70-year-old man was seen in the office on June 16, 2011. He is visiting his daughter in Florida. He has just gotten here and on the drive down he noticed a shadow creeping over the vision in the left eye and he no longer sees well out of that eye. He had cataract surgery two years ago and a YAG capsulotomy six months ago. VISUAL ACUITY: OD 20/20, OS 1/200. IOP: OD 13, OS 10. SLIT EXAMINATION: The posterior chamber intraocular lens is in good position both eyes with open capsules. EXTENDED OPHTHALMOSCOPY: OD: Vertical C/D ratio is 0.1. There is posterior vitreous separation with scleral depression and no retinal tears. OS: Vertical C/D ratio is 0.1. There is posterior vitreous separation. There is a retinal detachment extending from 12 o’clock to 3 o’clock. The retinal detachment looks to be macula-off or at least the retina is hanging over the macula. There is a small retinal break at 12:30 at the equator. IMPRESSION: 1. MACULA-OFF RETINAL DETACHMENT – LEFT EYE 2. POSTERIOR VITREOUS SEPARATION – BOTH EYES 3. RECENT YAG CAPSULOTOMY DISCUSSION: I explained to the patient he does have a retinal detachment in the left eye. With pneumatic retinopexy there is about a 90 percent chance of reattaching the retina. Using a retrobulbar anesthetic I treated the break with cryo therapy and injected him with a 0.5 cc SF6 bubble and also drew off some fluid from the anterior chamber. He knows to position. I have explained to him the sitting up and also some face down positioning for the next two days to avoid a macular fold. He will return for a check here tomorrow. |
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70-year-old man was seen in the office on June 16, 2011. He is visiting his daughter in Florida. He has just gotten here and on the drive down he noticed a shadow creeping over the vision in the left eye and he no longer sees well out of that eye. He had cataract surgery two years ago and a YAG capsulotomy six months ago. VISUAL ACUITY: OD 20/20, OS 1/200. IOP: OD 13, OS 10. SLIT EXAMINATION: The posterior chamber intraocular lens is in good position both eyes with open capsules. EXTENDED OPHTHALMOSCOPY: OD: Vertical C/D ratio is 0.1. There is posterior vitreous separation with scleral depression and no retinal tears. OS: Vertical C/D ratio is 0.1. There is posterior vitreous separation. There is a retinal detachment extending from 12 o’clock to 3 o’clock. The retinal detachment looks to be macula-off or at least the retina is hanging over the macula. There is a small retinal break at 12:30 at the equator. IMPRESSION: 1. MACULA-OFF RETINAL DETACHMENT – LEFT EYE 2. POSTERIOR VITREOUS SEPARATION – BOTH EYES 3. RECENT YAG CAPSULOTOMY DISCUSSION: I explained to the patient he does have a retinal detachment in the left eye. With pneumatic retinopexy there is about a 90 percent chance of reattaching the retina. Using a retrobulbar anesthetic I treated the break with cryo therapy and injected him with a 0.5 cc SF6 bubble and also drew off some fluid from the anterior chamber. He knows to position. I have explained to him the sitting up and also some face down positioning for the next two days to avoid a macular fold. He will return for a check here tomorrow.
