- Name: Mr. B S
- Age: 20 years
- Sex: Male
- Date of visit: 23-8-2004
Chief complaints:
- H/O injury to the rt. eye leading to an intra ocular foreign body- 2 years ago.
- He was operated upon and the foreign body was removed and Silicon oil was inserted in Nov. 2002.
- On 1-3-2004 the silicon oil was removed and AC IOL was implanted.
- At present complains of vitreous floaters in the rt. eye.
Life Situation and Mind:
His father irons clothes. The patient left studies because he had a series of school changes as the family was frequently shifting to different cities. He wants to study but is hesitant because he left school about 4 years ago. He fears darkness. Dislikes being alone. He feels sad and weeps if someone dies in the family. Does not readily show his anger.
Patient as a Person:
- Desires: vegetables, spicy food
- Aversion: sweets
- Thirst: normal
- Sweat: scanty
- Chilly patient
- Addictions/Habits: tea
Past History:
Malaria- 1 year ago
Family History:
- Father- Cx spondylosis, Pleural effusion (20 years ago)
- Mother- cholera- twice
- Sister- Cx lymph nodes
Examination findings:
- Vision: Rt. eye- 6/9; Lt. eye- 6/6
- IOP- 12.2 (both eyes)
- Slit lamp- vitreous floaters ++
Diagnosis:
Rt. vitreous floaters with sec. glaucoma and recurrent vitreitis
Treatment:
Arnica 200 tds x 2 weeks
Follow up:
- 06-09-2004: Pt. absent. Vision improved. Treatment- ct all x 2 weeks.
- 23-09-2004: Pt. absent. Floaters reduced. Treatment- ct all x 2 weeks.
- 15-10-2004: Pt. absent. Vision improved. Treatment- ct all x 7 days.
- 21-10-2004: Anterior Chamber wash was done on 18-10-2004. The vision became blurred and hazy after that. Vision Rt. eye: FC à 6/60.
- Treatment- ct all x 7 days.
- 27-10-2004: S/B Dr. Maniar today: Vision: Rt. eye- 6/9; Lt. eye- 6/6, IOP- 17.3; Slit lamp- AC clear, vitreous floaters +, pupils reacting, IOL in place. Treatment- ct all x 7 days.
- 09-11-2004: Floaters >>. Treatment- SL tds x 2 weeks
- 11-02-2005: S/B Dr. Maniar today: Vision: Rt. eye- 6/12; Lt. eye- 6/6, IOP- 17.3; Slit lamp- AC clear, vitreous floaters +, pupils reacting, IOL in place.
- Treatment- SL tds x 2 weeks then Arnica 200 tds x 2 weeks.
The patient was followed up on 17-3-2005, 12-4-2005, 5-7-2005, 30-7-2005 and 1-9-2005 when he was given SL. The vitreous floaters had reduced and he was asymptomatic. He was under observation to see if he gets a relapse of the vitreitis.