Clinical Scenarios

Case 1:

 Abdul Rehman Muhammad Al-Mutairi, a young

boy of 8 years, presents to eye clinic for evaluation
of vision. He complains of headache off and on,
and inability to read clearly the white board in the
classroom. He denies any previous visit to
ophthalmologist.
 How will you evaluate this patient?
 What questions will you ask during history taking?
 What will be the sequence of ophthalmic examination?
 How will your record the clinical notes?
 What is the differential diagnosis?
 What is the most likely diagnosis?
 What are the treatment options?
 Case 2
 A 74-year-old man says he has pain in his left eye and forehead and
blurry vision for two days.
 What questions will you ask during history taking?
 What will be the sequence of ophthalmic examination?
 How will your record the clinical notes?
 What is the differential diagnosis?
 What is the most likely diagnosis?
 What are the treatment options?
 Herpes zoster ophthalmicus (HZO; shingles).
 Hutchinson’s sign, which is a strong indicator of ocular involvement (nasociliary branch of the
ophthalmic nerve)
 Conjunctivitis, keratitis (epithelial, stromal, or endothelial), iritis, and increased IOP
 Oral antivirals (famciclovir or valacyclovir is preferable to acyclovir because of reduced risk of
postherpetic neuralgia (PHN)) and steroids (also reduces risk of PHN). Topical steroids and
cycloplegic for iritis, and monitor IOP. If corneal epithelial involvement occurs, then add a
topical antibiotic.
 Herpes zoster is rare in individuals younger than 40 years old unless they are
immunocompromised, therefore a history of immunosuppression (cancer, HIV, etc.) should be
determined and an HIV test considered
 Lid scarring (lagophthalmos, ectropion, entropion, trichiasis, madarosis), canalicular and
punctal stenosis, symblepharon, exposure keratopathy, neurotrophic keratopathy, corneal
scarring, scleritis, glaucoma, uveitis, iris atrophy and necrosis, cataract, cystoid macular edema,
optic neuropathy, retinitis, cranial nerve palsies, orbital apex syndrome, and PHN
 Case 3.

A 48-year-old man reports a tender swollen left upper

eyelid and tearing for 8 days. He denies any trauma or
change in vision.
A 48-year-old man reports a tender swollen left upper eyelid and tearing
for 8 days. He denies any trauma or change in vision.
 How will you evaluate him.
 What is differential diagnosis.
 What is the diagnosis.
Other features

 He does have a fever and reports some discharge from the eye, but there is no
diplopia.
 On exam, he has palpable preauricular lymphadenopathy.
 His vision is 20/25 in both eyes, pupillary response, extraocular motility, and
confrontation visual fields are normal.
 External exam shows a firm, tender mass of the lateral upper eyelid.
 Anterior and posterior segment exams are normal.
 An orbital CT scan shows:
Orbital CT