Patient History
HPI:
A 72 year-old female retired CEO reports that approximately 2 weeks ago she noticed the onset of decreased vision in her left eye associated with a “black spot” close to the center of her vision. The spot is present with both near and far vision and does not move away. The vision has been slightly blurred for a while. She denies any recent trauma, eye pain, redness or discharge. Peripheral vision is normal. She has not had an eye exam in 5 years.
Past Ocular History:
No prior eye surgeries. No hx of eye trauma, amblyopia or strabismus.
Ocular Medications:
None
Past Medical History:
Hypertension, hypercholesterolemia, coronary artery disease s/p myocardial infarction s/p stenting 5 years prior.
Surgical History:
C-sections x 2, appendectomy 15 years ago
Past Family Ocular History:
No evidence of blinding diseases, glaucoma or macular degeneration
Social History:
Past 50 pack/year smoking history. No alcohol or drug use. Currently retired and living with her husband
Medications:
Aspirin, Plavix, Lipitor, Lisinopril, Metoprolol
Allergies:
ROS:
Denies recent illness or any new CNS, heart, lungs, GI, skin or joint symptoms.
Ocular Exam
Visual Acuity (cc):
OD: 20/30
OS: 20/100
IOP (tonoapplantation):
OD: 16 mmHg
OS: 17 mmHg
Pupils:
Equal, round and reactive to light, no APD OU
Extraocular Movements:
Full OU. No nystagmus.
Confrontational Visual Fields:
Full to finger counting OU.
External:
Normal, both sides
Slit Lamp:
Lids and Lashes |
Normal OU |
Conjunctiva/Sclera |
Normal OU |
Cornea |
Clear OU |
Anterior Chamber |
Deep and quiet OU |
Iris |
Normal OU |
Lens |
1+ NSC OU |
Anterior Vitreous |
Clear OU
|
Dilated Fundus Examination:
OD |
Clear view, CDR 0.5 with sharp optic disc margins, flat macula, scattered large soft drusen within the arcades, normal vessels and peripheral retina |
OS |
Clear view, CDR 0.6 with sharp optic disc margins, flat macula, scattered soft drusen within the arcades, 1 disc area of subretinal hemorrhage in macular area near fovea |
Other:
Amsler grid:
OD: Normal
OS: Blurry spot near the center of the grid with wavy lines