75-year-old man was seen in the office on 4/6/2010. He noticed a sudden vision change in the right eye yesterday morning. When he woke up he noticed a cloud in the vision. Previous to this, the vision was good in both eyes. He does have a history in the left eye of endophthalmitis, treated in August of 2009 for which he recovered excellent vision, with a macular pucker. VISUAL ACUITY: Vision OU is 20/20. IOP: 11 OU. The posterior chamber intraocular lens is in good position in both eyes with open capsules. EXTENDED OPHTHALMOSCOPY: OD: Vertical C/D ratio is 0.0. There is whitening of the superior half of the retina inside the macula. OS: Vertical C/D ratio is 0.0. There is a 2+ epiretinal membrane. OCT SCAN: The OCT scan of the right eye shows thickening of the nerve fiber layer in the macula, as you would expect with an artery occlusion. The left eye has slight irregularities from a macular pucker. PHOTOGRAPHS: Photos confirm clinical findings. FLUORESCEIN ANGIOGRAPHY: FA shows very slow filling of the superotemporal branch retinal arteriole in the right eye. The left eye shows some telangiectasia. The vessels are consistent with the macular pucker. IMPRESSION: 1. BRANCH RETINAL ARTERY OCCLUSION – RIGHT EYE 2. MACULAR PUCKER – LEFT EYE DISCUSSION: I explained to the patient that he has had a branch retinal artery occlusion in the right eye which does count as a minor stroke. I will ask Dr. Neifeld to evaluate him for this. In the meantime, I asked the patient to start taking baby aspirin every day. He does not need to return here unless you or he note further problems. |
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75-year-old man was seen in the office on 4/6/2010. He noticed a sudden vision change in the right eye yesterday morning. When he woke up he noticed a cloud in the vision. Previous to this, the vision was good in both eyes. He does have a history in the left eye of endophthalmitis, treated in August of 2009 for which he recovered excellent vision, with a macular pucker. VISUAL ACUITY: Vision OU is 20/20. IOP: 11 OU. The posterior chamber intraocular lens is in good position in both eyes with open capsules. EXTENDED OPHTHALMOSCOPY: OD: Vertical C/D ratio is 0.0. There is whitening of the superior half of the retina inside the macula. OS: Vertical C/D ratio is 0.0. There is a 2+ epiretinal membrane. OCT SCAN: The OCT scan of the right eye shows thickening of the nerve fiber layer in the macula, as you would expect with an artery occlusion. The left eye has slight irregularities from a macular pucker. PHOTOGRAPHS: Photos confirm clinical findings. FLUORESCEIN ANGIOGRAPHY: FA shows very slow filling of the superotemporal branch retinal arteriole in the right eye. The left eye shows some telangiectasia. The vessels are consistent with the macular pucker. IMPRESSION: 1. BRANCH RETINAL ARTERY OCCLUSION – RIGHT EYE 2. MACULAR PUCKER – LEFT EYE DISCUSSION: I explained to the patient that he has had a branch retinal artery occlusion in the right eye which does count as a minor stroke. I will ask Dr. Neifeld to evaluate him for this. In the meantime, I asked the patient to start taking baby aspirin every day. He does not need to return here unless you or he note further problems.
