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Admissions Conference. Karen Faye M. Serrano July 30, 2011. Patient Data. E. D. Female 55 yo Tandang Sora , QC. Chief Complaint . “ Mahapdi ang kaliwang mata na parang may nakaharang .”. History of Present Illness. 4 months PTA March 24, 2011  Cataract surgery OS

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admissions conference

Admissions Conference

Karen Faye M. Serrano

July 30, 2011

patient data
Patient Data
  • E. D.
  • Female
  • 55 yo
  • TandangSora, QC
chief complaint
Chief Complaint
  • “Mahapdiangkaliwangmatanaparang may nakaharang.”
history of present illness
History of Present Illness
  • 4 months PTA
    • March 24, 2011 Cataract surgery OS
    • March 25, 2011  IOL displacement
    • March 26, 2011  swelling of the lens
      • Something is blocking her center vision
      • Painful (‘mahapdi’), redness, and tearing
      • No itchiness and discharge
      • Prescribed with 4 eyedrops
      • Minimal improvement
history of present illness1
History of Present Illness
  • 3 months PTA
    • Weekly check-up
  • 2 months PTA
    • May 28, 2011  scheduled for operation  was postponed due to persistence of swelling
  • 1 month PTA
    • June 22, 2011  scheduled for operation  was postponed due to persistence of swelling and schedule did not coincide with the doctors
history of present illness2
History of Present Illness
  • 5 days PTA
    • scheduled for operation  was postponed due to persistence of swelling and schedule did not coincide with the doctors
  • Day of admission (July 27, 2011)
    • Went to OPD
    • Got CP clearance
    • Scheduled for surgery the next day
past medical history
Past Medical History
  • Diabetic
    • 24 years ago
    • Metformin 500 mg; 3x a day
    • Glicazide (Diamicron) 80 mg; 4x a day
past medical history1
Past Medical History
  • Hospitalizations/Surgeries
    • 2009 Nov
      • Felt cold during the night
      • Fever
      • Admitted for 2 weeks
      • Wound in the L foot was already gangrenous and was excavated
    • 2010 Jan
      • Operation was done
      • Autograft from abdomen to L foot
      • Admitted for a week
family history
Family History
  • Father
    • Hypertension
    • Died of cancer
personal and social history
Personal and Social History
  • Housewife
  • Never smoked
  • Never drank or tried drinking alcohol
  • Never used illegal drugs
  • Maintained on a healthy diet
physical examination
Physical Examination
  • ROS unremarkable
  • Highest BP: 150/100
  • Normal BP: 130/70
  • Current BP: 140/80
  • RR: 16
  • HR: 82
  • Glucose 9.75 (NV: 4.1-5.9)
physical examination2
Physical Examination
  • Full and equal EOMs
physical examination3
Physical Examination
  • Gross
    • OD
      • Arcussenilis
      • Anictericsclerae
      • Pinkish conjunctiva
      • PRL, 2-3 mm pupil
physical examination4
Physical Examination
  • Gross
    • OS
      • Arcussenilis
      • Hyperemic limbal area
      • Swelling of cornea
      • Clouding on the cornea
      • Bullae on cornea
      • Hypermicsclerae
      • Indentations on the pupil border
physical examination5
Physical Examination
  • Gross
    • OS
      • Arcussenilis
      • Hyperemic limbal area
      • Swelling of cornea
      • Clouding on the cornea
      • Bullae on cornea
      • Hypermicsclerae
      • Indentations on the pupil border
physical examination6
Physical Examination
  • Tonometry
    • OD: 10 mmHg
    • OS: 10 mmHg
physical examination7
Physical Examination
  • Slit Lamp
    • OD
      • Grade 4
physical examination8
Physical Examination
  • Slit lamp
    • OS
      • Grade 4
admitting diagnosis
Admitting Diagnosis
  • Dropped IOL, OS
  • BullousKeratopathy
iol dislocation
IOL Dislocation
  • Early = before 3 months after surgery
  • Late = 3 months after surgery
  • Posterior dislocation
    • Posterior capsular rupture or zonular dialysis
    • Improper fixation within the capsular bag and instability of the IOL (capsular bag complex)
    • Solution: Continuous Curvilinear Capsulorrhexis
pseudophakic bullous keratopathy
PseudophakicBullousKeratopathy
  • Corneal edema from cataract extraction
  • Corneal endothelium is damaged  corneal swelling
  • Damaged endothelium  irregularly shaped and enlarged cells  pump function fail
  • Unable to pump to deturgesence the cornea  stroma swell (central)  folding of Descernet’s membrane  fluid accumulation  blisters and bullae  fluid to anterior chamber
pseudophakic bullous keratopathy1
PseudophakicBullousKeratopathy
  • Pain
  • Degree of pleomorphism and polymegathism increases
surgical procedure
Surgical Procedure
  • Penetrating Keratoplasty OS and Vitrectomy with IOL retrieval
specular microscopy
Specular Microscopy
  • Number of endothelial corneal cells per square millimeter inch
  • Percentage of hexagonal cells
  • Polymegathism
  • Polymorphism
specular microscopy1
Specular Microscopy
  • Endothelial cell count is normal if 2600-2800 cells per square millimeter
  • If below this level  greater likelihood of complications
    • Corneal edema
    • Loss of visual acuity
specular microscopy2
Specular Microscopy

799

001

599

002

799

001

785

001

785

001

penetrating keratoplasty
Penetrating Keratoplasty
  • Complete corneal transplant
  • Entire cornea is removed  replaced by a complete donor cornea
  • With decreased visual acuity due to corneal opacity
  • Pseudophakic corneal edema
penetrating keratoplasty2
Penetrating Keratoplasty
  • Possible Complications
    • Wound leak
    • Glaucoma
    • Primary endothelial failure
    • Persistent epithelial defect
    • Microbial keratitis
    • Late failure
    • Recurrence of primary disease
penetrating keratoplasty3
Penetrating Keratoplasty
  • Corneal graft rejection
    • Symptoms
      • Decreased vision, pain, redness, photophobia
    • Signs
      • Keratic precipitates, stromal edema, subepithelial edema, conjunctival injection, cells and flare, neovascularization
    • Treatment
      • Topical steroid (Prednisolone 1%)
      • Cycloplegics
vitrectomy
Vitrectomy
  • Surgical removal of the vitreous humor
pre op
Pre-op
  • BP 140-150/70-80
  • Moxifloxacin q4
  • At the OR:
    • BP 200-240/130-140
    • Nicardipine 10mg 10gtts
    • Uncontrolled BP
    • Deferred
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