13-year-old had an injury to the right eye on July 14th with a choroidal rupture. He had cryo to a retinal tear on July 27th and then six clock hours away laser to a retinal tear on October 20th. His vision is a little better in the eye. VISUAL ACUITY: Vision OD is 20/120. IOP: 18. The lens is clear. EXTENDED OPHTHALMOSCOPY: OD: Vertical C/D ratio is 0.2. There is a choroidal rupture just temporal to the optic nerve. There is laser to a nasal retinal tear as well as cryo to a temporal retinal tear and laser to lattice degeneration at 6:00 o’clock. There are some areas of vitreoretinal traction superiorly. IMPRESSION: 1. STATUS POST TREATMENT FOR RETINAL TEARS – RIGHT EYE 2. PREVIOUS TRAUMA – RIGHT EYE 3. CHOROIDAL RUPTURE DISCUSSION: I explained to the patient the eye is stable at this point. There is still a risk of subsequent retinal tears within the first year, especially with the injury. There are some areas at 12:00 o’clock though that might be starting to contract. I asked him to return for check in two months, sooner should he notice a problem, such as increased floaters or shadows, and to see you regularly. (Initial Visit): He was hit in the right eye about three weeks ago by an aluminum foil covered ball which was shot out of some sort of a tube. He needed surgery to repair a full-thickness corneal laceration. Since then you suggested he come here for an evaluation because of a choroidal rupture and macular hemorrhage. His vision in the eye is limited. |
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13-year-old had an injury to the right eye on July 14th with a choroidal rupture. He had cryo to a retinal tear on July 27th and then six clock hours away laser to a retinal tear on October 20th. His vision is a little better in the eye. VISUAL ACUITY: Vision OD is 20/120. IOP: 18. The lens is clear. EXTENDED OPHTHALMOSCOPY: OD: Vertical C/D ratio is 0.2. There is a choroidal rupture just temporal to the optic nerve. There is laser to a nasal retinal tear as well as cryo to a temporal retinal tear and laser to lattice degeneration at 6:00 o’clock. There are some areas of vitreoretinal traction superiorly. IMPRESSION: 1. STATUS POST TREATMENT FOR RETINAL TEARS – RIGHT EYE 2. PREVIOUS TRAUMA – RIGHT EYE 3. CHOROIDAL RUPTURE DISCUSSION: I explained to the patient the eye is stable at this point. There is still a risk of subsequent retinal tears within the first year, especially with the injury. There are some areas at 12:00 o’clock though that might be starting to contract. I asked him to return for check in two months, sooner should he notice a problem, such as increased floaters or shadows, and to see you regularly. (Initial Visit): He was hit in the right eye about three weeks ago by an aluminum foil covered ball which was shot out of some sort of a tube. He needed surgery to repair a full-thickness corneal laceration. Since then you suggested he come here for an evaluation because of a choroidal rupture and macular hemorrhage. His vision in the eye is limited.
