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Case Analysis I- Lecture 6

Liana Al-Labadi, O.D. Case Analysis I- Lecture 6. If you hear hoof beats, think horses—not zebras. The Dissatisfied Patient. A 78yo PF c/o persistent poor vision with new specs F requency: Constantly (all the time, everyday) @ D&N O nset: Since she got the specs L ocation: Both eyes

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Case Analysis I- Lecture 6

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  1. Liana Al-Labadi, O.D. Case Analysis I- Lecture 6

  2. If you hear hoof beats, thinkhorses—not zebras

  3. The Dissatisfied Patient • A 78yo PF c/o persistent poor vision with new specs • Frequency: Constantly (all the time, everyday) @ D&N • Onset: Since she got the specs • Location: Both eyes • Duration: Notices it all the time • Associated Factors: • No other symptoms • Relief: None • Old specs are just as bas as the new ones • Severity: N/A

  4. DIFFERENTIAL DIAGNOSIS????

  5. The Dissatisfied Patient • POH: • Negative for HA, DIPL, asthenopia, surgery, trauma, pain, F&F • Negative for AMD, DR & Glc • Positive for Cataracts OU • Fears surgery because of “weak” heart • LEE: 3 weeks ago by Dr. Curtis • FOH: Negative for AMD, DR, Glc, Cat • LPE: Last year by Dr. Nixon; 2 months ago saw “nutritionist” • PMH: Negative for HTN/DM/Cancer/Neuro • FMH: (+) HTN- parents; (+) DMII- father • MED: Dietary supplements • Allg: NKDA; No seasonal allergies • SH: Reading • Occupation: Retired • No alcohol consumption & no smoking

  6. Entrance Testing????

  7. The Dissatisfied Patient • Entrance Testing: • Lensometry (New glasses): • OD: +3.00 -1.00x 090 • OS: +3.25 -1.25x 090 +2.50 add • Lensometry (Old glasses): • OD: +2.25 -1.00x 090 VA: 20/40 • OS: -+2.75 -1.25x 090 VA: 20/40 +2.50 add

  8. The Dissatisfied Patient • Entrance Testing: • DVA (c): 20/30 OD; 20/25 OS • NVA (s): 20/30 OU • Motility: S&F OD, OS • Confrontations: Full OD, OS • Pupils: 4mm/4mm RRL OD, OS; No APD

  9. Additional Testing????

  10. The Dissatisfied Patient • Cover Test: • (D) : 2pd XP • (N): 2pd EP • Retinoscopy: • OD: +3.00 -1.00x 090 • OS: -+3.25 -1.25x 090 • Manifest Refraction: • OD: +3.00 -1.00x 090 VA: 20/30 • OS: -+3.25 -1.25x 090 VA: 20/25 • Add: +2.50 add (20/25)

  11. Additional Testing????

  12. The Dissatisfied Patient • SLE: • L/L: Quiet OD, OS • Conj: No injections OD, OS • K: Clear OD, OS • Iris: Flat & brown OD, OS • AC: No cell & no flare/ D&Q OD, OS • Lens: • OD: 2+ NS; trace-1+ cortical; tr PSC • OS: 1+ NS; tr cortical • IOP (TA): • 15mmHg OD; 15 mmHg OS @ 1:30pm • DFE: Unremarkable OD, OS

  13. FINAL DIAGNOSIS

  14. The Dissatisfied Patient • Assessment: • Visually significant cataracts OD>OS • Pt fears surgery 2˚ “weak heart” • Compound hyperopic astigmatism OU with presbyopia • Difficulty seeing with new specs • Plan: • Recommend PE IOL OD then OS • Discuss R&B/A-scan measurements/IOL options • Discuss limitation of new specs in the presence of cataracts/

  15. The Dissatisfied Patient • Exert care in advising what benefit the patient can expect with the new correction • Use trial lenses to demonstrate change or no change with the new specs vs. the old specs • Indicate to these patients that this is the best corrected vision possible

  16. Trace: 20/20 Trace-1: 20/20-20/25 1+2-: 20/30-20/40 2-2+: 20/50-20/60 3:20/70-20/100 4:20/100 or worse Nuclear Sclerosis- Grading Trace: 20/20 Trace-1: 20/20-20/25 1+2-: 20/30-20/40 2-2+: 20/50-20/60 3:20/70-20/100 4:20/100 or worse

  17. Trace: 20/20 Trace-1: 20/20-20/25 1+2-: 20/30-20/40 2-2+: 20/50-20/60 3:20/70-20/100 4:20/100 or worse Cortical Cataracts- Grading Trace: 20/20 Trace-1: 20/20 2-2+: 20/25 2+-3: 20/30-20/40 4:20/60 or worse

  18. Trace: 20/20 Trace-1: 20/20-20/25 1+2-: 20/30-20/40 2-2+: 20/50-20/60 3:20/70-20/100 4:20/100 or worse Posterior Subcapsular Cataracts- Grading 1:20/25 2—2: 20/25-20/40 2+: 20/30-20/60 3: 20/60-20/100 4: 20/200 or worse

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