Ophthalmology/Eye Institute

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 Department of Ophthalmology Case Studies

 

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General: He is alert and appropriate. 

External: The eyes appear symmetric, equally red with moderate crusting & mucopurulent discharge on the lower eyelids OU. Epiphora OU. Eyes non-tender to palpation OU. Nontender R & L preauricular lymphadenopathy.

Motility: Full extraocular movements. No nystagmus.

Vision: 20/20 OD; 20/25 OS

IOP: 17 mmHg OD, 14 mmHg OS

Pupils: PERRL; no APD. No leukocoria.

SLE:
L/L – crusted discharge on eyelashes OU, no follicles in inferior or superior fornix OU
C/S – moderate conjunctival injection OU, no chemosis
K – wnl OU, no pseudomembranes noted
AC – deep and quiet OU, no cell or flare
Iris – wnl OU
Lens – clear OU

DFE: C/D 0.2, crisp disc margins, no ON hypoplasia, +foveal light reflexes, vessels wnl

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