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Subjective
79 y/o white female presents for cataract evaluation on 11/06/2003. Patient complains of a sudden, painless decrease in vision in left eye 3 weeks prior and glare from headlights at night. Referral notes indicate that BCVA on 6/30/2003 was 20/30 OD and 20/100 OS but by 10/20/2003 it was reduced to 20/50 OD and 20/200 OS.
Objective
| |
BCVA |
Glare VA |
Potential VA |
| OD |
20/40-3 |
20/400 |
20/25 |
| OS |
20/200 |
20/400 |
No Improvement |
| Pupils: |
EERL (-) APD |
| IOP: |
OD) 06 mmHg |
OS) 07 mmHg |
|
| SLE: |
3+ nuclear sclerosis and 2+ cortical opacities OUPVD OU |
| DFE: |
OD) 1+epiretinal membrane |
| |
OS) full thickness macular hole with thin cuff of subretinal fluid |
Assessment
- Full thickness macular hole OS - recent
- Cataract OU - symptomatic from glare
- Epiretinal membrane OD
- PVD OU
Plan
Refer patient to retinal specialist for repair of macular hole OS. Proceed with cataract surgery when approved by retinal specialist.
Retinal Consult and Surgery
The patient underwent vitrectomy, membrane peel and a gas/fluid exchange on 1/12/2004 without complication. The retinal specialist then approved to proceed with cataract surgery. Uncomplicated cataract surgery with implantation of a foldable acrylic PC-IOL was performed on the left eye on 4/07/2004.
Six Weeks Post-op
BCVA improved to 20/60 OS, macular hole closed. Patient is happy!
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