64 year old African American male
Chief Complaint
“My vision went completely black all the sudden in the right eye about two weeks ago, but it started coming back slowly. My vision is still blurry though.”
Medical History
Chronic kidney disease
Bell’s palsy
Ocular History
Hx of cataract surgery OU in 2010
Wears OTC reading glasses
Last eye exam about 6 months ago
Takes about 10 meds a day
NKDA
Family History
Negative medical and ocular history
Applicable Testing & Results of Testing
Distance visual acuity (uncorrected)
OD: 20/30
OS: 20/25
Cover test: Ortho at distance and near
Confrontation fields: FTFC OU
Extraocular muscles: Full OU
Pupils: PERRLA, (-) APD OU
OD: +1.00-0.75 X 115, 20/25+1
OS: -0.25 sph, 20/25+1
Upper lid dermatochalasis OU
1+ conjunctival injection and racial melanosis OU
Cornea: 1+ superior punctate epithelial staining
No anterior chamber reaction
IOP: 19mm Hg OD and 16 mm Hg OS
1+ Nuclear sclerosis OU
Dilated Fundus Exam
OD – hazy view
– Unable to judge cup-to-disc ratio due to hazyness
– Few blood cells floating
OS –
– Cup-to-disc: 0.35/0.35
– Periphery: couple of dot blot hemorrhages
Differential Diagnosis:
– Vitreous hemorrhage due to diabetes, vitreous detachment or trauma
Assessment and Plan
Patient was diagnosed with vitreous hemorrhage due to proliferative diabetic retinopathy. Patient was educated on his condition and importance of controlling his sugar levels. The plan was to have him return to see the retinal Ophthalmologist for further retinal evaluation. It wasn’t an immediate threat to his vision since his vision was starting to come back. Patient was scheduled to return to clinic in two weeks. If the vitreous hemorrhage persists for three to six months, he would need pars plana vitrectomy.
