Visual Acuity:
OD: 20/25
OS: Counting Fingers at 3 feet

IOP:
OD: 16
OS: 11

Extraocular Movements: Intact

Pupils: PERRLA, no afferent papillary defect.

Confrontational visual fields: Normal OD, Central, inferior and nasal field deficits OS

Amsler Grid:
OD: Normal
OS: Blurry throughout, with nasal regions missing completely

Slit Lamp:
Lids and Lashes: Normal OU
Conjunctiva/Sclera: Normal OU
Cornea: Normal OU
Anterior Chamber – normal depth OU, some pigment noted OS
Iris: Normal OU, no lesions
Lens:
Anterior Vitreous – Pigment OS (Shafer’s sign)

Dilated Fundus Examination:
OD: CDR 0.3, no AV nicking, macula normal, periphery normal with no signs of retinal breaks or detachments.
OS: CDR0.3, large area of subretinal fluid extending from 10 o’clock to 4 o’clock with fluid under the macula (mac off retinal detachment). A horseshoe tear is identified at 2 o’clock. Small amount of vitreous hemorrhage noted at the site of the tear. Weiss ring visible.