This 18 year old male was assaulted on 3 weeks ago and seen in the emergency room for that. He returns today reporting his left eye is getting better and is not quite as blurry. OPHTHALMIC EXAM: Visual acuity without correction of 20/60 OS; PH improves to 20/40 OS. IOP: 21 OS. SLIT LAMP EXAM: Biomicroscopy reveals subconjunctival hemorrhage in the left eye. The cornea is clear. The anterior chamber is deep and quiet and the iris is dilated. He has a clear lens present in the normal anatomic position. The anterior vitreous is minimally syneretic. POSTERIOR SEGMENT EXAM: There is a clear view with minimal syneresis and no vitreous separation. C/D ratio is 0.1. The macula shows a very small macular hole with a condensed hyaloid membrane surrounding it and nasal superficial retinal hemorrhage below the internal limiting membrane which appears to be reducing in size. EXTENDED OPHTHALMOSCOPY: The retinal periphery is flat with no tears, breaks, or detachments to scleral depression. FUNDUS PHOTOGRAPHY: Color and red-free photographs correspond to clinical findings and show retinal hemorrhage in the left nasal macula of a reduced volume. The macular hole appears less visible on color and red-free photography. OCT SCAN: Time domain macular mapping shows the presence of a small full-thickness macular hole with some edema present on its nasal edge. There does not appear to be preretinal traction elevating it. IMPRESSION: 1. TRAUMATIC MACULAR HOLE LEFT EYE, SEEMS TO BE DECREASING IN SIZE 2. RETINAL HEMORRHAGE LEFT EYE |
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This 18 year old male was assaulted on 3 weeks ago and seen in the emergency room for that. He returns today reporting his left eye is getting better and is not quite as blurry. OPHTHALMIC EXAM: Visual acuity without correction of 20/60 OS; PH improves to 20/40 OS. IOP: 21 OS. SLIT LAMP EXAM: Biomicroscopy reveals subconjunctival hemorrhage in the left eye. The cornea is clear. The anterior chamber is deep and quiet and the iris is dilated. He has a clear lens present in the normal anatomic position. The anterior vitreous is minimally syneretic. POSTERIOR SEGMENT EXAM: There is a clear view with minimal syneresis and no vitreous separation. C/D ratio is 0.1. The macula shows a very small macular hole with a condensed hyaloid membrane surrounding it and nasal superficial retinal hemorrhage below the internal limiting membrane which appears to be reducing in size. EXTENDED OPHTHALMOSCOPY: The retinal periphery is flat with no tears, breaks, or detachments to scleral depression. FUNDUS PHOTOGRAPHY: Color and red-free photographs correspond to clinical findings and show retinal hemorrhage in the left nasal macula of a reduced volume. The macular hole appears less visible on color and red-free photography. OCT SCAN: Time domain macular mapping shows the presence of a small full-thickness macular hole with some edema present on its nasal edge. There does not appear to be preretinal traction elevating it. IMPRESSION: 1. TRAUMATIC MACULAR HOLE LEFT EYE, SEEMS TO BE DECREASING IN SIZE 2. RETINAL HEMORRHAGE LEFT EYE
