CASE OF A.D.G.

San Beda University – College of Medicine

Bautista, Bayona, Boñula
Ophthalmology Rotation
General Data

■ A.D.G.
■ 35 years old
■ Female
■ Single
■ Roman catholic
■ Resident of Quezon City
■ Chief Complaint
– Eye redness, right eye
History of Present Illness

■ One day history of eye redness OD associated with excessive tearing OD. Patient self
medication with EyeMo lubricant eye drops, 1 drop for two doses which provided no
relief. Persistence of symptoms prompted consult.

■ No episodes of visual loss, photophobia, visual distortion, flashing lights, floating

spots, oscillopsia, diplopia, eye pain, headache
Pertinent History:
Past medical, Family, Personal & Social

■ No known history of asthma, heart ■ Non-smoker

disease, hypertension, stroke,
■ Non-alcoholic beverage drinker
thyroid disease, allergies, COPD,
diabetes, glaucoma, serious eye ■ Denies narcotics use
injury, eye surgery, poor vision, eye
wear, recent eye disease(s) ■ No recent eye diseases among
family members
Review of Systems:
 General: (-) chills, (-) easy fatigability, (-)
sleep disturbance, (-) sweats
 Skin: (-) rashes, (-) wounds, (-) itching, (-)
lumps, (-) discoloration, (-) dryness
 HEENT: (-) headache, (-) dizziness, (-) sore
throat, (-) blurring of vision, (-) eye
discoloration, (-) discharge, (-) hearing loss,
(-) tinnitus, (-) nose bleed, (-) bleeding gums,
(-) dry mouth, (-) hoarseness, (-) dysphagia
 Respiratory: (-) hemoptysis, (-) shortness of
breath
 Cardiovascular: (-) palpitations, (-) chest
pain, (-) orthopnea, (-) edema, (-) PND
 Gastrointestinal: (-) hematochezia, (-) nausea, (-)
vomiting, (-) dysphagia, (-) diarrhea, (-) constipation, (-)
heartburn, (-) excessive belching, (-) change in stool
 Genitourinary: (-) oliguria, (-) changes in urine, (-)
dysuria, (-) nocturia, (-) dribbling, (-) urgency (-)
discharge
 Endocrine: (-) heat and cold intolerance, (-) changes
in hair distribution, (-) polydypsia, (-) polyphagia, (-)
polyuria
 Musculoskeletal: (-) cramps, (-) pain or swelling, (-)
stiffness, (-) backache, (-) limitation of movement, (-)
weakness
 Neurological: (-) changes in mood/behavior, (-)
disorientation, (-) tremors, (-) changes in speech, (-)
memory loss, (-) seizures, (-) fainting
Physical Examination
Visual Acuity

■ OD: 20/20
■ OS: 20/20
 Physical Examination
Direct Ophthalmoscopy
Structure Findings
Red Orange Reflex (ROR) Present
Media Clear
Optic Disc
• Disc margins Distinct
• Cup:disc ratio 0.3-0.5
Retinal Vessels
• A:V ratio 2:3
• Median light reflex Normal
• AV crossing defects Absent
• Hemorrhages and exudates Absent
Retinal Background Red orange
Macula
• foveal reflex Present
Physical Examination
External Inspection & Pupillary Reaction Testing

■ Lids: no ■ Direct Pupillary Reaction, OU

exophthalmos/enophthalmos, lid
retraction/ptosis – equally briskly reactive to light

■ No palpable or observable masses, ■ Consensual Pupillary Reaction, OU

lesions, ulcerations, in surrounding – Present
tissues, conjunctivae, palpebral
fissure ■ Clear Cornea
■ Diffuse redness of sclerae, ■ Round Pupil
conjunctiva (OD)
■ No esotropia, exotropia, hypotropia,
■ No eyeball protrusion, defects of hypertropia
orbital rim
Physical Examination
Ocular Muscle Testing

■ Full extraocular muscle movement

■ No nystagmus, limitations/weakness, diplopia
Differential Diagnosis
1. Conjunctivitis
1. Infectious – Bacterial, Viral
2. Non-infectious – Allergic, Dry
Eye, Toxic or Chemical
Reaction, Contact lens use,
Conjunctival Neoplasm,
Foreign Body
2. Uveitis
3. Episcleritis/Scleritis
4. Acute Glaucoma
5. Keratitis
1. Infectious – Bacterial, Viral,
Fungal, Acanthamoeba
2. Non-infectious – Recurrent
Epithelial Erosion, Foreign Body
6. Eyelid abnormalities
1. Entropion/Trichiasis
2. Lagophthalmos
7. Orbital Disorders
1. Preseptal and orbital cellulitis
2. Idiopathic orbital inflammation
 Differential Diagnosis
Eye Redness
Lids and Ocular
Globe
Adnexae

Pre-septal Conjunctivitis
cellulitis Subconjunctival
Orbital cellulitis hemorrhage
Uveitis Scleritis
Acute Glaucoma Iritis
Acute Glaucoma
Pterygium
Differential Diagnosis
Eye Redness
w/ Eye Pain w/o Eye Pain

w/ Discharge Microbial Keratitis w/o Discharge Dry Eye Syndrome

w/o Discharge w/ Discharge

w/ Photophobia Uveitis Mucopurulent Bacterial Conjunctivitis

w/o Photophobia Acute Watery

Glaucoma
w/ Itchiness Allergic Conjunctivitis
No complaints of
Eye Pain w/o Itchiness Viral Conjunctivitis
Viral Conjunctivitis

■ Epidemic keratoconjunctivitis
– Adenovirus Type 8, 19, 29, and 37

■ Transmission- direct contact w/ eye

discharge; highly contagious
– History of exposure to sore eyes
– Contaminated objects or surfaces
Viral Conjunctivitis:
Signs and Symptoms

■ Burning, sandy, or gritty sensation

■ Acute onset of:
– Eye redness
■ Unilateral → Bilateral
– Watery Discharge
■ Watery → Mucopurulent

■ First eye usually worse

■ Subconjunctival hemorrhage
■ Tarsal conjunctivae may be follicular or
‘bumpy’ in appearance
Viral Conjunctivitis:
Diagnosis

■ Clinical diagnosis of exclusion:

1. Eye redness & discharge
■ diffuse
2. Normal vision
3. No focal pathology
■ Hordeolum, ulcerations,
masses, lesions,
blepharitis
■ Cultures not necessary
– Rapid (10 min) test for
Adenoviral conjunctivitis
Viral Conjunctivitis:
Diagnosis & Red Flags

1. Reduction of visual acuity

2. Ciliary flush
3. Photophobia
4. Severe foreign body sensation
5. Corneal opacity
6. Fixed pupil
7. Severe headache w/ nausea
Viral Conjunctivitis:
Treatment & Prognosis
■ Usually self-limited
– Get worse 1st 3-5 days ■ Contact lens wearers + acute eye
– Resolve w/o sequelae in 1-2 weeks redness + discharge
– Total duration: 2-3 weeks – Advised to discontinue contact
lens wear immediately
A. Antihistamine/decongestant drops – Seek consult if no
– 1-2 drops QID as needed (not more than 3 weeks) improvement in 12-24 hrs
B. Eye lubricant drops/ointment
– 1-2 drops hourly or QID as needed
– Half inch at bedtime or QID as needed ■ Use of any other topical agent may
cause irritation or toxicity
■ Sub-epithelial opacities
– Blurring of vision
– Weeks to months
Thank
You!