Clinical Case Review February 2013 – Bhumika Patel


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


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.


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


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-


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.

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