INTERNATIONAL MEDICAL SCHOOL

CASE WRITE UP

OPHTHALMOLOGY

MBBS YEAR 4 OCT

IMS MSU SHAH ALAM

‘RIGHT EYE IMMATURE CATARACT’

NAME : SYAFIQAH BINTI SALLEH

MATRIC NO : 012015100040
ROTATION : ROTATION 4
HEAD OF DEPARTMENT : DR HESHAM
DATE OF SUBMISSION : 17th APRIL 2019
PATIENT’S PARTICULARS

Name: Pilchy A/P Sinnaiah

Age : 64 years old
Gender : Female
Race : Indian
Religion : Hindu
Address : Kg Jawa, Klang
Occupation : Unemployed
Date of admission : 11/04/19
Date of clerking : 14/04/19
RN : 1897793
Informant : Patient

CHIEF COMPLAINT

1. Blurring of vision on the right eye for the past 1 month

HISTORY OF PRESENTING ILLNESS

My patient Madam Pilchy, 64 years old Indian Lady is a known case of hypertension for 5
years and hyperlipidemia for 2 years presented with blurring of vision on the right eye for the past 1
month. My patient was apparently well until 1 month prior to admission. She started developing
painless blurring of vision on the right eye 1 month ago and it was progressively worsened.
Previously she was sensitive to light and glare and she had double vision on the right eye. There was
also fading of colour before she loss her vision on the right eye. This has disturbed her regular
activities at home.

There was no redness, swelling, discharge or headache. No history of trauma , multiple or distorted
images seen. Squinting of the eye doesn’t help with the vision.

She went to an optical shop thinking that she needed a pair of spectacles, but the optometrist asked
her to go clinic instead.

She went to the clinic in HTAR and was was given a date to do a surgery on 16/04/19. She has been
electively admitted into the ward on 11/04/19.

Otherwise , she has no symptoms of target organ damage such as increase in urgency or frequency
of urinating, chest pain, shortness of breath, muscle weakness or history of fall.

PAST OPHTHALMOLOGY

She has no past ophthalmology history.

PAST MEDICAL HISTORY

She is a known case of hypertension for 5 years and hyperlipidemia for 2 years. She went for regular
follow up in HTAR for both diseases. She took her medications according to the dosage prescribe and
on the correct timing. However, she has no lifestyle control.

PAST SURGICAL HISTORY

She had done heart valve replacement for severe Aortic Regurgitation 10 years ago in HTAR and
she’s on tab warfarin 4mg OD ever since.
DRUGS HISTORY

Ezetimibe 10mg 1 Tab OD

Perindopril 8mg 1 Tab OD

Felodipine 10mg 1 Tab BD

Atorvastatin 80mg ½ Tab OD

Metoprolol Tartrate 100mg 1 Tab BD

T. Warfarin 4mg 2 Tab OD

ALLERGY HISTORY

No known drug allergy or food allergy

FAMILY HISTORY

CHF

Dm , Htn
Dm , Htn Suicide

- Both her parents have passed away. Her mother died due to old age and her father died due
to Congestive heart failure at the age of 80 years old.
- Madam Pilchy has 5 siblings and she is the 4 th child.
- Her 3rd sibling died due to suicide.
- Both her first sister and younger brother have hypertension and diabetes.
- There is no family history of eye disease such as glaucoma or cataract.

SOCIAL HISTORY

- She is married and blessed with 3 children

- She and her husband are currently living with her son in a single storey house at KG Jawa,
Klang with basic amenities.
- She is a non-smoker and not an alcohol consumer.
PHYSICAL EXAMINATION

GENERAL EXAMINATION

My patient was sitting comfortably on the bed, she was alert to time, place and person. She was
cooperative and not in respiratory distress or in pain. She is medium built with good nutrition and
hydration status.

Vital signs :

Pulse rate : 50 bpm (regular rhythm, normal character

and good volume) (normal)
Blood pressure : 109/75 mmhg (normal)
Respiratory rate : 20 breath per min (normal)
Temperature : 37ºC (afebrile)
Pain score : 0

Hands:

- Palms were dry and warm on touch.

- No peripheral cyanosis or muscle wasting.
- Capillary refill time is less than two seconds.

Eyes:

- No jaundice on his sclera and no conjunctival pallor.

Mouth:

- Oral hygiene was good with no central cyanosis.

- Oral mucosa was pink and moist.

Neck:

- No lymphadenopathy or neck swelling.

Lower limbs :

- No ankle edema and no varicose vein.

OCCULAR EXAMINATION

1. Visual Examination

Right Eye Left Eye

Visual acuity (unaided) Hand movement at < 50 cm 6/9
Not improved with pin hole Pin hole – 6/9
Visual field Loss in all quadrants Normal in all quadrants
Extraocular muscle - Normal. No restriction of - Normal. No restriction of
Motility (EOM) Occulomotility in all direction Occulomotility in all direction
- No double vision - No double vision
- No pain - No pain

2. Inspection

- Face and eyes are symmetrical

- There’s no proptosis
- The alignment of eyes is central and symmetrical bilaterally
- Both eyelids are normal with no swelling, crusting or discharge. There’s no ptosis, ectropion or
entropion
- No lacrimal gland swelling
- Both eyes had no redness, no scar and no pigmentation

3. Local Examination

Right Eye Left Eye

BRIGHT ROOM
Conjunctiva - White and no discharge - White and no discharge
Cornea - Clear - Clear
- Corneal sensation normal - Corneal sensation normal
Anterior chamber - Deep and quiet - Deep and quiet
DIM ROOM
Pupil - Round, regular and symmetrical - Round, regular and symmetrical

- Light reflex : - Light reflex :

1. Direct light reflex: 1. Direct light reflex:
o Constricted pupil o Constricted pupil

2. Consensual light reflex: 2. Consensual light reflex:

o Constricted pupil o Constricted pupil

3. Swinging light test 3. Swinging light test

o Negative RAPD test o Negative RAPD test
 Lens - Opacity - Clear
- Reduced red reflex - Normal red reflex
- Phakia - Phakia
Retina - Unable to appreciate due to - Normal optic disc and macula
Opacity on the lens - Cup disc ratio (CDR) = 0.5

SYSTEMIC EXAMINATION

RESPIRATORY EXAMINATION

 On inspection, there was scar on the chest, thorax was normal and symmetrically expanded on both
sides. No accessory respiratory muscles were used and dilated vein.
 On palpation, the trachea was centrally located. There was normal chest expansion and normal vocal
fremitus on both sides of the chests which are anterior and posterior.
 On percussion, both lungs were equally resonance.
 On auscultation, vesicular breath sound was heard at both lungs with no added sound. Vocal resonance
was normal. No rhonchi and crepitation were heard.

CARDIOVASCULAR EXAMINATION

 On inspection, there was scar on the chest, no precordial bulge, dilated veins and visible pulsation seen.
 On palpation, apex beat was found at the 5 th intercostal space at the mid clavicular line. No other
pulsation was noted.
 On auscultation, there was mechanical valve click on aortic region. Both first and second heart sounds
can be heard on other regions of the heart. No murmur or added sound were heard.

SUMMARY

My patient Madam Pilchy, 64 years old Indian Lady is a known case of hypertension for 5
years and hyperlipidemia for 2 years presented with painless and progressively worsen blurring of
vision on the right eye for the past 1 month. She had sensitivity to light and glare , double vision
fading of colour before she totally lost her vision on the right eye. The blurring of vision was not
associated with swelling, redness, discharge or headache.

On ocular examination, right eye visual acuity is at hand movement with a distance of less than 50cm
and visual field is loss on all quadrants. On the right eye there was opacity on the lens and reduced
red reflex. Retina is unable to appreciate due to the opacity on the lens. Otherwise, conjunctiva,
cornea, anterior chamber and pupil are all normal on the right eye. Left eye visual acuity is 6/9,
otherwise all are normal.
PROVISIONAL DIAGNOSIS

Right eye immature nuclear cataract

- Age (64 years old) is a risk factor

- Painless gradual loss of vision
- Sensitive to light and glare
- Fading of colour
- History of monocular diplopia
- Reduced visual acuity (hand movement)
- Loss of vision field on all quadrants
- Lens opacity
- Reduced red reflex

DIFFERENTIAL DIAGNOSIS

Differential diagnosis Point supporting Point against

1. Refractive error - Painless gradual - No headache
blurring of vision - Squinting of eye
- Sensitive to light and doesn’t improve vision
glare - Not improve with pin
hole test
2. Open angle glaucoma - Age is a risk factor - No headache
- Painless gradual loss of - No family history
vision - Lens opacity
- Reduced visual acuity - Reduced red reflex
- Loss of visual field - Unable to appreciate
optic disc due to
opacity on the lens
- Normal pupillary reflex

3. Age related macular - Age is a risk factor - No multiple/ distorted

degeneration - Hypertension image
- Painless gradual loss of - Unable to appreciate
vision optic disc due to
opacity on the lens

4. Corneal ulcer - Progressive loss of - No pain

vision - No red eye, swelling or
- Sensitive to light and discharge
glare - No headache (indicate
increase intraocular
pressure increase)
- No exaggerated
corneal sensation
- Clear cornea
INVESTIGATION

(done by hospital)

1. Coagulation profile
- PT : 28.7 (high)
- INR : 2.83
- APTT : 55.8 (high)
- APTT RATIO : 1.43

(proposed investigations)

- A scan and keratometry (to check for axial length and IOL power calculation)
- B scan (to check for vitreous or retinal disorder)
- Fasting blood sugar level ( to screen for diabetes)

FINAL DIAGNOSIS

Right eye immature nuclear cataract

MANAGEMENT

(done by hospital)

- Withhold warfarin
- Start SC Clexane 60mg BD (stop 1 day prior to surgery)
- T. Felodipine 10mg BD
- T. metoprolol 100mg BD
- T. Ezetimibe 10mg OM
- T. Perindopril 8mg OD
- T. Atorvastatin 40mg OD
- Lid hygiene
- Surgery
o Phacoemulsification with intra Ocular Lens implantation under local
anaesthesia
o Patient has been briefed about the complications that may arise from the
operation.
DISCUSSION

My patient Madam Pilchy has age-related cataract. The morphological of this cataract is nuclear
cataract and immature. She has all the symptoms and signs of cataract.

Definition of cataract is the opacification of the lens.

Types of cataracts can be divided according to the morphology :

Location

1. Nuclear cataract
2. Cortical cataract
3. Posterior subcapsular (PSC)/ anterior subcapsular (ASC)

Maturity

1. Immature
2. Mature
3. Hypermature
4. Morgagnian

In my patient, she had nuclear cataract which occurs in the centre of the lens. In early stages, patient
may become more near-sighted or even experience a temporary improvement in reading vison.

Upon ocular examination , her visual acuity and visual field were reduced. Red reflex was also
reduced, and this indicates immature cataract.

Causes of cataract can be divided into congenital and acquired.

Congenital

1. Genetic and metabolic diseases

2. Intrauterine
3. Infection
4. Hereditary cataract

Acquired

1. Age-related cataract (cause of cataract in my patient)

2. Traumatic cataract
3. Diabetes
4. Drugs

The signs and symptoms of cataract are :

Symptoms Signs
- Painless gradual loss of vision - Lens opacity
- Sensitivity to light and glare - Reduced visual acuity and visual field
- Colour appears dull - Reduced red reflex
- Monocular diplopia
Indication for surgery

- Before proceed to surgery its important to look at the indications for surgery in this patient.
- In my patient her indication is optic (visual). She can only see hand movement at a distance
of less than 50cm on the right eye.
- Other indications can be due to medical or cosmetics purposes.

Investigations

- The parameters should be done before surgery are A Scan and Keratometry. This is to check
the axial length and IOL power calculation.
- B scan can be done to check for any vitreous or retinal disorder because retina cannot be
view through fundoscopy since there’s opacity on the lens.

Management

- The choice of treatment is phacoemulsification with IOL

 Benefit of this are :
- Small incision
- No suture ( no post-operation astigmatism)
- No irritation
- Early recovery
- No need for hospital stays after surgery

Complications

Intraoperation complications

- Bleeding
- Chances of posterior capsular rent and the need for anterior vitrectomy and implantation of
anterior chamber lens
- Complication of local anaesthesia like retrobulbar haemorrhage, brain stem anaesthesia and
respiratory depression
- Non placement of intraocular lens or placement of IOL not as originally planned
- Chances of nucleus drop and need for posterior segment surgery in same or later sitting

Post- operation complication

- Post operation hyphema, iris prolapse, wound leak , wound dehiscence, severe
inflammatory reaction, post op uveitis, post op mydriasis, glare, double vision.
- Chances of decentration, dislocation, subluxation of IOL
- Chances of infection/ endophthalmitis
- Chances of posterior capsular opacification (PCO) requiring a capsulotomy at a later date.
- High post op astigmatism requiring suture removal
- Possibility of spectacle correction for distance and near vision
- Prolonged follow up in eye clinic and need for re-admission and further surgery if required

My patient was admitted early to the ward for warfarin conversion and also to monitor her other
comorbidity (hypertension and hyperlipidemia)
REFERENCE

1. Kanski’s Clinical Ophthalmology, A Systemic Approach, 8th Edition.

2. Lecture Notes