Age/Sex/Race
45 year old Caucasian male
Chief Complaint
Blur at distance for awhile, left eye worse than right eye
Sometimes his left eye hurts
Medical History
Last exam 1 month ago and everything was normal
NKDA
Ocular History
Uses readers for near
Retinal detachment in left eye 15 years ago (I found this out when I went to check his VA). He had silicone oil put in to keep the retina intact. He said that he never went back to get the oil taken out since he didn’t have medical insurance.
Patient had seen an Opthalmologist three months ago, who prescribed the medications listed below.
Medications
He knew he was taking “eye drops” for something but didn’t know their names or why he was taking it. I found out the names of them halfway into the exam.
Prednisolone 1% Acetate
Atropine
Drozolamide (Generic of Trusopt)
Patient said that he was supposed to take all drops once a day in right eye and three times a day in left eye.
Family History
Maternal grandmother had diabetes and heart disease
Social History
Smokes cigarettes every day, social drinker
Diagnosis and Initial Plan of Action
He had retinal detachment in his left eye so it makes sense that his vision is worse in the left eye than right eye. Initially, I thought he has an uncorrected refracted error causing distance blur. I was excited to get started so that I can dilate him to look at his retinal detachment.
Applicable Testing & Results of Testing
Distance visual acuity (uncorrected):
OD: 20/25-
OS: NLP
Near visual acuity (uncorrected): 20/50+ OU
Cover test: 20 constant XT
Confrontation fields: FTFC OD
Extraocular muscles: Full OD, Grossly full OS
Pupils: PERRLA, (-) APD OD; pupil fixed and dilated OS
Manifest Refraction:
OD: -0.25-1.00 X170; Add +1.00
OS: Balance (no red reflex)
Slit lamp examination:
Lids/lashes – clear OU
Conjunctiva – Clear OD, mild injection OS
Cornea – clear OD, diffuse SPK OS
Anterior chamber – clear OD, moderate silicone oil droplets OS (What I saw was bunch of white, clear dots like a mixture of oil and water. I didn’t know what I was I was seeing until I got my preceptor to look.)
My patient’s left eye looked little bit like this but less oil and smaller droplets.
The credit for the picture goes to Edward S. Harkness Eye Institute (Digital Reference of Opththalmology)
Angles – open OD, unable to view OS
IOP – 16 mm Hg OD, 52 mm Hg OS
Dilated fundus exam:
Lens – Clear OD, hypermature posterior subcapsular cataract OS
C/D – 0.3/0.3 OD, unable to view OS
Posterior pole / macula / periphery – normal OD, unable to view OS
Assessment and Plan
Our first goal was to get his pressures down in the left eye. We gave him one drop of Azopt, Travatan, Lumigan, Timolol and Alphagan. We checked his pressures 20 minutes later and it had gone down to 47mm Hg. We gave him another set of drops as above, and it brought IOPs down to 42mm Hg. Before he left, we gave him one more set of drops for his pressures. Since we couldn’t see his angles, we believe that pressure in left eye was high due to blockage of trabecular meshwork from silicone oil. When the oil came in the anterior chamber, it slowly started blocking the trabecular meshwork causing him to have occasional pain in the left eye from elevated IOP. In addition, he denied taking the drops regularly, which could have caused spike in his IOP. We educated him on symptoms of angle closure attack and to seek medical help right away.
We couldn’t figure out why he was taking Prednisolone 1% Acetate and Atropine. The patient did not remember having any kind of infection that his ophthalmologist mentioned. He was scheduled to see his ophthalmologist in one month so we just told him to follow up with ophthalmologist.
This is really interesting case as you normally don’t see silicone oil in the anterior chamber in patients with retinal detachment.
