Dhanashree Ratra SANKARA NETHRALAYA

MS,DNB,FRCSEd C.U. SHAH OPHTHALMIC POST GRADUATE

TRAININGCENTRE
Senior Consultant
UNITS OF
Dept Of Vitreoretinal Diseases
Email: drdad@snmail.org MEDICAL RESEARCH
Phone: FOUNDATION (Regd.)
Fax: (An ISO 9001:2000 Certified Organisation)

MR No. 2882170 Address : C / O BODU RAM JI AGARWAL,

Name MR. DIVY GUPTA NEAR JAIN TEMPLE, MAIN MARKET,
Age 20 Year(s) , RAIPUR,
Sex male RAJASTHAN, INDIA - 306304.

Mr . Divy Gupta (Our MRD no: 2882170), a 20 year old Male patient was seen hereon
28-02-2019. by Dr.DHANASHREE RATRA The detailed case summary is given below.

Purpose of
Second opinion for Retina------------------
Visit
Main Complaints
• Both eyes Night blindness 3 Year(s) Onset Gradual Progression Worsening
feels need more adapatation after coming from sunlight.
• Both eyes Diminision of vision 3 Year(s) Onset Gradual Progression Worsening
OU; C/O diminision of vision with glasses for D, feels field of view is constricted. OU: c/O
mild irritation. OU: No other specific ocular complaints.
Past Ocular History
• Both eyes Nil
E/W diagnosed retinitis pigmentosa in both the eyes. Baseline vision OD: 6/10,
OS: 6/12. Came here for further mangement.
Past Medical History
Nil Nil GH: Good No
Family History
Nil No
Allergy History
Not aware of

Visual Acuity Refraction

REFRACTION
Cycloplegic
Retinoscopy Quality of Reflex
refraction
Eye Sph Cyl Axis Type DSph DCyl Axis
RIGHT - -
180 Clear HA+T-9.00 -2.00 180
EYE 8.50 2.00
LEFT - -
160 Clear HA+T-9.00 -2.00 160
EYE 9.00 2.00
GLASS PRESCRIPTION
Distance Vision ADD
Eye Sph Cyl Axis BCVA Sph BCVADistance
RIGHT - - 6/9
10 N6 30
EYE 9.00 2.00 (0.20)
LEFT - - 6/12
160 N6 306/12+3
EYE 9.00 2.00 (0.30)
Cover Test
Hirschberg Ortho
CoverTestDistanceOrtho
CoverTestNear Ortho
 Ocular Movement
OcularMotility
Full
OD
OcularMotility
Full
OS

PUPIL
Right Eye Left Eye
Size Normal Normal
Shape Normal Normal
Reaction to
Normal Normal
Light
Reaction to
Normal Normal
Near
REMARKS: No RAPD

EXTERNAL EXAM
Posture Normal
Face Normal

Lid/Lash & Conjunctiva: Both Eyes Normal

CORNEA/ANTERIOR CHAMBER
Right Eye Left Eye
Sclera Normal Normal
Cornea Normal Normal
Anterior
Chamber Normal Normal
Central Depth
Anterior
Chamber
Normal Normal
Periphral
Depth
Von Henrick's
IV IV
Grading

Iris/Lens: Both Eyes Normal

CONFRONTATION
Right Eye Left Eye
Ishihara 1/21 1/21
REMARKS: OU: Not improving with red filter, adequate time given.
Intra Ocular Pressure
Method Actual Time Right Eye Value Left Eye Value
Applanation 12:05 16 mm of Hg 16 mm of Hg

Fundus Drawing
 Keratometry
Right Eye Left Eye
K1 Reading(in
43.50 D @ 180 43.75 D @ 165
Dioptres)
K2 Reading(in
45.25 D @ 45.25 D @
Dioptres)
Method Auto Auto
Comments OU: Clear and round mires

Diagnosis
EYE DESCRIPTION
Both
Myopia - H52.10
Eyes
Both
Astigmatism - H52.20
Eyes
Follow Up/Action Plan
both eyes findings as noted, no similar history in family, no history of
consanguinity, complaints of progreesive night blindness and color blindness with
severe photophobia. Suspect cone rod dystrophy advice: both eyes Clarus iwth AF,
OCT, fferg and Humphrey Visual Field/Perimetry 24 24-2,genetic
2,genetic counselling, Low
visual aids clinic and review. ? cone rod dystrophy LVA trials.

Dr.DHANASHREE RATRA

Numb
Test Mean
er Of Ey Strate Diagno Patte CPS Stagi Impress
Repeat Defects Deviati
Time e gy sis rn SD D ng ion
ed on
s
Rig SITA CONSTRIC
NO ht FAST TED 42409
Eye 30
30-2 FIELDS
SITA CONSTRIC
Left
NO FAST TED
Eye
30
30-2 FIELDS
Test Numb Mean
Ey Strate Diagno Patte CPS Stagi Impress
Repeat er Of Defects Deviati
e gy sis rn SD D ng ion
ed Time on
 s
Rig SITA CONSTRIC
NO ht FAST TED 42409
Eye 30-2 FIELDS
SITA CONSTRIC
Left
NO FAST TED
Eye
30-2 FIELDS

Correlate Clinically.
REMARKS: OU:Foveal thinning seen with thinning of ellipsoid
layer,RPE alterations,I/R hyper reflective dot echoes
,ERM and ILM wrinkling noted.FT OD: 138 OS: 132
microns

Patient Has Undergone ERG :FFERG OU: Grossly reduced scotopic and photopic
responses,S/o RP.

Visit Date Consultation Consultant

2019-03-01 SHORT REVIEW Dr.DHANASHREE RATRA

Follow Up/Action Plan

Investigations reviewed. Humphrey Visual Field/Perimetry shows constricted fields,
electroretinogram shows grossly reduced scotopic and photopic responses. OCT
shows fovea sparing degeneration of photoreceptor layers. Could be cone rod
dystrophy or early RP..Review with Low visual aids and genetics clinic. Review 1
year or as and when required.

Dr.DHANASHREE RATRA

For queries, get in touch with your doctor or to fix up an appointment please use
following contact details :
Secy. Name / Tel.No
drdad@snmail.org
SANKARA NETHRALAYA
41/18, College Road, Nungambakkam
Chennai - 600 006, TamilNadu, India.
Address Fax : +91-44-2825 4180
Phone : +91-44-2827 1616
E-Mail : appointment@snmail.org
Web : Http://www.sankaranethralaya.org