Chief Complaint: Blurred VA OU
Location: Distance and near
Severity: Mild
Duration: Constant
Relieving Factors: None
Patient Ocular History:
- s/p CE OD 2006 with corneal decompensation s/p DSEK 2007
- Cataract OS, stable
- h/o Postoperative OHTN OD, now off all anti-glaucoma meds
- Anisometropia
Presenting VA (CC):
R 20/25- NIPH
L 20/30- NIPH
Spectacle Rx:
OD: -0.75 +1.50 x044
OS: -4.50 +0.50 x045
Clinical Findings:
Cornea:
OD: DSEK button, central cornea clear, pigment on endo between 4-8 o'clock at edge of button, -edema
OS: diffuse guttata and scattered pigment on the endothelium, -edema
A/C:
OD: small retained Descemet's tissue remnant linearly (horizontal)folded
on self within vitreous prolapse inferiorly, motile
OS: deep and quiet
Lens: PCIOL OD, 2+ NS OS
Assessment and Plan in the comments
1. s/p CE/IOL OD with corneal decompensation s/p DSEK.
ReplyDelete-continue with PF qd OD
-rtc 4-6 mos for IOP check, sooner if decrease in vision or eye appears red, painful, or experiences symptoms of photophobia
2. cataract OS
-NVS, monitor at DFE
3. H/o postoperative OHTN OD, now off all anti-glaucoma meds
-IOP today: 19/16
-no clinical evidence of glaucoma.
4. Fuch's endothelial dystrophy OS
-monitor at next DFE and continue current management