Case 1

A 14-year-old child presented in eye OPD with history of decreased vision in both eyes which
deteriorates at night.
.
A 40-year-old patient presented in OPD with complaint of decreasing vision especially at
night.
What is your differential diagnosis?
What is the most probable diagnosis?
What are its ocular and systemic associations?
What are different treatment modalities?

Most probable diagnosis:

Retinitis pigmentosa (RP)

Differential diagnosis:
• Vitamin A deficiency
• Congenital stationary night blindness
• Choroideremia
• Gyrate atrophy
• Cone rod dystrophy
• Refsum Disease
• Late stage syphilitic retinopathy
• Usher Syndrome
• Fundus flavimaculatus

Ocular associations:
• Posterior sub capsular cataract
• Optic disc pallor
• Attenuated retinal vessels
• Macular edema
• Cystoid macular edema
• Myopia

Systemic associations:
• Usher syndrome (RP + congenital deafness)
• Bardet–Biedl syndrome
• Refsum disease
• Kearns–Sayre syndrome

Treatment modalities:
• No definitive cure
• Genetic counseling
• Low vision aids
• Vitamin A supplementation (under supervision)
• Cataract surgery if posterior sub capsular cataract develops
• Management of macular edema with carbonic anhydrase inhibitors
• Regular follow-up with retinal evaluation
📘 Jatoi p. 298–301 | Jogi p. 304–307

Case 2
A 50-year-old female came to OPD with complaint of gradual decrease of vision in both eyes
since last 5 years. She is diabetic and hypertensive since last 5 years. Anterior segment is
normal with slightly sluggish pupillary reaction. Vision is 6/60 in right eye and 6/24 in left eye.
IOP is 30 mmHg in right eye and 24 mmHg in left eye. She was advised to use some drops
previously but did not use them regularly. The fundus view is hazy too in both eyes.

Diagnosis: Chronic Open Angle Glaucoma

(Ref: Jogi p. 101–102; Jatoi p. 95–97)

Investigations:
1. Intraocular pressure: raised (>21 mmHg)
2. Gonioscopy: confirms open angle
3. Fundus exam: glaucomatous cupping (cup-disc ratio >0.5)
4. Visual field testing (perimetry): arcuate scotoma, nasal step
5. OCT: thinning of RNFL
6. Pachymetry: to assess corneal thickness

Treatment:
Medical:
• Prostaglandin analogues (Latanoprost once daily at night)
• Beta-blockers (Timolol twice daily)
• Carbonic anhydrase inhibitors (Dorzolamide)
• Alpha agonists (Brimonidine)

Surgical (if medical treatment fails):

• Trabeculectomy
• Laser trabeculoplasty (ALT or SLT)

Case 3
A 50-year-old lady came to OPD with complaint of sudden decrease of vision in her left eye.
She is a known diabetic since last 5 years and hypertensive since last 12 years.
What are the causes of decrease of vision in her eye?
How will you classify this disease?
What investigations are required for this patient?

Diagnosis: Diabetic Retinopathy (likely with macular edema or retinal vascular occlusion)
(Ref: Jogi p. 146–148; Jatoi p. 135–137)

Classification:
1. Non-proliferative diabetic retinopathy (NPDR)
2. Proliferative diabetic retinopathy (PDR)
3. Diabetic macular edema (focal or diffuse)

Causes of visual loss in diabetic patients:

1. Macular edema
2. Vitreous hemorrhage
3. Retinal detachment
4. Ischemia of macula
5. Neovascular glaucoma

Investigations:
• Fundoscopy: microaneurysms, hemorrhages, cotton wool spots
• Fundus Fluorescein Angiography (FFA): areas of ischemia, leakage
• OCT: macular edema, retinal thickening
• Visual acuity and Amsler grid testing
• B-scan (if fundus view is hazy)

Case 4
A 45-year-old man with uncontrolled diabetes mellitus presented in OPD with complaint of
sudden deviation of eyes. Patient noticed gradual increase in deviation too.
What is your most probable diagnosis?
How will you investigate the patient?
What are the treatment options?

Diagnosis: Sixth nerve palsy

(diabetic mononeuropathy)
(Ref: Jogi p. 188; Jatoi p. 173–174)

Investigations:
1. Ocular motility testing: limitation of abduction
2. Diplopia charting: horizontal diplopia increasing on gaze toward affected side
3. MRI brain (if no improvement after 3 months or atypical features)
4. Blood sugar control (HbA1c, fasting BSR)

Treatment:
• Control of diabetes
• Observation (often recovers within 3 months)
• Temporary prism glasses for diplopia
• Strabismus surgery (only if deviation persists after 6 months)

Case 5
A young patient came to OPD with complaint of lacrimation, itching and discomfort behind
the eyeball. On systemic examination he has fever, cough and sinusitis. On ocular examination
he shows mild lid oedema, conjunctival congestion and some restriction of extra ocular
movement.

Diagnosis: Orbital cellulitis

(Ref: Jogi p. 127; Jatoi p. 115)

Differential Diagnosis:
• Preseptal cellulitis
• Thyroid orbitopathy
• Cavernous sinus thrombosis
• Intraorbital tumor

Investigations:
1. CT orbit: shows orbital inflammation/posterior extension
2. CBC: leukocytosis
3. Blood cultures
4. Nasal and conjunctival swabs for culture

Management:
1. IV antibiotics (Ceftriaxone + Metronidazole or Vancomycin)
2. Nasal decongestants
3. Analgesics + antipyretics
4. Surgical drainage if abscess develops
5. Monitor for optic nerve involvement

Case 6
A 50-year-old male presented in OPD with complaint of sudden onset of flashes of light and
then decrease of vision in his right eye. He is using high-powered glasses since childhood.
Vision in his right eye was CF and in left eye was 6/9 with abnormal pupillary reaction too.

Diagnosis: Rhegmatogenous Retinal Detachment

(Ref: Jogi p. 158; Jatoi p. 147)

What is differential diagnosis and how do you differentiate it?

Vitreous hemorrhage (fundus view obscured)
Posterior vitreous detachment (no retinal elevation)
Choroidal detachment (convex dome elevation)

Investigations:
1. Indirect ophthalmoscopy: detached retina with retinal tear
2. B-scan: if fundus not visible
3. OCT: elevation of retinal layers

Management:
Bed rest with head positioning
Surgical:
• Scleral buckling
• Pars plana vitrectomy
• Pneumatic retinopexy (for superior breaks)

Case 7
A 2-year-old child was brought in OPD with complaint of inward deviation of right eye. His
refractive error was +6 D in both eyes.
What is your diagnosis?
How will you investigate?
How will you treat the case?

Diagnosis: Accommodative Esotropia (Refractive type)

Investigations:
1. Visual acuity testing appropriate for age
2. Cycloplegic refraction: shows +6 diopters hypermetropia
3. Cover-uncover test: confirms esotropia
4. Hirschberg test: confirms angle of deviation
5. Fundus examination: rule out any organic pathology

Treatment:
• Full cycloplegic hypermetropic correction with convex glasses
• Amblyopia therapy: patching of better eye if amblyopia is present
• Follow-up to assess improvement of deviation with glasses
• If deviation persists despite correction (partially accommodative type), consider squint surgery
(medial rectus recession) after 4–5 years

Case 8
A 1-year-old child was brought in OPD as parents noticed white reflex and deviation of the
eye in his right eye. On CT scan there was intraocular calcification.
What is the most possible diagnosis?
What are the different modes of presentation?
What are the different treatment options?

Diagnosis: Retinoblastoma

Modes of Presentation:
• Leukocoria (most common presenting sign)
• Strabismus (often due to poor fixation)
• Poor vision
• Painful red eye with glaucoma (in advanced cases)
• Proptosis in extraocular extension
• Orbital mass in late-stage tumor

Treatment Options:
1. Enucleation: for unilateral large tumors without useful vision
2. Chemoreduction: systemic chemotherapy (Vincristine, Etoposide, Carboplatin) to shrink tumor
3. Focal therapies: laser photocoagulation, cryotherapy, thermotherapy
4. Radiotherapy: external beam radiation for advanced but intraocular disease
5. Intra-arterial chemotherapy: for selected cases
6. Genetic counseling: important in bilateral/familial cases

📘 Jatoi p. 310–313 | Jogi p. 292–295

Case 9
An obese female aged 40 presents in OPD with complaint of severe headache associated with
nausea and vomiting which is aggravated by coughing and straining. Headache is relieved by
vomiting. Her vision is 6/12 in both eyes with normal anterior chamber. BP 160/100, BSR 190
mg/dL.
What is the differential diagnosis?
What are the ocular signs?
How will you investigate the patient?

Differential diagnosis:
• Idiopathic intracranial hypertension (Pseudotumor cerebri)
• Brain tumor
• Malignant hypertension
• Cerebral venous sinus thrombosis
• Space-occupying lesion
• Intracranial hemorrhage

Ocular signs:
• Bilateral papilledema
• Visual obscurations
• Enlarged blind spot
• Diplopia due to sixth nerve palsy
• Normal anterior segment and pupillary reflexes
• Transient visual loss on change of posture

Investigations:
• Fundoscopy – bilateral disc edema
• Visual field testing – enlarged blind spot
• MRI brain – to exclude mass lesion
• MRV – to rule out venous sinus thrombosis
• Lumbar puncture – high opening pressure, normal CSF composition
• Blood sugar and BP monitoring

📘 Jatoi p. 278–280 | Jogi p. 268–270

Case 10
A 6-month-old child was brought by his mother with the history of photophobia and watering
in both eyes. On examination, there was corneal haze and increased corneal diameter.

Diagnosis: Primary congenital glaucoma

Differential diagnosis:
• Congenital hereditary endothelial dystrophy
• Sclerocornea
• Mucopolysaccharidosis
• Congenital rubella syndrome
• Peter’s anomaly
• Congenital megalocornea

Management:
Medical (temporizing):
1. Topical beta blockers (Timolol)
2. Topical carbonic anhydrase inhibitors(Dorzolamide)
3. Avoid prostaglandin analogs in infants
Surgical (definitive):
1. Goniotomy – if cornea is clear
2. Trabeculotomy or Trabeculectomy – if cornea is hazy
3. Combined Trabeculotomy–Trabeculectomy in severe cases
4. Regular IOP monitoring and vision assessment
5. Genetic counseling if familial

📘 Jatoi p. 316–318 | Jogi p. 287–290

Case 11
A 50-year-old hypertensive female presented in OPD with complaint of sudden painless loss of
vision in right eye. On examination, there were haemorrhages in all four quadrants of fundus
along with cotton wool spots.
What is the most probable diagnosis?
What are the different risk factors?
How will you treat neovascularization in this case?
.
A 50-year-old female presented in eye OPD with sudden loss of vision in right eye. She is
hypertensive and diabetic. On examination, there are haemorrhages in four quadrants and
cotton wool spots.

Diagnosis:Central Retinal Vein Occlusion

Investigations:
• Fundoscopy: flame-shaped hemorrhages, cotton wool spots, disc edema
• Fundus Fluorescein Angiography (FFA): delayed venous filling, leakage
• OCT: macular edema
• Blood sugar and BP profile

Treatment of neovascularization:
• Pan-retinal photocoagulation (PRP) laser therapy
• Intravitreal anti-VEGF injections (e.g., Ranibizumab)
• Monitor for neovascular glaucoma
• Control systemic comorbidities (HTN, DM)

Risk factors:
• Systemic hypertension
• Diabetes mellitus
• Hyperlipidemia
• Glaucoma
• Hyperviscosity syndromes
• Smoking
• Oral contraceptive use

Case 12
A 30-year-old female patient was presented in eye OPD with decreased vision and pain in
lumbosacral column. On examination there are precipitates on the corneal endothelium along
ciliary congestion.
.
A 30-year-old with low back pain and ↓vision in right eye. Exam: fine pigmented endothelial
deposits.
What is your diagnosis?
How will you investigate this patient?
What are the aims of treatment?
What are the treatment options?

Diagnosis: Anterior uveitis (likely HLA-B27 associated)

Investigations:
• Slit-lamp: cells, flare, KPs
• IOP measurement
• Fundoscopy
• ESR, CRP, HLA-B27
• Chest X-ray (TB/Sarcoid), VDRL, ANA

Aims of Treatment:
• Reduce inflammation
• Relieve pain
• Prevent complications (e.g., synechiae, glaucoma)

Signs:
• Keratic precipitates (fine or mutton-fat)
• Aqueous flare and cells
• Ciliary congestion (violaceous limbal injection)
• Posterior synechiae
• Small, sluggish pupil
• Possible elevated or low IOP

Treatment:
1. Topical corticosteroids: Prednisolone 1% hourly
2. Cycloplegics: Atropine 1% or Homatropine to relieve pain and prevent synechiae
3. Topical NSAIDs if needed
4. Monitor IOP and treat if raised
5. Systemic workup for underlying spondyloarthropathy
6. Oral steroids or immunosuppressives in severe/recurrent cases

📘 Jatoi p. 214–216 | Jogi p. 216–220

Case 13
A patient was operated for cataract surgery which was uneventful, but on the first post-op
day, there was decreased vision along with corneal edema and poor fundal glow.
What is your diagnosis?
What is differential diagnosis?
How will you treat this case?

Diagnosis: Acute postoperative endophthalmitis

Differential diagnosis:
• TASS (toxic anterior segment syndrome)
• Corneal edema due to surgical trauma
• Raised IOP
• Vitreous hemorrhage
• Retained lens fragment

Treatment:
• Immediate ophthalmic emergency referral
• Intravitreal antibiotics: Vancomycin + Ceftazidime
• Vitreous tap or diagnostic vitrectomy
• Systemic antibiotics (if severe)
• Topical fortified antibiotics (e.g., cefazolin, gentamicin)
• Topical corticosteroids after culture taken
• Pain management and cycloplegics

📘 Jatoi p. 235–237 | Jogi p. 234–236

Case 14
A mother brought her 1-year-old child with history of watering and photophobia. On
examination, there was corneal haze and increased corneal size.
What is the provisional diagnosis?
What is your differential diagnosis?
What is the treatment option?

Provisional diagnosis: Congenital glaucoma

Differential diagnosis:
• Congenital hereditary endothelial dystrophy
• Birth trauma to cornea
• Congenital rubella syndrome
• Sclerocornea
• Megalocornea

Treatment options:
Surgical management is the mainstay
• Goniotomy (if cornea is clear)
• Trabeculotomy or Trabeculectomy (if cornea is hazy)
Medical therapy (temporary):
• Topical beta blockers (e.g. timolol)
• Carbonic anhydrase inhibitors (e.g. dorzolamide)
• Lifelong monitoring of IOP and optic nerve
📘 Jatoi p. 192–194 | Jogi p. 180–183

Case 15
An 18-year-old boy was wearing −8D with −1.5 cylinder.
What is your diagnosis?
Name other types of refractive error.
How will you treat this case?

Diagnosis: High myopic astigmatism

Other types of refractive errors:

• Myopia
• Hypermetropia
• Astigmatism (simple, compound, mixed)
• Presbyopia

Treatment options:
Optical:
• Spectacles (concave spherical and cylindrical lenses)
• Contact lenses
Surgical:
• LASIK
• PRK
• Phakic IOLs (for very high myopia)

📘 Jatoi p. 86–90 | Jogi p. 85–90

Case 16
A patient presented in OPD with decreased vision and was wearing −8D glasses.
What is your diagnosis?
What are the available treatment options?
What are the types of this condition?

Diagnosis: High myopia

Treatment options:
• Spectacles (concave lenses)
• Contact lenses
• Refractive surgery (LASIK, PRK, SMILE, phakic IOL)
• Regular fundus exams to monitor complications
• Low vision aids (if degenerative myopia)

Types of myopia:
• Simple myopia (school-age, stable)
• Pathological (degenerative) myopia
• Nocturnal myopia
• Pseudomyopia

📘 Jatoi p. 88–91 | Jogi p. 86–89

Case 17
A 40-year-old female patient was presented in OPD with sudden loss of vision in her right eye.
Fundus is normal but there is pain on extra-ocular movements.
What is your diagnosis?
How will you investigate?
How will you treat the case?

Diagnosis:Retrobulbar neuritis (optic neuritis)

Investigations:
• Visual acuity and color vision testing
• Relative afferent pupillary defect (RAPD)
• Visual field testing (central scotoma)
• MRI brain and orbits with contrast (to assess demyelination)
• VEP (Visual evoked potentials)

Treatment:
• IV methylprednisolone 1g/day for 3 days
• Followed by oral prednisolone (1 mg/kg tapered over 11 days)
• Neurology referral to rule out multiple sclerosis
• Counseling on prognosis (vision usually recovers in weeks)

📘 Jatoi p. 279–281 | Jogi p. 260–263

Case 18
A mother brought her 2-year-old child with history of inward turning of eyes. Cycloplegic
refraction showed +2.5 DS. There is cross fixation.
What is your diagnosis?
How will you investigate?
How will you manage this case?

Diagnosis: Infantile Esotropia (congenital esotropia)

Investigations:
• Hirschberg test (corneal light reflex medially displaced)
• Cover-uncover test (movement of uncovered eye)
• Cycloplegic refraction
• Fundoscopy to rule out organic causes
• Check for amblyopia and dominance
• Assess for cross fixation and nystagmus

Management:
• Full hypermetropic correction (+2.5 D) if accommodative element present
• If no significant improvement → Surgery:
• Bilateral medial rectus recession (preferably before 2–3 years of age)
• Amblyopia therapy:
• Occlusion of dominant eye
• Monitor for binocular vision development

📘 Jatoi p. 60–63 | Jogi p. 117–120

Case 19
A 60-year-old female patient presented in eye OPD with loss of vision in right eye. On
examination: ciliary congestion, shallow anterior chamber, fixed dilated pupil, IOP = 36
mmHg.
.
A 50-year-old female presented in OPD with vomiting, eye pain, and haloes. On exam: corneal
edema + IOP 36 mmHg.
What is your diagnosis?
What are the other signs?
What are the treatment options?

Diagnosis: Acute angle-closure glaucoma

Other signs:
• Corneal edema
• Mid-dilated non-reactive pupil
• Pain, nausea, vomiting
• Halos around lights
• Shallow anterior chamber
• Hard globe on palpation

Causes of Red Eye:

• Conjunctivitis
• Acute angle-closure glaucoma
• Uveitis
• Corneal ulcer/abrasion
• Scleritis/episcleritis
• Trauma

Treatment options:
Immediate:
• IV acetazolamide (500 mg stat), oral CAI
• Topical beta-blockers (timolol), pilocarpine, steroid drops
• IV mannitol (if IOP very high)
Pilocarpine drops (after IOP lowers)
Definitive:
• Laser peripheral iridotomy (once cornea clears)
• Prophylactic iridotomy in fellow eye

📘 Jatoi p. 190–193 | Jogi p. 177–180

Case 20
A 55-year-old hypertensive and diabetic patient presented in eye OPD with loss of vision. On
examination, both eyes’ fundus showed macular edema and neovessels along with pre-retinal
hemorrhage.
What is your diagnosis?
How will you investigate?
How will you treat this case?

Diagnosis: Proliferative Diabetic Retinopathy (PDR) with Diabetic Macular Edema (DME)

Investigations:
• Fundoscopy: neovascularization, hemorrhages
• FFA: areas of capillary non-perfusion, leakage
• OCT: macular edema
• Blood sugar, HbA1c, BP profile

Treatment:
• Pan-retinal photocoagulation (PRP) for neovessels
• Intravitreal anti-VEGF (Bevacizumab) for macular edema
• Control of DM and HTN
• Vitrectomy for non-clearing hemorrhage or tractional retinal detachment

📘 Jatoi p. 211–216 | Jogi p. 195–198

Case 21
A 16-year-old boy presented in eye OPD with good accommodation and convergence, but
absent light reflex.
What is your diagnosis?
What different disorders cause this condition?
Write causes of dilated pupil.

Diagnosis:Argyll Robertson Pupil

Disorders causing this condition:

• Neurosyphilis (tabes dorsalis)
• Diabetes mellitus
• Multiple sclerosis
• Chronic alcoholism
• Parinaud syndrome

Causes of dilated pupil:

• Physiological mydriasis
• Third nerve palsy
• Adie’s tonic pupil
• Pharmacologic dilation (atropine,tropicamide)
• Trauma to sphincter pupillae
• Acute angle-closure glaucoma

📘 Jatoi p. 173–175 | Jogi p. 154–156

Case 22
Diabetic with decreased vision, diagnosed with diabetic retinopathy and has macular edema.
What is chronic cystoid macular edema?
What investigations are done to diagnose and assess prognosis?
How will you treat this case?

Definition:
Chronic cystoid macular edema is fluid accumulation in macula forming cystic spaces, leading to
vision loss.

Investigations:
• OCT: shows cystic spaces
• Fundoscopy: retinal thickening
• FFA: petaloid pattern of leakage
• HbA1c, BP monitoring

Treatment:
• Strict blood glucose and BP control
• Intravitreal anti-VEGF (e.g., Bevacizumab)
• Intravitreal steroids (e.g., Triamcinolone)
• Focal/grid laser if indicated

📘 Jatoi p. 211–216 | Jogi p. 195–198

Case 23
A 65-year-old had cataract surgery. After 6 months: corneal edema, bullae, and IOP 28
mmHg.
What is your diagnosis?
What are other signs/symptoms?
How will you treat this case?

Diagnosis: Pseudophakic bullous keratopathy with secondary glaucoma

Other Signs/Symptoms:
• Pain, photophobia
• FBS (foreign body sensation)
• Decreased visual acuity
• Epithelial bullae
• Raised IOP

Treatment:
• Hypertonic saline (5%) for edema
• Antiglaucoma medications
• Bandage contact lens for comfort
• If not resolved:
• Anterior chamber wash
• Descemet membrane endothelial keratoplasty (DMEK)
• Penetrating keratoplasty (PK) if severe

📘 Jatoi p. 129–131 | Jogi p. 140–141