Patient History
HPI:
58 year-old administrative assistant Hispanic female complains of decreased vision in her left eye. She first noticed it when she closed her right eye while washing off her make-up about 2 weeks prior to her visit. The vision in her left eye is still blurred and dark and may have gotten slightly worse. She does have occasional symptoms of dry eyes with burning; for which she uses artificial tears. She denies any pain, redness, double vision, flashing lights, or new floaters.
Past Ocular History:
Slight myopia, uses glasses. No history of eye surgeries, amblyopia, strabismus, or eye trauma.
Ocular Medications:
Artificial tears occasionally
Past Medical History:
Menopause at 51, history of pulmonary embolism 5 years ago following L foot surgery, hypertension on medication
Surgical History:
L foot surgery after trauma
Past Family Ocular History:
Negative for macular degeneration, glaucoma or blindness.
Social History:
Married, 2 children. Smokes ½ ppd x 15 years. No alcohol or other recreational drugs.
Medications:
Calcium supplement, Multivitamin, Hydrochlorothiazide, Lisinopril
Allergies:
None
ROS:
Denies recent illness or any new CNS, heart, lung, GI, skin or joint symptoms.
Ocular Exam
Visual Acuity (cc):
OD: 20/25
OS: 20/200
IOP (tonoapplantation):
OD: 21 mmHg
OS: 21 mmHg
Pupils:
Equal, round and reactive to light, trace APD OS
Extraocular Movements:
Full OU. No nystagmus.
Confrontational Visual Fields:
Full to finger counting OD, inconsistent responses OS
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, no NVI OU |
Lens |
1+ NS OU |
Anterior Vitreous |
Clear OU |
Dilated Fundus Examination:
OD |
Clear view, CDR 0.5, with sharp optic disc margins; flat macula with normal foveal light reflex; slightly dilated retinal veins, mild arterial/venous nicking, normal peripheral retina |
OS |
Clear view, edematous optic nerve with blurred margins; scattered intraretinal hemorrhages in all 4 quadrants, few cotton wool spots, macula thickening with loss of foveal light reflex, tortuous vessels. |
Other:
OCT of the L eye - intra and subretinal fluid in the retina, distortion of the normal foveal architecture