Agam - Ophthalmology Case Profoma
History:
Demographic details:
Name:
Age:
Sex:
Occupation:
Locality:
Chief complains:
History of presenting illness:
The patient was apparently normal before ______, after which he/she developed
1. Decreased vision – Left or Right or Both eyes
a. Onset
b. Progression or non-progressive
c. Near or far vision
d. Diurnal variation
e. Aggravating and relieving factors
f. Associated factors
2. Mass on Right or Left eye
a. Onset
b. Progressive or non-progressive
c. Associated factors:
i. Diplopia
ii. Irritation
iii. Foreign body sensation
iv. Redness
3. Discharge
a. Onset
b. Duration
c. Amount of discharge
1
d. Type of discharge
e. Diurnal variation
f. Aggravating and relieving factor
4. Other histories: (after describing chief complains)
a. H/O Pain
b. H/O redness
c. H/O diplopia, polyopia
d. H/O photophobia
e. H/O colored halos
f. H/O flashes
g. H/O floaters
h. H/O glare
i. H/O trauma
j. H/O foreign body sensation
Past history:
o H/O similar complaints in the past
o H/O other ocular complaints
o H/O any systemic illness:
Diabetes mellitus
Hypertension
Asthma
Tb
Epilepsy
Coronary artery disease
Duration, treatment – regular or irregular and type of medication
H/O surgical history
Personal History:
Diet
Sleep
Appetite
Bowel and bladder movements
Alcohol, smoking
Family history:
If any, to be mentioned
2
Examination:
General Examination:
Built and nourishment
Consciousness and orientation
Vitals
o Temperature
o Blood pressure
o Respiratory rate
o Pulse rate
Palor, icterus, clubbing, cyanosis, lymphadenopathy, pedal oedema
Systemic examination:
Central Nervous System
o Cranial nerves intact
o Superficial and deep reflexes normal
Cardiovascular System
o S1 and S2 heard
o No abnormal sound heard
Respiratory System
o Normal vesicular breath sound
o No added breath sound
Abdomen
o No organomegaly
o No tenderness
Ocular Examination:
Head position
o Tilt – lagophthalmuos, ptosis
o Face turn - squint
o Chin up/ down
Facial symmetry
Right Eye followed by left eye
Visual acquity Improvement on pinhole?
Eyebrow Present or absent
Extent – med. To lat. Canthus
In supra orbital ridge
Madarosis TB, Leprosy, radiation
Poliosis senile
Eyelids Closed:
o Eyelid proper
3
Lagophthalmos 7th nerve palsy
Check for bells phenomenon
Surface - scar, swelling (chalazion, hordeolum internum), ulcer,
elevation, depression
Open:
Interpalpebral fissure
(9 to 11mm)
Ptosis(<9mm)
Lid Retraction (>11mm)
o Lid margin
Ectropion, Entropion
Crusting, scaling, ulcer (ulcerative blepharitis)
Ant. Border – round
Post. Border – angulated
Meibomian gland duct opening – normal
o Eye lashes
Madarosis, Poliosis
Trichiasis (trachoma), Districhiasis
Lacrimal Apparatus Punctum (lower) – visible
Signs of inflammation Dacryocystitis
ROPLAs test
Orbit and its contents
Orbit (margin of Inspection – scar, irregularity, swelling
orbital inlet) Palpation – irregularity, tenderness
Eyeball Position, Visual access, Size, Movement
Conjunctiva Bulbar – color, congestion, chemosis, discharge, fleshy vascular mass,
Bitot’s spot
Palpebral – color, ulcer, swelling, concretions, papillae, follicle
Fornix – congestion, discharge,
Cornea Dimension
Edema
Sensation
Active ulcer – location, size
Scaring – location(peripheral/pupillary), size
Opacity
Sclera Color
Signs of inflammation
Traumatic perforation
Dilation/bulging
Anterior Chamber Depth
Eclipse sign
4
Hypopyon, hyphema
Abnormal constituents present or absent
Iris Present / absent
Colour
Pattern
Iris nodules iridocyclitis
Iridodonesis
pupil Number of pupil
Shape
Pupillary light reflex
Lens Present/ absent/ IOL
Transparency?
greyish white, milky white, pearly white, dirty white opacity
Provisional Diagnosis:
5
lens keeps growing
-
ectodermal origin
}
✓ pain RA scleritis
VIVA Questions
-
✗ vision
probs
1. Occupation related diseases
a. Farmers – pterygium, cataract, traumatic fungal ulcers
2. Loss of vision
a. Sudden painful loss of vision
dictated ← i. Acute angle closure glaucoma
vertically Lor
old painters
small pupil
←← ii. Iridocyclitis → 30
yrs •
but 6/6 vision
irregular
iii. Trauma pgpyg Tunnel vision
.
1. Chemical
•
2. Mechanical Cataract
•
b. Sudden painless loss of vision vision loss
total ARMD Distortion of image
-
i. CRAO very old age
-
ii. Massive vitreous haemorrhage to ✓
iii. Ischemic CRVO old age Gross
-
vision
loss Young painters
c. Sudden painless defective vision Isyr RE •
i. Optic neuritis
ii. Methyl alcohol amblyopia
30-40yr .
iii. Central serous chorioretinopathy
loss
iv. Non ischemic central vein occlusion some vision
-
d. Gradual painful defective vision
i. Chronic iridocyclitis Beller vision
¥
ii. Corneal ulceration
e. Gradual painless defective vision Daytime High lime
i. Progressive pteryium
ii. Corneal degeneration / distrophy cuneiform wpiliform
cataract
iii. Developmental / senile cataract cataract
iv. Optic atrophy
v. Chorioretinal degeneration
vi. Age related macular degeneration
vii. Diabetic retinopathy → intra rilreal
viii. Refractive errors
3. Floaters
a. Vitreous hemorrhage
b. Vitreous degeneration
4. Photopsia – flashes of light
a. Posterior vitreous detachment
b. Vitreous traction band
6
5. Photophobia
a. Conjunctivitis
b. Keratitis halo
vs
c. Anterior uveitis
6. Coloured halos vs Glare
break hay a. Intumescent cataract Gorlice Blurred image
-7
Fincham
→ No bnk
→ b. glaucoma
c. Corneal edema
halo
d. /Conjunctivitis blink go away
-
Cataract
-
Polyopia :
7. Diplopia Knuth'Re lights or )
Moons
a. Uniocular
i. Double pupil
ii. Keratoconus
iii. Incipient cataract
No Diplopia
b. Binocular children squint
:
paralysis
i. Paralytic Squint jtflhcn as
( supression )
'
I ①
Lala Hgs ptosis
early stages
.
→
② Unilateral squint
8. DD mass in the eye t
a. Pterygium Brain aprons
b. Pseudo-pterygium
one eye
+
c. Pingicula Amblyopia
iridocyiilis
Pain ,
9. Discharge → DCT
→
a. Watery/ serous – viral
b. Mucoid – allergic
c. Stringy/ ropy – VKC/ spring catarrh
d. Mucopurulent – acute conjunctivitis, bacterial, chlamydial
e. Bloody (sanguinous) – gonococcal
f. Purulent – gonococcal
10. Colors of sclera
a. Yellow – icterus
b. Blue – cyanosis, thinning of sclera
c. Brown – melanin deposition
11. Corneal opacity grading
a. Nebula
b. Macula
c. Leucoma
7
d. Adherent leucoma
