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Case presentation

Dr.Prathibha.M.Chachadi

12/19/2012

Sanjay M (op no: 725436) 18 years /male Student Bangalore; 20/11/12 at emergency

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h/o fall by tripping on a pipe Sustained injury with a stone in his right eye c/o pain and swelling around the right eye with blurring of vision h/o poor vision in right eye since childhood Using glasses and contact lenses (occasionally) since 2 years yearly disposable soft contact lenses. No h/o epistaxis; nausea or vomiting/loss of consciousness Was started treatment and followed up closely 0n 28/11/12 he came with c/o sudden painless decrease of vision-1 day

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Treatment history: o/e right eye had periorbital edema with echymosis- lower lid No e/o orbital wall # Extraocular movement were full and normal Subconjunctival haemorrhage was seen temporally cornea clear Anterior chamber- +4 cells with grade 1 hyphaema+ Pupil- Round regular and reactive;iridodenesis+ Lens- Normal Vision: with previous glasses right eye- cf- 1mt left eye 6/6;N6 IOP- digitally normal
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On follow up- 21/11/12 IOP 17 mmhg RE 15 mmhg LE Vision Status quo Grade 3 GonioscopyRE LE Grade 4
Grade 4 Grade 4 Grade 4 Grade 3 Grade 3

360 deg angle recession

Grade 4

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Retinal examination BE- Myopic fundus with tessellated back ground \periphery- no treatable lesions Ocular medications: RE- oflacin Dx- 12 t/d RE-Ocupol d e/o- at bed time RE- homide e/d- 3 t/d Tab combiflam 1-0-1 for 5 days
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Personal history Family history General physical examination: Height : 5 feet 4 inches ; Weight : 58 kgs Arm span= height Cardiac and respiratory system : Normal

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Ocular examination
Head posture: normal Facial symmetry: normal Ocular symmetry: normal

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Right Eye
Lids and adnexa Lacrimal Sac area Conjunctiva:Bulbar Forniceal Cornea: Size Shape Transparency Sensation Epithelium Stroma Endothelium Anterior chamber Depth Content Iris: Color Surface
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Left Eye normal

normal Subconjuctival haemorrhage Clear normal

Clear normal

Deep AC +2 cells; flare+ Vitreous pigment Iridodenesis+

normal

normal

Right Eye
Pupil: Size Number Margin Centration Light reflex: Direct Indirect Lens: Transparency Position Zonules Extra ocular movements Ductions Versions Convergence

Left Eye Round regular reactive

Pharmacologically dilated

Inferior early cortical cataract changes seen Phacodonesis+ Inferior zonules weakness+ Full and normal

Normal

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Right Eye

Left eye

Anterior Chamber depth


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Angle recession

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Right Eye
Vision :Unaided/pinhole Distance Near
Refraction Hand movement+ NIL Media hazy

Left Eye
Cf 3meter N6 6/18

-6.00 -6.00
(-5-1) Tropicamide plus 1 meter

Subjective refraction

No improvement

-4.25 sphere diopters 6/6; n6 Contact lens power: -3.75 Sphere OU

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Fundoscopy
78 D lens Media Disc: size Shape Color Margin Blood vessels on disc Cup disc ratio Posterior pole: Blood vessels A:V ratio Foveal reflex Right Eye hazy Pigment in anterior vitreous Left eye clear Normal 0.4

Details not made out

Normal 1:3 Fr+

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Indirect ophthalmoscopy:Right eye

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Indirect ophthalmoscopy:Left eye

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Diagnosis
Right Eye: High myopia with anisometropic amblyopia Blunt injury(contusion) with early cortical cataract(inferior zonular weakness);traumatic iritis;angle recession Superior giant retinal tear with total retinal detachment with early proliferative vitreoretinopathy changes (grade b) Left eye: Simple myopia

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Management
Right Eye:Phaco+/-CTR +/- IOL implantation band+PPV+removal of PVR membranes+PFCL for eversion of GRT flap+EL(barrage)+silicone oil injection GVP-under local+sedation Left eye: Simple myopia(glasses/ CL)

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RE- Phaco+ctr+IOL+PPV+membrane removal+FAE+EL+Silicone oil injection

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