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Subjective
73 year old white male patient complains of a gradual decrease in vision at distance and near and glare in his left eye. Ocular history remarkable for severe loss of vision in his right eye after being hit in the head with a baseball bat as a child.
Objective
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BCVA |
Glare VA |
Potential VA |
| OD |
Hand motion @ 3 ft. |
NA |
NI |
| OS |
20/30-2 |
20/200 |
20/20 |
| SLE: |
OS) Remarkable for 3+ nuclear sclerosis and 1-2+ cortical opacity |
| IOP: |
OS) 11 mmHg |
| DFE: |
OS)
0.50 c/d with healthy rim tissue
+ posterior vitreous detachment
Vessels normal
Macula clear
Horseshoe retinal tear with pigmented borders @ 2:30
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Assessment
- Cataract OS with decreased vision
- Old horseshoe retinal tear OS - patient asymptomatic
Plan
Risks/benefits of cataract surgery reviewed at length including retinal detachment. Due to patient being one eyed, a retinal consult was arranged to determine if prophylactic treatment of a long standing retinal tear was warranted prior to cataract surgery.
Retinal Consult and Surgery
Following a retinal consult the patient underwent prophylactic treatment of the tear with cryoretinopexy on 3-29-04. Uncomplicated cataract surgery with implantation of a foldable acrylic PC-IOL was performed on 4-22-04.
Six Weeks Post-op
On 6-03-04 patient was seen and reported that vision was good with no signs or symptoms of retinal detachment. Best corrected vision improved to 20/20 and patient is happy!
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