Case 67

Young Caucasian male (31 year old) with no history of eye disease or refractive problems came in after a minor blunt force trauma to his right eye. His two year daughter old managed to hit him in the right eye with a feather duster. Since the incident he noticed that the acuity in the right eye has decreased slightly compared to the left eye and that vertical as well as horizontal lines kink. My examination revealed normal acuity with plano refractions in both eyes. He attained right 6/6-2 and left 6/6+2. IOP was 12mmHg right and left. Slitlamp examination showed normal corneas, lids and lenses. Fundus examination revealed macular changes in the form of lost reflex and a yellow apearance, as well as blotchy lesions in the mid periphery and around the disc with more marked changes noted around the disc in the left eye. Fundus photos, OCT’s, FAF’s and visual fields are attached. Your diagnosis and treatment recommendations?  Dirk Booysen practice logo    
Case 67 1

Right eye: Note macular appearance and blotchy lesions

 
Left eye: Note changes superior to the disc and macular appearance

Left eye: Note changes superior to the disc and macular appearance

                       
DB case 67 3

Right eye: Note loss of fluorescence and marked mid peripheral lesions

             
Left eye: Note loss of fluorescence, macular and mid peripheral lesions

Left eye: Note loss of fluorescence, macular and mid peripheral lesions

   
DB case 67 5

Right eye

                         
DB 67 6

Left eye: Note the significantly enlarged blind spot

                  DB case 67 9 DB case 67 pic 10                   DB case 67 pic 7
Right
DB case 67 pic 8

Left

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