34 year old man. The patient reports he was assaulted by a couple of adolescents near downtown St. Petersburg about forty-eight hours ago. He reports he had pain in his left orbit and was evaluated at the St. Anthony’ Emergency Department Saturday evening. He reports the pain in the left eye has significantly improved, but his vision is a little fuzzy and he sees some floaters in the left eye. He denies any flashes, curtains, or change in his peripheral visual field.
The patient reports he has a past ophthalmic history of refractive error, characterized as astigmatism, and he used to wear glasses more so for the right eye than the left. He denies any surgery, laser, or prior ophthalmic trauma.
Past medical history is negative. Family history is negative for retinal detachment, macular degeneration or blindness of unknown cause. He smokes and drinks alcohol. He is using Tobramycin Ointment in the left eye four times a day, which was prescribed in the ER.
Conversation with the attending physician in the ER revealed he had a CAT scan which showed the absence of any orbital fractures, the absence of any retro-orbital hemorrhage, and intact globe.
OPHTHALMIC EXAMINATION: Visual acuity without correction of 20/125 OD, 20/20 OS. Pinhole improves in the right eye to 20/50. IOP: 15 OD, 13 OS.
SLIT LAMP EXAMINATION: Biomicroscopy reveals 3+ pupillary reaction OD, 2+ OS with no afferent pupillary defect. The anterior segment shows normal lids and lashes, quiet conjunctivae, clear compact corneas, deep anterior chambers free of cell and flare OD with 1+ cell and no flare OS. The iris dilates well and is round OU. There is a clear crystalline lens. The anterior vitreous is well-formed and acellular.
EXTENDED OPHTHALMOSCOPY: Extended funduscopy with Volk 90-diopter lens and fundus drawings of both eyes reveal a clear view with no posterior vitreous separation. C/D ratio is 0.2. There is no vitreous debris or hemorrhage. Large retinal vessels and macula are healthy. The retinal periphery, inspected with scleral depression for 360° shows no retinal tears, breaks, or detachments.
IMPRESSION:
1. MILD TRAUMATIC IRITIS, LEFT EYE
2. PERIORBITAL ECCHYMOSES, LEFT EYE, WITHOUT ORBITAL FRACTURE
3. REFRACTIVE ERROR, RIGHT EYE, PRE-EXISTING
DISCUSSION: The patient and I talked about his eye’s health. I explained he has some inflammation in his left eye associated with blunt trauma. I recommended Pred Forte four times a day for five days and gave him a sample.
Regarding his decreased vision in the right eye, I recommended a refraction at his optometrist of choice. Because of the differential in his refractive error in his eyes, I suspect he may have a component of some mild amblyopia in the right eye, and he may not correct to 20/20. Only a good refraction can resolve that question.
I am going to bring The patient back in three weeks for re-evaluation to make sure his inflammation has resolved.
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Choroidal Rupture and small Hemorrhage - Assault1159 views34 year old man. The patient reports he was assaulted by a couple of adolescents near downtown St. Petersburg about forty-eight hours ago. He reports the pain in the left eye has significantly improved, but his vision is a little fuzzy and he sees some floaters in the left eye. 20/125 OD, 20/20 OS. Pinhole improves in the right eye to 20/50. IOP: 15 OD, 13 OS.
SLIT LAMP EXAMINATION: Biomicroscopy reveals 3+ pupillary reaction OD, 2+ OS with no afferent pupillary defect. EXTENDED OPHTHALMOSCOPY: Extended funduscopy with Volk 90-diopter lens and fundus drawings of both eyes reveal a clear view with no posterior vitreous separation. C/D ratio is 0.2. There is no vitreous debris or hemorrhage. Large retinal vessels and macula are healthy. The retinal periphery, inspected with scleral depression for 360° shows no retinal tears, breaks, or detachments.
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Choroidal Rupture and small Hemorrhage - Assault833 views34 year old man. The patient reports he was assaulted by a couple of adolescents near downtown St. Petersburg about forty-eight hours ago. He reports the pain in the left eye has significantly improved, but his vision is a little fuzzy and he sees some floaters in the left eye. 20/125 OD, 20/20 OS. Pinhole improves in the right eye to 20/50. IOP: 15 OD, 13 OS.
SLIT LAMP EXAMINATION: Biomicroscopy reveals 3+ pupillary reaction OD, 2+ OS with no afferent pupillary defect. EXTENDED OPHTHALMOSCOPY: Extended funduscopy with Volk 90-diopter lens and fundus drawings of both eyes reveal a clear view with no posterior vitreous separation. C/D ratio is 0.2. There is no vitreous debris or hemorrhage. Large retinal vessels and macula are healthy. The retinal periphery, inspected with scleral depression for 360° shows no retinal tears, breaks, or detachments.
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Choroidal Rupture and small Hemorrhage - Assault685 views34 year old man. The patient reports he was assaulted by a couple of adolescents near downtown St. Petersburg about forty-eight hours ago. He reports the pain in the left eye has significantly improved, but his vision is a little fuzzy and he sees some floaters in the left eye. 20/125 OD, 20/20 OS. Pinhole improves in the right eye to 20/50. IOP: 15 OD, 13 OS.
SLIT LAMP EXAMINATION: Biomicroscopy reveals 3+ pupillary reaction OD, 2+ OS with no afferent pupillary defect. EXTENDED OPHTHALMOSCOPY: Extended funduscopy with Volk 90-diopter lens and fundus drawings of both eyes reveal a clear view with no posterior vitreous separation. C/D ratio is 0.2. There is no vitreous debris or hemorrhage. Large retinal vessels and macula are healthy. The retinal periphery, inspected with scleral depression for 360° shows no retinal tears, breaks, or detachments.
(0 votes)
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Choroidal Rupture and small Hemorrhage - Assault654 views34 year old man. The patient reports he was assaulted by a couple of adolescents near downtown St. Petersburg about forty-eight hours ago. He reports the pain in the left eye has significantly improved, but his vision is a little fuzzy and he sees some floaters in the left eye. 20/125 OD, 20/20 OS. Pinhole improves in the right eye to 20/50. IOP: 15 OD, 13 OS.
SLIT LAMP EXAMINATION: Biomicroscopy reveals 3+ pupillary reaction OD, 2+ OS with no afferent pupillary defect. EXTENDED OPHTHALMOSCOPY: Extended funduscopy with Volk 90-diopter lens and fundus drawings of both eyes reveal a clear view with no posterior vitreous separation. C/D ratio is 0.2. There is no vitreous debris or hemorrhage. Large retinal vessels and macula are healthy. The retinal periphery, inspected with scleral depression for 360° shows no retinal tears, breaks, or detachments.
(1 votes)
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Choroidal Rupture and small Hemorrhage - Assault869 views34 year old man. The patient reports he was assaulted by a couple of adolescents near downtown St. Petersburg about forty-eight hours ago. He reports the pain in the left eye has significantly improved, but his vision is a little fuzzy and he sees some floaters in the left eye. 20/125 OD, 20/20 OS. Pinhole improves in the right eye to 20/50. IOP: 15 OD, 13 OS.
SLIT LAMP EXAMINATION: Biomicroscopy reveals 3+ pupillary reaction OD, 2+ OS with no afferent pupillary defect. EXTENDED OPHTHALMOSCOPY: Extended funduscopy with Volk 90-diopter lens and fundus drawings of both eyes reveal a clear view with no posterior vitreous separation. C/D ratio is 0.2. There is no vitreous debris or hemorrhage. Large retinal vessels and macula are healthy. The retinal periphery, inspected with scleral depression for 360° shows no retinal tears, breaks, or detachments.
(0 votes)
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Choroidal Rupture and small Hemorrhage - Assault620 views34 year old man. The patient reports he was assaulted by a couple of adolescents near downtown St. Petersburg about forty-eight hours ago. He reports the pain in the left eye has significantly improved, but his vision is a little fuzzy and he sees some floaters in the left eye. 20/125 OD, 20/20 OS. Pinhole improves in the right eye to 20/50. IOP: 15 OD, 13 OS.
SLIT LAMP EXAMINATION: Biomicroscopy reveals 3+ pupillary reaction OD, 2+ OS with no afferent pupillary defect. EXTENDED OPHTHALMOSCOPY: Extended funduscopy with Volk 90-diopter lens and fundus drawings of both eyes reveal a clear view with no posterior vitreous separation. C/D ratio is 0.2. There is no vitreous debris or hemorrhage. Large retinal vessels and macula are healthy. The retinal periphery, inspected with scleral depression for 360° shows no retinal tears, breaks, or detachments.
(0 votes)
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34 year old man. The patient reports he was assaulted by a couple of adolescents near downtown St. Petersburg about forty-eight hours ago. He reports he had pain in his left orbit and was evaluated at the St. Anthony’ Emergency Department Saturday evening. He reports the pain in the left eye has significantly improved, but his vision is a little fuzzy and he sees some floaters in the left eye. He denies any flashes, curtains, or change in his peripheral visual field.
The patient reports he has a past ophthalmic history of refractive error, characterized as astigmatism, and he used to wear glasses more so for the right eye than the left. He denies any surgery, laser, or prior ophthalmic trauma.
Past medical history is negative. Family history is negative for retinal detachment, macular degeneration or blindness of unknown cause. He smokes and drinks alcohol. He is using Tobramycin Ointment in the left eye four times a day, which was prescribed in the ER.
Conversation with the attending physician in the ER revealed he had a CAT scan which showed the absence of any orbital fractures, the absence of any retro-orbital hemorrhage, and intact globe.
OPHTHALMIC EXAMINATION: Visual acuity without correction of 20/125 OD, 20/20 OS. Pinhole improves in the right eye to 20/50. IOP: 15 OD, 13 OS.
SLIT LAMP EXAMINATION: Biomicroscopy reveals 3+ pupillary reaction OD, 2+ OS with no afferent pupillary defect. The anterior segment shows normal lids and lashes, quiet conjunctivae, clear compact corneas, deep anterior chambers free of cell and flare OD with 1+ cell and no flare OS. The iris dilates well and is round OU. There is a clear crystalline lens. The anterior vitreous is well-formed and acellular.
EXTENDED OPHTHALMOSCOPY: Extended funduscopy with Volk 90-diopter lens and fundus drawings of both eyes reveal a clear view with no posterior vitreous separation. C/D ratio is 0.2. There is no vitreous debris or hemorrhage. Large retinal vessels and macula are healthy. The retinal periphery, inspected with scleral depression for 360° shows no retinal tears, breaks, or detachments.
IMPRESSION:
1. MILD TRAUMATIC IRITIS, LEFT EYE
2. PERIORBITAL ECCHYMOSES, LEFT EYE, WITHOUT ORBITAL FRACTURE
3. REFRACTIVE ERROR, RIGHT EYE, PRE-EXISTING
DISCUSSION: The patient and I talked about his eye’s health. I explained he has some inflammation in his left eye associated with blunt trauma. I recommended Pred Forte four times a day for five days and gave him a sample.
Regarding his decreased vision in the right eye, I recommended a refraction at his optometrist of choice. Because of the differential in his refractive error in his eyes, I suspect he may have a component of some mild amblyopia in the right eye, and he may not correct to 20/20. Only a good refraction can resolve that question.
I am going to bring The patient back in three weeks for re-evaluation to make sure his inflammation has resolved.
