2. Particulars of the patient
Name : X
Age : 65 years
Sex : Female
Religion : Islam
Occupation : House wife
Marital status : Married
Address : Keraniganj, Dhaka
Date of examination : 26/01/2016
3. Chief Complaints
• Total loss of vision in left eye for 3 months.
• Gradual dimness of vision in both eye for about 2 years.
4. History of Present Illness
She was reasonably alright 2 years back.
She gave the history of
• Total loss of vision in left eye for 3 months.
• Gradual dimness of vision in both eye for about
2 years.
5. History of Present Illness: Cont
• Difficulties in vision particularly in peripheral field & in near
work.
• Frequent changes of spectacles for last 2 years.
6. History of Present Illness Cont…
Her visual problems were associated with
• Recurrent redness.
•Watering.
•Foreign body sensetion.
•Mild headache.
7. History of Present Illness Cont…
There is no history of
•Image distortion
•Nausea
•Vomiting
•Transient visual loss.
•Trauma in the eye.
8. History past ocular illness
• She was operated for cataract in left eye 1 year back in
keraniganj.
10. General surgical history
• She has no significant general surgical history.
Drug History
• No significant history of taking medication.
Allergy History
• No significant history of systemic , ocular or drug allergy.
11. Personal history
• Take betel leaf for 25years.
Family history
• Her father had a history of low vision.
• She has 2 sons and 1 daughter, all are in good health.
Socio Economic History
• She comes from a middle class family.
12. General Examination
• Appearance : Normal
• Body built : Average
• Co operation: Co- operative
• Anemia : Absent
• Jaundice : Absent
• Cyanosis : Absent
• Edema : Absent
• Blood pressure : 130/ 80
mmHg
• Pulse : 74 beats per
minutes
• Respiratory rate: 18 breathes
per minutes
• Temperature : 98°F
14. Ocular Examination
R/E L/E
Color vision Trichromatic ---
Hirschberg reflex Central Central
Light reflex Brisk Sluggish
RAPD Present
Field of vision Superior & Inferior
field constriction
---
EOM Full in all gaze Full in all gaze
15. Slit Lamp Examination
R/E L/E
Eye lid ,Lash Normal Normal
Conjunctiva Normal Normal
Cornea Normal Normal
A/C Depth Normal Normal
Iris Normal Normal
Pupil Round, Regular,
Reacting
Round, Regular
16. Slit Lamp Examination
R/E L/E
Lens PSC with
cortical cataract
with NS Grade 2
Pseudophakic
IOP at 10 A.M
by GAT
25 26
Gonioscopy 3
3
3
3
3
3 3
3
17. Slit Lamp Examination
R/E L/E
Fundus:
Media Hazy Clear
C/D Ratio 0.8:1 GOA
Color of disc Mild pallor Severe pallor
NRR Inferior &superior
thinning
Generalized thinning
Blood vessels Nasal shifting Nasal shifting
Macula Normal Normal
18. Other System Examinations
Respiratory system
Cardiovascular system
Elementary system
Genitourinary system
Nervous system including all cranial nerves.
Nothing
significant
19. Provisional Diagnosis
• POAG with age related cataract (R/E)
• Glaucomatous optic atrophy with pseudophakia (L/E)
24. Management
• Medical therapy.
– Combet E/D 1 drop 2 times
– Travest E/D 1 drop at night
– Tab. Acemox 1+1+1
– Tab Electroe ½+½+½
25. 1st Follow up
IOP @ 11.45AM
• Right eye: 06 mm of Hg
• Left eye : 06 mm of Hg
Contineu treatment
• Combet E/D 1 drop 2 times
• Travest E/D 1 drop at night
26. 2nd Follow up
IOP @ 10.15AM
• Right eye: 12 mm of Hg
• Left eye : 12 mm of Hg
Plan of treatment
• Trabeculectomy + Phacoemulcification/SICS with PCIOL
under L/A .
