She is compliant
to her eye checkup in Eye Ward of Hospital and she is planned for a
cataract surgery this April in HTAR after her right eye movement is
corrected.
Previously, she had the similar cataract problem on her left eye for 3 years
and went for cataract surgery last year. Now it has been treated.
Besides, she also has been diagnosed with Diabetes Mellitus for 9 years.
Her usual fasting bloos sugar level measured before breakfast is 6 mmol/L.
She is compliant to the medication and currently on regular follow up at
Klinik Kesihatan.
Other than that, she is also diagnosed with hypertension and dyslipidemia
since 5 months ago. She is compliant to the medication for both and also on
regular follow up at Klinik Kesihatan.
Besides, she was on homeopathy medication for 2 years and recenlt stopped
since she was admitted to the ward.
PHYSICAL EXAMINATION
GENERAL EXAMINATION
Patient was sitting comfortably on her bed. She was alert, conscious and well
oriented to time, place and person. ID tag was present on her left wrist. She was
not in respiratory distress, no signs of pallor or jaundice. She was large built with
good hydration and nutritional status.
VITAL SIGNS
Temperature : 37.0 C
̊ (afebrile)
Weight : 95 kg
Height : 166 cm
BMI : 34 kgm-2
OCULAR EXAMINATION
1) VISUAL ACUITY
Right eye Left eye
Visual acuity Able to recognize hand 6/6
movement.
Near visual acuity - Good
2) INSPECTION
There was no syndromic feature on patient’s face.
Right eye Left eye
Red reflex Absent Presence
Lid No ptosis and swelling No ptosis and swelling
Eye position Light fell on the pupil Light fell on the centre of
margin temporally. pupil
Conjunctiva White, not injected White, not injected
Cornea Clear Clear
Anterior chamber Normal (deep) Normal (deep)
Pupil Normal - Irregular (oval in shape)
- Presence of 3 stitches at 10,
11 and 12 o’clock position.
- Presence of whitish
incisional wound scar at the
above pupillary margin.
Lens Opaque Pseudophakic lens.
3) PUPILLARY EXAMINATION
4) DIRECT OPHTALMOSCOPY
6) VISUAL FIELD
• sensory : normal
• reflex : normal
no facial asymmetry
no parotid enlargement
upper and lower motor neuron are intact
8th cranial nerve : Vestibular
SUMMARY
Ms. Z, a 57-year-old Malay lady, with underlying right eye cataract for 1
year, diabetes mellitus for 9 years and hypertension and dyslipidemia for 5
months, presented to the hospital because she was unable to move her right eye
to the right as noticed by her son. She herself did not notice the problem since
she had lost her right eye vision completely due to cataract since 5 months ago. It
was associated with right eyebrow pain which was continuous throughout the day
until the day she was admitted. Otherwise there was no history of fever, history
of previous infection, asymmetrical of her face, any muscle weakness of other
part of the body, loss of weight, loss of appetite or recent trauma to the head or
eye.
Upon examination, she was unable to move her right eye temporally upon
extraocular motor examination and the visual field test was not performed on her
right eye as she could not see due to cataract.
PROVISIONAL DIAGNOSIS
Supporting points:
She was noticed by her son that she could not move her right eye to the
right.
On examination, patient could not perform abduction of the right eye,
but adduction was done very well.
Patient has multiple underlying factors: diabetes mellitus for 9 years
and has a history of carbuncle removal surgery twice indicating
uncontrolled diabetes. Besides, she has been diagnosed with
hypertensive and dyslipidemia as well.
DIFFERENTIAL DIAGNOSIS
Proposed investigations:
Full blood count (FBC) – to look for signs of infection and anemia from the
white cell count and hemoglobin level respectively.
HbA1c level – to ensure whether patient’s diabetes is controlled since the
last 3 months.
Fasting blood sugar (FBS) - to check whether patient’s blood sugar is
controlled.
Renal function test – to check for Creatinine level as a sign of diabetes
complication.
Urine FEME (UFEME) – to look for presence of albuminuria as a sign of
diabetes complication.
PROPOSED TREATMENT
Patient is admitted to the eye ward in order to control her blood sugar
since diabetes is the primary cause of the palsy.
Plan the right time for patient’s right eye cataract surgery only after the
abducens nerve palsy is totally treated.
Once she is discharged, patient needs to continue taking her medications
for diabetes, hypertension and dyslipidemia and come for regular follow up
to ensure her condition is stable and under control.
NAME : SITI NUR BAITI BINTI SHAIK KHAMARUDIN
COORDINATOR : DR KHAING
Since diabetes is the primary cause of this abducens nerve palsy, the most
relevant treatment is to optimize her blood sugar level. The best option is to
admit her for a few days in the ward to monitor her blood sugar, as well as her
blood pressure readings and cholesterol level until her condition improves and so
that she will be fit for the planned right eye cataract surgery.
REFERENCE
1. Brad Bowling. Ocular Motor Nerves. Kanski – Clinical Ophthalmology A Systemic
Approach, Eighth Edition. 2016; Chapter 19: Neuro-opthalmology. 828-830.
2. http://emedicine.medscape.com/article/1198383-overview