Ophthalmology/Eye Institute

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 Department of Ophthalmology Case Studies


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Vitals: T 99.6, HR 118, BP 148/96, RR 26

General: Patient is distressed, in pain

Ophthalmic Exam:
VA: 20/20 OD , 20/ 200 OS
Ta: 13,16
Pupils: circular, reactive, no APD
CVF: no defects, unable to perform
External: WNL, erythematous and excoriated skin surrounding L eye


L/L WNL erythematous, indurated
C/S white/quiet 3+ injected, mild chemosis
K Clear edema, epithelial defects with fluorescein
AC Deep and Quiet 1+ cell, deep
I Round OU
L Clear OOU

DFE: OD – Arteries, Veins, Macula, and Periphery WNL. OS – Difficult exam due to photophobia but retina attached.

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Page Updated 08/15/2014