CASE
PRESENTATION
1
Patient Details
• Name-Mr.Shiv
• Age-62 years
• Sex-Male
• Residence-Amroha
• marital status- married
2
Chief Complaints 3
u Diminution of vision in right eye since 6 months and in left eye
since 1 year.
4
HISTORY OF PRESENT ILLNESS
■ Patient was apparently asymptomatic 6 months back when he developed diminution of
vision in right eye which was gradual in onset , progressive and painless in nature . Colored
halos seen in right eye.
■ No diurnal variations seen.
■ Negative History :- Diminishing of vision was not associated with photophobia , diplopia ,
floaters, redness, glare.
Past History
• Similar ocular problem 6 months back
• History of spectacle use.
• History of trauma in left eye 40 years back.
• No surgical history
• Medical history – no drug intake history
• No history of Diabetes mellitus, Hypertension, Tuberculosis, Asthma,
Thyroid disorder.
• No history of allergy. 5
FAMILY HISTORY
• No significant family history of Diabetes, Hypertension, TB, Asthma , COPD or any other
chronic illness.
• No history of glaucoma, ptosis, squint, refractive error, blindness in the family
6
PERSONAL HISTORY
He is vegetarian by diet
Appetite is normal
Regular bowel and bladder movements
Sleep – Adequate
No history of Smoking and alcohol intake
No history of drug addictions
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Examination
8
General Physical Examination
The patient was conscious, well oriented to time, place and
person. The patient was examined after taking consent and in well
lighted room.
VITALS :
BP-130/92
Pulse-88
RR-16
Temperature- Afebrile
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Pallor - absent
Icterus - absent
Cyanosis -absent
Clubbing - absent
Lymphadenopathy - absent
Pedal edema - absent
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Ocular Examination – Visual Acuity
RE LE
Finger counting Hand movement
PL Positive PL Positive
PR Accurate PR Accurate
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External Ocular Examination
Head posture = Normal ( Straight looking forward )
Forehead = Wrinkling seen (Normal)
Facial symmetry = B/L symmetrical
Eyebrows = normal ( aligned normally )
Orbit = Normal, No tenderness ,no swelling and no defect
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Eyeball Right eye Left eye
POSITION Normal in position Normal in position
Centrally placed Centrally placed
ALIGNMENT 15 degree divergent squint Alignment is straight
(BY HIRSCHBERG REFLEX)
SIZE AND MOVEMENTS Normal Normal
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Eyelid Right eye Left eye
POSITION Normal Normal
MOVEMENTS Normal Normal
SKIN Normal Normal
LASHES Normal Normal
LID MARGINS Normal Normal
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Right eye Left eye
LACRIMAL APPARATUS Normal on inspection , Normal on inspection ,
Regurgitation(ROPLAS) not seen Regurgitation(ROPLAS) not seen
Puncta patent Puncta patent
CONJUNCTIVA No congestion , concretion, follicles, No congestion , concretion, follicles,
papillae, scarring, foreign body. papillae, scarring, foreign body.
SCLERA White colour White colour
No scarring No scarring
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Cornea Right eye Left eye
SIZE Normal Normal
SHAPE Normal Normal
TRANSPARENCY Normal Cloudy
SHEEN Present Present
SENSATIONS Present and normal Present and normal
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Right eye Left eye
ANTERIOR CHAMBER Deep Deep
IRIS Color – brown Color – brown
Pattern – Distorted Pattern – Distorted
PUPIL Number – 1 Number – 1
Location – centrally placed Location – centrally placed
Size – Regular shape and size Size – regular and round
Direct and Consensual Reaction Direct and Consensual Reaction
– normal – normal
Iris shadow is absent Iris shadow absent
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Colour – Cloudy with cortical Colour – greyish- white
mass seen
Right eye Left eye
LENS Position – normal Position – normal
Shape – normal Shape – normal
Color – greyish white Color – greyish white
Transparency – cloudy or hazy Transparency – white
Opacification
IOP soft soft
(Felt by digital tonometry)
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Probable Diagnosis
■ Right eye immature senile cataract.
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