A discussion on neuroretinitis ,Pseudo tumour orbit and Posterior scleritis pending for now,...

1. An ATYPICAL CASE OF DISC
EDEMA
(DUE TO POSTERIOR
SCLERITIS)
Dr Samuel Ponraj
Post graduate
Department of Ophthalmology
MMC & RI

2. History
Mrs Valli ,42 yr old ,Home maker
Chief Complaints : Headache of left side - 1 week
Diminshed vision of left eye - 1 week

3.  History of Presenting illness
Complaints of sudden loss of vision of left eye
for 1 week associated with headache ,dull
character and left sided .
Complaints of cough and cold for 2 days.
No complaints of photophobia ,
floaters,diplopia,watering,frequent change of
glasses,joint pains, skin rashes , fever.
No complaints of weakness or sensory disturbance
.

4.  Past history :
History of intermittent pain and redness of left
eye since 2 years which subsided after instillation
of Ciplox – D eye drops in left eye .
History of Hypertension - 6 months on treatment.
History of contact with pet dogs for 2 years.
Not a diabetic or Asthmatic.

5.  General Examination :
Patient is cooperative,conscious, oriented
Vital Parameters – Blood pressure : 130/80
mm/Hg
Pulse : 84/min
No Pallor ,Icterus, Cyanosis , Clubbing , Lymph
node enlargement , Edema.

6. Ocular Examination
 Head Posture – Normal
 Gaze in Primary Position – Orthophoric
 Facial Symmetry – Normal
 Orbital Symmetry – Normal
 Extra Ocular Movements – Full in both eyes

7. FUNDUS –RIGHT EYE
EYE

LEFT

8. RED FREE FILTER
RE
LE

9. Ocular Examination
16/11/2013
Right Eye
Left Eye
Distance Vision
6/6
1/60 No improvement
with pinhole
Near Vision
N6
N60
Eyelids
NORMAL
NORMAL
Conjunctiva
NORMAL
NORMAL
Cornea
Clear
Clear
Anterior Chamber
Depth Normal
Clear Anterior
Chamber
Depth Normal
Clear Anterior
Chamber
Iris
Colour – Normal
Pattern – Normal
Colour - Normal
Pattern - Normal
Pupil
Reacting briskly to
light
RAPD +
Lens
Clear
Clear

10. RIGHT EYE
LEFT EYE
Colour Vision
Normal
Defective
IOP
17.3 mmHg
17.3 mmHg
Fundus
Media – Clear
Media – Clear
Disc – Size
– Normal Disc – Size
- Normal
Colour -- Normal
Colour – Pallor
Cup/Disc – 0.4
No
Vessels - Normal
hyperemia
Fovea – Normal
Margin - Blurry
Peripapillary
Edema
Vessels – Normal
Fovea – Edema
Serous
detachement
few exudates +
superior to
macula

11. B scan of Left Eye

12. B Scan of left eye

13. Neurological Examination




Other cranial nerves – Normal
Motor System - Normal
Sensory System – Normal
Cerebellar system – Normal
Respiratory System
Normal breath sounds heard
No added sounds
Cardiovascular System
S1 ,S2 heard
No murmur

14.  B Scan of Right Eye : Normal
Left Eye : Vitreous Cavity – Normal
Edema around Optic nerve
head
RC complex –thickened
Macula – Serous
detachment
“ T” Sign present
No Visible Orbital mass
lesion.

15.  Differential Diagnosis
- Posterior Scleritis
- Idiopathic Orbital inflammatory disease
- Optic Neuritis
- Neuroretinitis
- Vogt Koyanagi Harada Syndrome
- Central Serous Chorio Retinopathy
- Non Arteritic Anterior Ischaemic Optic Neuropathy
- Hypertensive Retinopathy

16. Investigations :
Hb : 8.6 gm %
PCV : 29 %
RBC : 4.27 million/cumm
MCV : 68 fl
MCH : 20 pg
MCHC : 30
ESR : 39 after 1 hr
TC: 12,300 cells/cumm
N : 87 % E : 4 % , L : 9 %
AEC : 492/cumm
HIV : Non reactive
VDRL : Negative
Platelet : 4.85 lakh/cumm
RBS :98 mg/dl
ANA : negative
RF : negative
CRP : within limits
Mantoux Test – Negative
Chest X Ray – Normal
MRI Brain - Normal

17.  Treatment started on 16/11/2013
Tablet Predmet 16 mg 2 – 0 – 2
Tablet Rantac 150 mg 1 - 0 – 1
Tablet Doxycycline 100 mg 1-0-1 x 1 week
On review – 18/11/2013
Right Eye
Left Eye
Distance Vision
6/6
6/18 NIP
Near Vision
N8
N8
Pupil
RTL
RTL
Fundus
Normal
Media –Clear
Disc –Normal
Vessels – Normal
Fovea – Exudates
present

18. FUNDUS – LEFT EYE

19.  Admission on 25/11/2013
Started on Inj IV Methyl Prednisolone 1 gm in 200 ml –
5 days
and Mutltivitamins then was Discharged ,
Oral Tab Predmet 16 mg 2-0-2
Review after 1 week.
Condition at time of discharge
Left eye - Vision improved to 6/9
- Colour vision continued to be defective

20.  On Review following 2 weeks , Patient came
with congestion in her left eye and a history of
frequent use of steroids.