Ophthalmology/Eye Institute

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 Department of Ophthalmology Case Studies

 

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VAcc: OD: 20/20; OS: 20/40

Pupils: normal pupil reaction R, sluggish L pupil, no APD

CVF: constricted inferiorly OS

EOM: Full OU

Ta: 15 OD, 23 OS

External: no lid lacerations

SLE:
L/L: normal OD and OS
C/S: normal OD, mild diffuse conjunctival hyperemia OS
K: normal OD and OS, no corneal epithelial defects
AC: deep and quiet OD, hyphema obscuring 1/3 of the anterior chamber.
I: normal OD, round pupil OS, no obvious neovascularization
L: normal OD, no evidence of cataract or dislocation OS

DFE:
Vitreous: No vitreous heme OU
CDR: 0.3 OU, no papilledema or neovascularization of the disc OU
M: No retinal hemorrhages, edema or RD.
V: WNL OU
P: WNL OU
 

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