WELCOME TO MORNING

SESSION
LONG CASE PRESENTATION
BY -

DR. MIR ASHRAFUL KABIR

MS,Resident, Phase-A , Department of Ophthalmology,

BSMMU,DHAKA.
Particulars of the patient

 Name- Mrs Rehana Begum

 Age- 40 years
 Sex-Female
 Marital status-married
 Occupation- Housewife
 Address- Moinakandi, Daudkandi, Comilla.
 Date of examination- 10.04.2016
Chief complaints

1. Watering from left eye -for 4 years.

2. Watering from right eye for 3 years.
History of present illness

According to the statement of the patient , she developed

watering from left eye 4 years back. Initially watering was
scanty in amount but gradually it increasing in nature. It was
associated with redness & discharge. She gave no history of
any ocular trauma , or falling of foreign body to her eyes .
She consulted with a local ophthalmologist for watering and
was treated with some eye drops ,but, watering did not
stopped. After 1 year , she developed watering from another
eye , which was also associated with redness & discharge.
That time, she did not consult to any doctor. She is non
diabetic, normotensive, non asthmatic. Now she has come to
ophthalmology OPD of BSMMU for better management.
History of past illness

She has history of abdominal hysterectomy 18 months

back.
Family history

 She has two sons & one daughter, all of them are
healthy. Her father undergone dacryo-cysto-
rhinostomy 5 years back.
Drug history

 She takes domperidone & lansoprazole irregularly.

Personal history

She maintains personal hygiene properly , but takes regular

pond bathing.
Socio-economic history

 The patient belongs to a middle class family.

 She lives in a soil made house with proper sanitary
facilities.
 General examination
 Appearance- Normal
 Co operation-Co-operative
 Body built- Average
 Nutrition-Good
 Decubitus- On choice
 Anaemia- present (+)
 Jaundice-Absent
 Cyanosis- Absent
 Oedema-Absent
 Dehydration: Absent
 Clubbing-Absent
Continued….

 Neck vein-Not engorged

 Lymph node –Not enlarged
 Thyroid gland-Not enlarged
 Pulse -80 beats/minute
 BP-100/70 mm of Hg
 Temperature-98 degree F
 Height- 5 feet 1 inch.
 Weight-50 kg
Local examination
On inspection-
 Head position is normal.
 No facial asymmetry.
 Eyelids: Normal in both side.
 Eye lashes: Matted in both eyes.
 Punctum : both upper and lower puncta are normal in both
sides.
 Lacus lacrimalis was full of water in left side.
 Nasal cavity-normal in both sides , there is no deviation of
septum ,polyps or tumor . Nasal mucosa is normal.
 Oral cavity- normal .
Continued…

On palpation
 Temperature-normal
 Tenderness-absent
 Regurgitation test-
left eye - positive
right eye - negative
 Ocular examination
Ocular Right eye Left eye
examination
Visual acuity, 6/6 6/9 with PHNI
distant vision

Near vision N5 N5

Pupillary light Brisk Brisk

reflex
Hirschberg reflex Central Central

Ocular motility Full in all gaze Full in all gaze

 Slit lamp findings
Right eye Left eye
EYE LIDS Normal Normal

Eye lashes Matted Matted

CONJUCTIVA Not congested Not congested

CORNEA Transparent Transparent
ANTERIOR CHAMBER Normal in depth and Normal in depth and
content both in centre content both in centre
and periphery and periphery
IRIS Normal in color and Normal in color and
pattern pattern
PUPIL Round and regular Round and regular
LENS Transparent Transparent
IOP(by GAT) 11 mm of Hg 12 mm of Hg
Fundus examination
Fundus Right eye Left eye
examination
(Direct
ophthalmoscopy)
Media Clear Clear
Color of optic disc Pink Pink
Margin of optic disc Well defined Well defined
CD ratio 0.4 0.4
Small blood vessels Clear Clear
over the disc
margin
Background Normal Normal
Foveal reflex Present Present
Special ocular examination

 Sac patency test-

On left side-
 Blocked
On right side
 Blocked
Examination of the
cardiovascular system
 Inspection –
 Shape of the chest-normal.
 Anaemia present ; cyanosis , clubbing , coldness of extremities , pyrexia ,
oedema absent.
 Arterial pulse- 80 beats/min
 Blood pressure- 100/70 mm of Hg(on both hands)

 Palpation-
Apex beat-present in left fifth intercostal space just medial to the mid
clavicular line . There was no thrill.
 Percussion-area of superficial cardiac dullness normal.
 Auscultation-
The first and second heart sounds were audible . There is no added sound.
Examination of the Respiratory System

Inspection
 Nasal cavity-normal
 Nasopharynx-NAD
 Oral cavity-NAD
 Oropharynx-NAD
 Respiratory rate-16 breaths/min
 Shape of the chest-normal ,bilaterally symmetrical
 Palpation-position of the trachea central.
 Percussion-resonant
 Auscaltation-vesicular breath sound
Examination of the Nervous System

 Higher cerebral function- intact

 Patient is conscious and oriented , gait normal.
 All cranial nerves-intact
 Motor function-
 There is no muscle wasting ,bulk and tone of muscle is
normal in both upper and lower limbs .
 Reflexes- are intact and normal.
 Sensory function-Temperature ,touch , pain and vibration
and position sense intact.
 Cerebellar function- intact
 Signs of meningeal irritation -absent
Salient feature

Mrs Rehana Begum, 40 years old housewife, regular takes bath

on pond, hailing from Daudkandi, Comilla , comes to the OPD
of ophthalmology of BSMMU on 10.04.16 with the complaints of
watering from the left eye for 4 years & from the right eye for 3
years . Ocular examination reveals that eye lash was matted on
both eyes, lacus lacrimalis was full of water in the left eye ,and
regurgitation test was positive on left eye . Sac patency test
reveals block on both side,her vision was normal in right eye &
6/9 on left eye. She is mildly anaemic & other ocular, general
and systemic examinations were within normal limit . The
patient was normotensive ,non diabetic and non asthmatic.
Provisional diagnosis

Chronic dacryocystitis of both side.

Differential diagnosis

Pump failure of both side.

Investigations
 Ocular investigation

Schirmer’s test-(i)
Left eye- 33 mm
Right eye- 12 mm
Routine investigations:
 RBS- 5.9 mmol /l
 ECG
 X ray PNS O/M view
 BT, CT – within normal limit.
MANAGEMENT

Dacryo-cysto-rhinostomy with intubation of both side

under L/A ( Left > Right).
Thank you all.