IGNACIO, Richelle Angelika E. Dr.

Shiela Jimenez
2017-0116 Ophthalmology

[January 27, 2020 8:00-10:00 AM]

IDENTIFYING DATA
Patient. J.T. is a 45-year-old male residing in Cubao, Quezon City.
Referral. SLMC-OPD.
Source & Reliability. Information acquired from the patient. He was consistent and reliable.

CHIEF COMPLAINT
Referral to Ophthalmology for assessment of diabetic retinopathy

HISTORY OF PRESENT ILLNESS

Three years prior to consult, patient was in the process of getting surgical clearance for his anal fistula surgery when it was
diagnosed with diabetes, with an HbA1c of 8. Metformin 1000 mg BID was prescribed. Patient attends his scheduled check-ups
regularly. One month prior to consult, patient came in for his regular consult and had his CBC and FBS checked which turned out
normal. He was referred to the Ophthalmology department for assessment of diabetic retinopathy. Two weeks prior to consult,
upon being referred to Ophthalmology, diagnosis of diabetic retinopathy was not established. Physical examination revealed that
both of his eyes were dry; scratches were also present. No itching, tearing, and redness noted. He was diagnosed with exposure
keratopathy and prescribed with Lacryvisc gel used at night, which afforded him better vision.

On the day of consult, patient reported no symptoms and no recent trauma. No blurring of vision or excessive tearing. He was
prescribed to wear glasses with a grade of -50 OS and -75 OD.

PAST MEDICAL HISTORY

Childhood Illnesses. History of chickenpox and measles noted. No mumps and asthma.
Adult illnesses. 3-year history of diabetes. Managed with Metformin 1000 mg BID taken with good compliance; brings his Hba1c
to 6.2. Non-hypertensive. No kidney, heart, or liver diseases. No asthma or tuberculosis.
Medical treatment and hospitalization. None.
Surgeries. Appendectomy (2018). Anal fistula (2017) done 2 times.
Accidents. Motor accident (2014); superficial bruises at the face and arms treated at home.
Allergies. None.
Immunization. Unrecalled. No recent immunizations.

FAMILY HISTORY
Father died of stroke. Mother died of kidney disease. History of hypertension and diabetes noted. Patient’s siblings have diabetes.
No history of ophthalmologic diseases, and cataracts. No one else wears glasses in the family.

PERSONAL AND SOCIAL HISTORY

J.T. is an SUV driver before pursuing to be a Grab motorcycle driver. He drives 5 hours a day. He does not smoke and drinks
occasionally, starting at the age 0f 13. J.T. eats 3 times a day; his meals consist of meat, vegetables, and 1 cup of rice. He does not
drink coffee a lot. He is not fond of sugary and fatty foods. He takes basketball as his exercise. No other medications and
supplements taken.

REVIEW OF SYSTEMS
General. No headache or fever. No weight gain and weakness.
Skin. No rashes, lumps, sores, itching, and dryness. No changes in color or changes in hair or nails.
HEENT. Head—No headache or dizziness. No head injury reported. Eyes—Dryness noted. Patient prescribed with reading glasses
with a grade of L -50 and R -75. No redness, spots, specks, and flashing lights. No sensitivity to light. No double vision or blurring.
Ears—No discharge, redness, pain, and hearing loss. Nose & Sinuses—Occasional colds noted. No nasal stuffiness, discharge,
itching, hay fever, nosebleeds, and sinus trouble. Throat—No sore tongue, dry mouth, sore throats, and hoarseness.
Respiratory. Episodes of cough and colds lasted 3 weeks; no hemoptysis.
Cardiovascular. No chest pains and palpitations. No history of rheumatic fever. No heart murmurs and paroxysmal nocturnal
dyspnea. No edema.
Gastrointestinal. No change in appetite, trouble swallowing, and nausea. Regular bowel movement. No pain with defecation,
rectal bleeding or black or tarry stools. No hemorrhoids, constipation, diarrhea.
Urinary. No change in urination. No kidney or flank pain, kidney stones, ureteral colic, suprapubic pain and incontinence.
Musculoskeletal. No joint pains. No arthritis, gout, stiffness of muscles, and backache.
Peripheral vascular. No edema, cramps or claudication.
Psychiatric. No nervousness, tension, depression, memory change, suicidal ideation, and suicide plans or attempts. No history of
counseling, psychotherapy, or psychiatric admissions.
Neurologic. No changes in mood, attention, or speech; No changes in orientation, memory, insight, or judgment. No episodes of
fainting, blackouts, and seizures. No tinnitus.

PHYSICAL EXAMINATION
General Survey. Patient appears healthy and well-groomed. He is conscious, coherent, and cooperative. No noted body or breath
odors.
Vital Signs. Height and weight not taken. Blood pressure (right arm) 140/90 mmHg. Heart rate 82 bpm; regular. Respiratory rate
17 bpm. Body temperature (temporal) 36.3°C.
Eyes.
Visual Acuity. with glasses 20/20-1 OD; 20/25+4 OS. Near VA OD 20/25-1 OS 20/25 OU 20/20.
Gross Eye Exam. Eyes symmetric; no scars or lesions; sclera white, conjunctiva pink, yellowish-brown discoloration in
lateral conjunctiva of both eyes. No palpable mass.
Pupils. Equally round and reactive to light and accommodations. Direct and indirect pupillary reflex intact.
Confrontation Visual Fields. Intact; no perceptual deficits.
EOMs. Intact range of motion for both eyes
Digital Tonometry. Firm; normal intraocular pressure.
Fundoscopy. Full ROR on both eyes. AV Ratio 2:3. Clear media. Optic nerve 0.3mm. Disc margins sharp; no hemorrhages
or exudates.

SALIENT FEATURES
This is a case of a middle-aged male driver from Cubao, Quezon City, with a 3-year history of diabetes, coming in for diabetic
retinopathy screening. Patient is asymptomatic upon presentation. He reports that he occasionally rubs his eyes during driving.
He was previously diagnosed with exposure keratopathy and was given Lacryvisc gel at bedtime. After a week and upon follow up,
patient reports better vision. He was given prescription reading glasses with a grade of -50/-75. Physical examination shows a well
patient with high blood pressure. Reduced visual acuity. Yellowish-brown discoloration in the lateral conjunctiva on both eyes
were noted. No redness, itchiness, and excessive tearing noted. Other findings are unremarkable.

WORKING IMPRESSION
Error of refraction, pinguecula on both lateral conjunctiva, and exposure keratopathy; rule out diabetic retinopathy

DIFFERENTIAL DIAGNOSES
The patient’s slight abnormality in visual acuity could be attributed to different conditions. Considering that the patient is diabetic
and is under assessment for diabetic retinopathy (DR), this is a possible differential. In diabetic retinopathy, macular edema
primarily causes the visual loss by retinal thickening and edema. However, in the patient’s physical examination, no abnormal
blood vessels, swelling, blood, or fatty deposits in the retina, growth of new blood vessels and scar tissue, and abnormalities in
the optic nerve were seen. Moreover, his diabetes is a relatively new diagnosis and is controlled. However, only a fundoscopic
exam was done, hence, further tests (i.e. dilated fundus examination or retinal photography) may be warranted to confirm this
diagnosis. Another possible differential diagnosis is cataracts, which is the clouding of the normally clear lens. Given that the
patient is in his middle age years and is diabetic presenting with blurring of vision, having a cataract is likely since it is prevalent as
aging occurs and diabetics are at a higher risk for developing cataracts. However, further tests (i.e. slit lamp exam, retinal exam)
are needed in order to rule out this diagnosis. Since the patient has a history of wearing prescription glasses and exhibits blurring
of vision, error of refraction (EOR) is highly likely. EOR happens either due to the shape of the eyeball or the curve of the retina.
However, a refraction test should be done to determine which EOR the patient has.

Another significant physical examination finding seen in the patient is the yellowish-brown discoloration in the lateral conjunctiva
of both eyes. One of the differentials for this condition is nodular episcleritis, which is the inflammatory condition affecting the
episcleral tissue which usually presents as redness, irritation, and watering of the eye with preserved vision. Given the patient’s
condition, this diagnosis is unlikely since the patient does not exhibit any of the symptoms. However, slit-lamp exam may be done
to rule out this diagnosis. Moreover, it is important to note that nodular episcleritis is not associated with reduced visual acuity,
which our patient exhibits. Another differential that can be considered is scleritis. It is a potentially blinding inflammatory disorder
of the sclera that may also involve the cornea, adjacent episclera, and underlying uveal tract. It has a highly symptomatic clinical
presentation consisting of pain, tearing or photophobia, ocular tenderness, and decreased visual acuity. Although the patient
exhibits decreased visual acuity, he does not present with any other symptoms. Also, scleritis exhibiting decreased visual acuity
would only signify the extension of the inflammation to other structures. Hence, this diagnosis is unlikely. Given the characteristics
of the discoloration seen in the patient, pinguecula is highly considered. Pinguecula is a degenerative eye condition characterized
as a yellowish, slightly raised conjunctival lesion arising at the limbal conjunctiva. It is often generally small and asymptomatic and
associated with sunlight exposure in susceptible individuals. Given the occupational history of the patient as a driver presenting
with no symptoms with a yellowish-brown discoloration finding, this is highly likely the diagnosis.

CASE DISCUSSION
Basing from the patient’s physical examination, his visual acuity is slightly reduced. Given his history of having prescription glasses,
it is highly likely that he already has an error of refraction. Refractive disorders are common among ages 40 and above, which
makes our patient highly susceptible. Upon testing with his glasses on, there is still an impairment in visual acuity when looking
afar. However, normal visual acuity was achieved when looking near. Hence, it can be assumed that he is myopic (near-sighted).
Myopia is a common refractive disorder wherein the axial length of the eye is either too long or the refractive power of the eye's
optical system is too great, which may be due to corneal protrusion resulting in steep corneal curvature. There are several factors
that cause this condition such as heredity. However, none of the patient’s family members have this condition. Being diabetic also
makes him likely to have this condition because the alterations in serum osmolarity secondary to changes in blood glucose levels
can cause an influx of osmotic fluid into the lens subsequently causing lens swelling and a transient increase in refractive power
or myopia. Another risk factor that the patient has is his occupation which predisposes him to sunlight. According to studies,
persons who are near-sighted have higher serum melatonin levels, suggesting a role for light exposure in the myopic growth
mechanism. Refractive disorders are known to occur due to cellular and/or physiologic mechanisms that cause retinal defocusing
with resulting altered axial length and myopia during the developmental process. Some of these processes are form deprivation,
excessive accommodation, scleral stretching, and autonomic deficits during accommodation.

Another condition that the patient is suspected to have is pinguecula, which is a degenerative eye condition that may be confused
with pterygium. Pinguecula is a yellowish, slightly raised conjunctival lesion composed of a deposit of protein, fat, or calcium. It
usually arises from the nasal conjunctiva, but in the patient’s case, arose from the temporal conjunctiva. It is differentiated from
a pterygium by its extension on to the corneal surface—the former is limited only at the limbal conjunctiva while the latter
encroaches the cornea. Like EOR, it is also associated with sunlight exposure, again, putting the patient susceptible for this
condition. In addition to that, the exposure of the patient to dust and wind may contribute further to developing this condition.
Patient also reports of dryness of the eyes, which he is given Lacryvisc gel for. The dryness in his eyes may be attributed to the
pinguecula being a raised bump on the eyeball causing the natural tear film to spread unevenly across the surface of the eye.
However, dryness is a nonspecific symptom which may be attributed to other factors such as the patient’s exposure to the outside
environment and his diabetes. Another possible cause of the patient’s dryness of the eyes is his previous diagnosis of exposure
keratopathy. Given the nature of his work, it is possible that his cornea is exposed to too much air causing the said dryness and
possibly, the blurry vision.
 DIAGNOSTICS AND ANCILLARY TESTS
First and foremost, given that the patient came for diabetic retinopathy screening, it is important to primarily rule it out which
can be done by assessing the patient’s FBS and HbA1c levels to evaluate diabetes control. Imaging studies such a fluorescein
angiography may be done to determine the presence of microaneurysms typically present in DR. Optical coherence tomography
may also be done to determine the thickness of the retina and the presence of swelling within the retina, and vitreomacular
traction. If the media is obstructed by vitreous hemorrhage, B-scan Ultrasonography may be warranted.

After confirming that the patient has an error of refraction, a refraction test is warranted in order to evaluate which EOR the
patient has and which prescription lens best fit the patient. Special imaging and other tests are rarely necessary. In the same line,
pinguecula is generally diagnosed clinically through physical examination. Special tests are not needed.

TREATMENT AND MANAGEMENT

Refractive error. Given that the patient already has prescription glasses, it is advised that he updates his lenses in order to better
fit his current grade. In any case that the EOR proves to be too uncomfortable and eye strain becomes too great, refractive surgery
may be an option. However, in the patient’s case, his visual acuity is only slightly reduced and does not cause him much discomfort,
hence, surgery is not yet advised.

Pinguecula. Pinguecula is often mild and self-limiting, hence it is often ignored by the patient and ophthalmologist. However,
some simple ways to protect the eyes from its risk factors are wearing sunglasses to keep out UV light and wearing glasses or
goggles to keep the dust out, given the patient’s occupation. Artificial tears, such as the one being used by the patient is
recommended to maintain moisture. However, if it bothers the patient such as when it starts to grow over the cornea or is
constantly severely inflamed, he can have it surgically removed.

Exposure keratopathy. Given the patient’s case, it can be assumed that his EK is only mild and may be managed with artificial
tears, gel, or ointment, as was prescribed to him. Some doctors may also recommend wearing moisture chamber glasses to keep
the eyes moist even if they are slightly open. It is important to watch out for certain complications such as ulcer, for which the
doctor may prescribe antibiotics.

REFERENCES
Bhavsar, A. (2019, November 10). Diabetic retinopathy: Practice essentials, pathophysiology, etiology. Retrieved from
https://emedicine.medscape.com/article/1225122-overview
Bixler, J. (n.d.). Refractive errors. Retrieved from https://www.umkelloggeye.org/conditions-treatments/refractive-errors
Hellem, A. (2019, April). What is a Pinguecula? Retrieved from https://www.allaboutvision.com/conditions/pinguecula.htm
Jacobs, D. (2018, June 18). Pterygium. Retrieved from
https://www.uptodate.com/contents/pterygium?search=pinguecula&source=search_result&selectedTitle=1~6&usage
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Kellogg Eye Center. (n.d.). Exposure Keratopathy. Retrieved from
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Rajaii, F., & Prescott, C. (2016, May 4). Management of Exposure Keratopathy. Retrieved from
https://www.aao.org/eyenet/article/management-of-exposure-keratopathy-2
Roque, M. (2019, November 10). Scleritis workup: Laboratory studies, imaging studies, other tests. Retrieved from
https://emedicine.medscape.com/article/1228324-workup