OPTHALMOLOGY CASE SUMMARY

AHMAD SUKRI NAWI MEM080005 GROUP 4

History of Presenting Illness Name: Mrs Rajambal , 66 year old Indian lady , with background history of hypertension , bronchial asthma , and corrected atrial septal defect , was electively admitted 2 days ago for intraocular lens implantation. 2 months ago, she started to notice a fixed black spot (measuring of 20 cents coin in size) in her right eye vision which disturbed her reading, with normal vision in her left eye.There was no associated symptoms and no aggravating or relieving factors.It started as tiny black dot and progressively become bigger that has prompted her to seek medical intervention from University Malaya Medical Centre Eye Clinic.

After some eye tests, she was straight away diagnosed to have cataract in her right eye which does not require surgery as her vision is still not affected. However, my patient insists to have surgery to solve the condition as she couldnt see comfortably with the presence of the black spot.According to her , the cataract does not Other than the cataract, she has no other remarkable past ocular history.

Past Medical History She was a known case of hypertension for quite many years ( patient could not quantify duration ) , and currently well controlled on medication which is hydrochlorothiazide.There has been no complications of hypertension such as renal failure , heart failure , stroke , myocardial infarction and so on. She also had history of Atrial Septal Defect and successfully underwent closure surgery 27 years ago with no further complications.She is now stable with no history of symptoms suggestive of heart failure or infective endocarditis. However, few months after the surgery, she developed episodes of difficulty in breathing which were associated with wheezing and aggravated by emotion and dusts, and was later diagnosed to have bronchial asthma.Since then, she had been on Ventoline and just had 2 to 3 asthmatic attacks per year with the last attack was 2 months ago . The medication was changed to budesonide 3 years ago as she had quite frequent tremors everytime she took her Ventoline puffs.According to the patient, her asthma is currently well-controlled and she has been symptom-free for the past 2 months with no recent hospital admission due to her asthma. She is not diabetic with normal past blood sugar tests.she has no other significant past medical history. Family history: She has family history of cataract which is her mother, who got it at the age of 81.Both of her parents have passed away due to old age whereas her siblings are well and healthy.She has no family

history of asthma , diabetes mellitus , and hypertension.there is no other known inherited disease in her family

Drug history: She is currently on Budesonide Inhaler 2 puffs / day for asthma, hydroclorothiazide for hypertension. There is no past history of topical eye steroids or oral steroid intake, or history of traditional medication intake. She has no allergy to medication or foods She is not a smoker and never consumes alcohol Social history: She currently lives with her husband who is a government retiree, in a single storey house. She has two sons who are now both working and living on their own.She depends on her husband monthly pension (she refused to disclose the amount), and claimed that her family is financially stable. In summary, my patient, Mrs Rajambal , 66 year old Indian Lady with background history of Bronchial asthma , Hypertension , and corrected ASD , came in with chief complaint of right eye black spot , and now admitted for phocoemulsification with intraocular lense implantation. Physical Examination General examination: Patient appeared to be conscious, alert, and comfortable.there was no cyanosis, pallor or jaundice.

Vital signs are all normal with temperature of 36.7 C, blood pressure of 128/68 mmHg, pulse rate of 86 beats/min, and respiratory rate of 20 breath/min. Ophthalmology examination Visual acuity: 6/12 bilaterally Visual Field: there is no peripheral or central scotoma on both eyes Colour Vision is normal on both eyes suggested by absence of red colour desaturation Size of the pupils is equal bilaterally with normal direct and consensual reflexes.there was no Relative Afferent Pupillary Defect on both eyes. Ocular movement: normal with no strabismus, diplopia, and vertigo On examination of outer eye, there are no signs of inflammation of eyelids and conjunctiva, no discharge, no loss of corneal clarity, and no corneal ulceration. Fundoscopy : Red reflex was absent on right eye.fundus of the eye cant be appreciated on the right eye.Left eye was normal with presence of red reflex, normal appearance of optic disc, with no other abnormality detected. Respiratory Examination: On inspection, patient was not in respiratory depression evidenced by absence of nasal flaring and usage of accessory respiratory muscles. Chest expansion is symmetrical bilaterally.tactile vocal fremitus was normal bilaterally.

On auscultation, normal vesicular breath sounds were heard with absence of ronchi and crepts.vocal resonance was equal bilaterally. Cardiovascular examination: Pulse rate was 86 beats/min,with good volume and regular rhythm.there was nor were radioradial delay, no radiofemoral delay, and all peripheral pulses present and normal. Apex beat was not displaced.There were no thrill, pulsation, and left parasternal heave.On auscultation , normal first and second heart sound was heard with no added sounds or murmur.Ausculaltion of the posterior chest revealed no bibasal crepitations.On examination of the legs , there was no pedal edema.

Abdominal examination was unremarkable. Neurological Examination: Cranial Nerves Examination: all are intact Motor examinations of upper and lower limb were unremarkable Abdominal Examination was unremarkable Impressions from physical examination: Eye examination: optic nerve function is intact.absence of red reflex in right eye suggests cataract of the right eye. (The most common cause of red reflex).the other eye was normal. 2. Respiratory examination: normal respiratory examination shows that she is stable and not having any asthma at the moment. So she is fit for the surgery.
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Cardiovascular examination: normal findings show that she doesnt have heart failure secondary to the atrial septal defect .so , she is fully fit for the operation 4. Vital signs show that she is not having fever and wellcontrolled blood pressure which allow her to undergo surgery. 5. All other systems are intact.
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Investigations: Pre-op assessment: 1. Routine Blood Investigation : Full Blood Count, Liver Function Test, Renal Profile , Coagulation Profile 2. Visual perimetry : to look for more accurate assessment of visual fields 3. Chest x-ray (PA view) signs of heart failure? Any pulmonary pathology? 4. ECG 5. Echocardiography : to assess the function of heart ( ejection fraction ) 6. Spirometry: to look for FEV1/FVC. normal should be > 70 %

Diagnosis: Right Eye Cataract (posterior subcapsular cataract)

Management: The mainstay of the treatment would be surgery which is Phacoemulsification with intra-ocular lense implantation or Extracapsular Cataract Extraction with intraocular lens implantation.

Discussion:

She has right eye cataract which has been disturbing her quality of life , especially when she reads .so , she wants it to be done to improve her quality of life. 2) Pre-operative assessment was required due to the fact that her bronchial asthma , hypertension, and history of atrial septal defect can influence the success rate of the operation 3) If her asthma is not well controlled, she could have exacerbation during the operation which may halt the procedure. 4) Atrial septal defect could lead to heart failure and thats the reason why ECG, Echocardiography, and Chest X-ray were done.any signs of heart failure may render the patient unfit for the operation. 5) Hypertension should be controlled as this could lower the success rate of operation. 6) Cataract is loss of clarity of the lense ( become opaque ) which is quite prevalent in the world.almost everybody over the age of 70 has some degree of lense opacification due to ageing process. 7) According to the age of presentation , there are 3 types of cataract which are senile cataract ( old age group ) , presenile cataract ( young or early middle age group ) , and congenital cataract ( present at birth ) 8) Pre-senile cataract almost has underlying causes and should be investigated further.below are some of the causes of presenile cataract:
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One third of congenital cataract is inherited through autosomal dominant pattern.another is due to birth trauma, infection during pregnancy such as toxoplasmosis and rubella

Types of Cataract according to morphology

Nuclear sclerosis : the nucleus of the lense become opaque Subcapsular cataract : anterior and posterior subscapular ( much more common, especially in those with history of steroid usage ) Cortical ( spoke like opacicity of the cortex)

Clinical Features of cataract: Gradual loss of vision Progressive myopia ( those with nuclear sclerosis type ) Glare Fixed black spot ( like in the case of Mrs Rajambal ) Infants and children do not complain of vision loss.cataract may be detected at routine follow up or in photo when leucoria become obvious History and examination is more focused on assessing the visual impairment and finding the cause. Visual acuity does not correlate well with functional impairment.as in the case of my patient , her visual acuity on both eyes were 6/12 which is quite good.however, the fixed black spot has been disturbing her vision. The characteristic finding of cataract would be , loss or reduced red reflex on fundoscopy as the opaque lense would have blocked the transmission of light from hitting the retina and reflected back.

In children , often congenital cataract would present as leucoria as the cataract has become so dense and gives white pupil appearance.as other conditions such as retinoblastoma , toxocara granuloma may give rise to leucoria , additional investigations such as ultrasound and electrophysiology may be required to rule them out.

Treatment: As mentioned earlier, cataract is treated surgically.there are two options :

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Phacoemulsification with Intraocular lense implantation in which the content of the lens ( nucleus + cortex ) is removed to create a capsular bag.then intraocular lense inmplanted into the capsular blug to replace the destroyed lens.it is the most widely used cataract surgery as it requires small incision and patient can go back on the same day of surgery ECCE ( extracapsular cataract extraction) requires larger incision and is more preferred for dense mature cataract .

Cataract surgey is indicated for those with severe vision loss, and it depends on the degree of impairment and the visual needs of the individual.others are diabetic retinopathy as cataract prevents adequate retinal examination or laser therapy. Prognosis: 80 % achieve 6/12 vision or better postoperatively.failure to improve is usually due to pre-existing disease, rather than surgical failure. Common perioperative complication is rupture of posterior capsule which leads to anterior movement of vitreous gel and in

certain occasions lead to retention of nuclear fragments in the vitreous cavity.Posoperatively , intraocular infection ( endopthalmitis can develop if antibiotics and steroids are not adequately given to patient , and this will lead to devastating blindness which requires removal of the eye ball.the late postoperative complication is posterior capsule opacification which sometimes called as secondary cataract which can impair the vision.treatment would be laser capsulotomy.other post-operative complications are corneal astigmatism, macular edema , and retinal detachment.