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CASE PRESENTATION

CASE PRESENTATION. Identifying Data. RM 79/F Cubao , Quezon City. Chief Complaint. Blurring of vision.

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CASE PRESENTATION

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  1. CASE PRESENTATION

  2. Identifying Data • RM • 79/F • Cubao, Quezon City

  3. Chief Complaint • Blurring of vision

  4. Patient is a known case of senile mature cataract OS and microbial keratitis with corneal ulceration OD which is managed by moxifloxacin and atropine. The patient is supposedly for scheduling of cicatricialectropion repair

  5. History of Present Illness • 3d PTC • Blurring of vision • Right eye • Progressive, gradual • Increasing dependency on shapes • Declining ability to distinguish faces • No pain, redness, pruritus, trauma, • No fields of dark areas, flashes • No complaints on the left eye Consult

  6. Past Medical History • Uncontrolled hypertension, Stage II • Diabetes Mellitus, Type 2 • Last checkup was >3 years ago • Fire victim (39y ago) • Multiple burn scars on the head, body and extremities • s/p ECCE w/ extraocular lens implant, OD, 2010 • QMMC • s/p Dacryocystorhinostomy, OD, 2010 • St. Lukes • Cicatricialectropion, OD

  7. Personal Social History • Lives with relatives • Unemployed • No alcohol intake • No use of illicit drugs • (+) Smoking • Ocassionally • 5 sticks/day at most

  8. Family History • (+) Hypertension • (+) Diabetes • (-) Asthma • (-) Tuberculosis

  9. Review of Systems • General: (-) fever, weight changes, weakness, • Skin/Breast: Rash, pruritus, changes in hair growth or loss, nail changes • HEENT: (-) headache, dizziness, light-headedness, tearing, neck stiffness, double vision, dark patches in vision

  10. Cardiovascular: (-) Precordial pain, palpitations, syncope, edema, cyanosis, hypertension, heart murmurs • Respiratory: (-) shortness of breath, wheezing, stridor, cough, hemoptysis, respiratory infections, • Gastrointestinal: (-) Poor Appetite, dysphagia, abdominal pain, nausea, vomiting, constipation, or diarrhea, recent changes in bowel habits • Genitourinary: (-) frequency, dysuria, nocturia, hematuria, polyuria, oliguria, unusual (or change in) color of urine • Musculoskeletal: (-) Pain, swelling, redness or heat of muscles or joints, muscular weakness, atrophy, cramps • Neurologic/Psychiatric: (-) anxiety, depression, previous psychiatric care, unusual perceptions, hallucinations

  11. Physical Exam • General: Awake, comfortable, cooperative • Vital Signs • BP 130/80 HR 80 RR 20 T 37 • Not in pain or cardiorespiratory distress

  12. Skin: (+) Age spots, multiple burn scars on face and extremities with contractures • Head: No open wounds, (-) erythema, (-) aural or nasal discharges, dry lips, (-) lymphadenopathies

  13. Chest • Symmetric chest expansion, (-) retractions, (-) rales, crackles, clear breath sounds • Adynamic precordium, (-) murmurs, distinct S1 and S2 • Abdomen • Flat, soft, (-) organomegalies, normoactive bowel sounds • Genitourinary exam • Deferrred • Extremities • Thin, (-) limitations range of movement, 5/5 muscle strength

  14. Ophthalmologic Exam • Visual Acuity

  15. OD

  16. OS

  17. Gross Exam

  18. Salient Features

  19. Admitting diagnosis: • Corneal ulcer, OD • Plan • Admission • For treatment of hypopyon

  20. Workups done • Chest X-Ray • Fibrosis, left upper lung • Atheromatous aorta • Electrolytes • Na 136 (136-145) • K 4.9 (3.5-5.1) • Cl 103 (97-102)

  21. CBC • Hgb105 • Hct0.31 • WBC 4.2 • Plt adequate • Urinalysis • Yellow • Sl. Turbid • 1.010 • 6 • (-) sugar • (-) albumin • WBC 20-25 • RBC 2-5

  22. Corneal Scrapings (January 16) • No growth after 4 days

  23. Problem List • Blurring of vision • Corneal Ulcer • Microbial keratitis • Cicatricialectropion • Hypertension • Diabetes

  24. Blurring of vision

  25. Microbial keratitis/Corneal Ulcer • Keratitis  Inflammation of the cornea. • Central ulcers usually are infectious ulcers secondary to corneal epithelial damage.

  26. Common symptoms • Since the cornea has many pain fibers, can cause pain and photophobia. • Occasional blurring of vision, especially if centrally located. • Although tearing and photophobia commonly accompany corneal disease, there is usually no discharge except in purulent bacterial ulcers.

  27. The lesion is situated centrally, away from the vascularized limbus. • It is often accompanied by hypopyon, a collection of inflammatory cells seen as a pale layer in the inferior anterior chamber.

  28. Pertinent History • Contact lens wear • Trauma • Topical ocular medications • Decreased immunologic defenses • Aqueous tear deficiencies • Recent corneal disease • Structural alteration or malposition of the eyelids

  29. Workup • Examination of corneal scrapings, stained with Gram's and Giemsa's stains • Cultures for bacteria are usually obtained in all cases at first presentation. • It is important that therapy is not withheld if an organism cannot be identified on microscopic examination of corneal scrapings, although it may have to be empirical based upon the clinical features.

  30. Central suppurative ulceration was once caused almost exclusively by S.pneumoniae infection complicating corneal trauma, particularly occurring in patients with obstructed nasolacrimal ducts.

  31. Dacryocystorhinostomy • DCR is a surgical procedure to restore the flow of tears into the nose from the lacrimal sac when the nasolacrimal duct is blocked. • 77.5% Ex.DCR • 90% in Ex.DCR with silicone intubation

  32. Treatment

  33. Ectropion • Usually bilateral and is a frequent finding in older persons. • May be caused by relaxation of the orbicularis oculi muscle, either as part of the aging process or following seventh nerve palsy. • The symptoms are tearing and irritation. • Exposure keratitis may occur.

  34. Cicatricialectropion • Caused by contracture of the anterior lamella of the lid. • Treatment requires surgical revision of the scar and often skin grafting.

  35. Hypertension • Currently managed on clonidine, amlodipine • Diabetes • No medications given

  36. Course in the Wards • Day 2 • Patient noted blurring of vision on the left eye, abrupt, no trauma, pain, pruritus, tearing,photophobia

  37. Day 3 • GS/CS of corneal scrapings • Start tobramycin

  38. Day 4

  39. Day 5 • Ulcer, OD • Dimensions: 2.2mm x 2mm

  40. Day 6 • Plan: for cicatricialectropion repair once corneal ulcer resolves • Do lid taping before sleeping

  41. Day 7 • Decreased level of hypopyon

  42. Day 9 • Ulcer, OD • Dimensions: 1.6mm x 1.6mm • Decreased level of hypopyon

  43. Day 10 • Ulcer, OD • Dimensions: >1mm X >1mm • (+) hypopyon

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