February 10, 2014 | POSTED BY | Clinical Optometry, News, Retina
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Age/Sex/Race

64 year old African American male

Chief Complaint

“My vision went completely black all the sudden in the right eye about two weeks ago, but it started coming back slowly. My vision is still blurry though.”

Medical History


Type II Diabetes

Hypertension

Chronic kidney disease

Bell’s palsy

Ocular History

Hx of cataract surgery OU in 2010

Wears OTC reading glasses

Last eye exam about 6 months ago

Medications

Takes about 10 meds a day

NKDA

Family History

Negative medical and ocular history

Applicable Testing & Results of Testing

Distance visual acuity (uncorrected)

OD: 20/30

OS: 20/25

Cover test: Ortho at distance and near

Confrontation fields: FTFC OU

Extraocular muscles: Full OU

Pupils: PERRLA, (-) APD OU

Refraction:

OD: +1.00-0.75 X 115, 20/25+1

OS: -0.25 sph, 20/25+1

slit lampSlit lamp examination:

Upper lid dermatochalasis OU

1+ conjunctival injection and racial melanosis OU

Cornea: 1+ superior punctate epithelial staining

No anterior chamber reaction

IOP: 19mm Hg OD and 16 mm Hg OS

1+ Nuclear sclerosis OU

Dilated Fundus Exam

OD – hazy view

–        Unable to judge cup-to-disc ratio due to hazyness

–        Few blood cells floating

OS –

–        Cup-to-disc: 0.35/0.35

–        Periphery: couple of dot blot hemorrhages

 

Differential Diagnosis:

–        Vitreous hemorrhage due to diabetes, vitreous detachment or trauma

Assessment and Plan

Patient was diagnosed with vitreous hemorrhage due to proliferative diabetic retinopathy. Patient was educated on his condition and importance of controlling his sugar levels. The plan was to have him return to see the retinal Ophthalmologist for further retinal evaluation. It wasn’t an immediate threat to his vision since his vision was starting to come back. Patient was scheduled to return to clinic in two weeks.  If the vitreous hemorrhage persists for three to six months, he would need pars plana vitrectomy.