SUBJECTIVE: We had the pleasure of seeing this lovely gentleman for retinal evaluation. He is a pleasant (XX)-year-old status post recent cataract surgeries in both eyes. He states that his vision has significantly improved; however, it is still blurry, right eye greater than the left eye. His past ocular history is significant for choroidal neovascularization. He has had multiple injections of Avastin to his left eye in the past.
OBJECTIVE: On examination, the patient’s vision is 20/200 in the right eye and 20/80 in the left eye. Anterior segment examination demonstrated well-centered posterior chamber intraocular lenses in both eyes. The intraocular pressures are 17 in the right and 18 in the left.
Fundus examination of the right eye reveals the retina to be attached 360 degrees without any tears or holes. There are patches of hyperplastic and atrophic RPE changes in the posterior pole. There is a descending tract pattern of RPE changes inferiorly. There is subretinal fibrosis involving the central macula. There is no subretinal fluid or hemorrhage present.
Fundus examination of the left eye reveals the retina to be attached 360 degrees without any tears or holes. There is an approximately 1 mm flat choroidal nevus inferiorly without any orange pigment or subretinal fluid. There are atrophic and hyperplastic RPE changes in the posterior pole and involving the superior portion of the macula. There is moderate cystoid macular edema present as well.
OCT examination of the right eye reveals no fluid.
OCT examination of the left eye reveals moderate cystoid macular edema.
Fluorescein angiography of the right eye reveals window defects and staining without active leakage.
Fluorescein angiography of the left eye reveals window defects. There is moderate diffuse leakage in the macula.
ASSESSMENT AND PLAN: The patient has patches of RPE changes forming descending tracts in both eyes. This is highly consistent with chronic central serous retinopathy. The subretinal fibrosis in the right eye is likely due to choroidal neovascularization secondary to CSR. He has moderate macular edema in the left eye.
We reviewed therapeutic options, including injection of anti-VEGF medications versus laser treatment versus eye drops. At this point, the patient has elected for eye drops. We prescribed him Acular eye drops to be taken three times a day and plan to re-evaluate him in one month.
Ophthalmology Sample # 2
SUBJECTIVE: The patient is a pleasant (XX)-year-old who has experienced acute flashes and floaters in her left eye for the last couple of weeks. She has not noted curtain-type loss of vision. There is no family history of retinal tear or detachment.
OBJECTIVE: On exam, her vision is 20/25 in the right eye and 20/20 in the left eye. Intraocular pressures are 16 mmHg in each eye. Fundus examination reveals the retina to be attached 360 degrees without any tears or holes in both eyes. There is a PVD present in the left eye. There is an approximately 2 mm flat choroidal nevus inferonasal to the optic disk. There are drusen on top. There is no orange pigment or subretinal fluid present.
ASSESSMENT AND PLAN:
1. Acute symptomatic posterior vitreous separation in the left eye. We reviewed in detail the nature of this finding with her and at this point recommend close monitoring. She knows to contact us promptly should she experience any worsening of her symptoms.
2. Choroidal nevus, left eye. We do not see any high risk features associated with this nevus and recommend regular monitoring.
Ophthalmology Sample # 3
SUBJECTIVE: The patient was seen for evaluation.
OBJECTIVE: The patient’s vision with correction in a pinhole device was recorded as 20/40, right eye, and 20/30, left eye. The cornea and the anterior segment of each eye were clear and unremarkable. However, there were some cortical lens opacities in both eyes, more pronounced on the right. Examination of the fundi showed the retinal periphery in each eye to be normal in appearance. The disks and major vessels also were normal. However, there was a depigmented area centrally in the right eye. The foveal region of the left was not remarkable.
A fluorescein angiogram was performed. The study showed some transmission defects of the fovea of the right eye with two small sites of leakage just superior to the edge of the foveal avascular zone. The left eye was normal. An OCT also was done. It showed subretinal fluid centrally in the right eye. The left was normal.
ASSESSMENT AND PLAN: In general, clinical examination and testing are consistent with a central serous retinopathy in the right eye. It is difficult to know whether this has been persistent for the past year or whether there has been a recurrence and may be subsiding at this time. We plan to check the patient again in three to four weeks to determine whether there is any change in the amount of subretinal fluid. If the fluid is increasing or if it has not diminished, we will consider focal laser photocoagulation to the two small sites of leakage. We will keep you posted of her condition following the next examination.
