PARTICULARS OF THE PATIENT:

 Name : Momotaz Begum

 Age : 55 years

 Sex :Female

 Occupation :House wife

 Address : Jamalpur

 Date of Reporting : 05/11/2019

 Date of Examination : 05/11/2019

 Mobile : 01781628221
CHIEF COMPLAINTS:

 Gradual dimness of vision of both eyes for 2 years

 Black spot moving infront of both eyes for

2months
 HISTORY OF PRESENT ILLNESS
 According to the statement of the patient, she
was reasonably well 2 years back. Then she
noticed gradual dimness of vision ,Which was
deteriorated r for last 6 months. She went to
Ophthalmology department at Mymensingh
Medical College Hospital and taken treatment
but she can not mentioned the medicine. For
the last 2 months vision was rapidly deteriorated
in both distance and near and complaining black
spot moving in her both eyes visual field. It was
not associate with pain, redness, photophobia.
 Patient is diabetic for 12years which is uncontrolled and
taking hypoglycemic agent. Patient is also hypertensive
and taking antihypertensive for 8yrs. Patient did not give
history of recurrent fever, spontaneous bleeding ,and
trauma.
 For above mentioned problems she came to Vitreo Retina
department of NIOH for better management.
HISTORY OF PAST ILLNESS:

 No history of other systemic disease

PAST OCULAR HISTORY:

 Using spectacles for 10yrs

 No history of ocular surgery, Laser and intraocular injection
DRUG HISTORY:

 DM –Tab Glix 80mg (Gliclazide), Tab Gluvan Plus

850mg(Metformin Hydrochloride + Vildagliptin) for 12
years.

 HTN –Tab Osartil 50 plus for 6 years

 PERSONAL HISTORY:
• Patient is non smoker and non alcoholic and take

betel nut (including tobacco leaf)

FAMILY HISTORY:
• Her parents are diabetic and hypertensive

 ALLERGIC HISTORY:
• Nothing significant
GENERAL EXAMINATION:

 a. Appearance : Well alert

 b. Body Built : Average

 c. Anaemia : absent

 d. Jaundice : Absent

 e. Cyanosis : Absent

 f. Edema : Absent

 g. Dehydration : Absent
GENERAL EXAMINATION:

 h. Clubbing : Absent

 j. Koilonychia : Absent

 k. Leuconychia : Absent

 l. Lymph Node : Not palpable

 m. Pulse rate : 88 beat/min

 n. Blood pressure : 130/90 mm of Hg

 o. Respiratory rate : 14 breaths/ min

 p. Temperature : 98.40 F
Cardio vascular system
Respiratory System
Gastro-intestinal System
Nervous System
Musculoskeletal System
Endocrine System
-All reveals normal
 Ocular examination:
Visual acuity
Distance:
R/E L/E
Un-aided 6/60 6/60

With pin hole 6/60 6/60

BCVA NI NI

Near:
R/E L/E
Can not read N 18
letters
 Ocular examination cont…:

R/E L/E
Colour vision Trichromatic Trichromatic
Field of vision Intact Intact
(confrontation)
Hirschberg Central Central
reflex

Ocular motility Full in all gazes Full in all gazes

Pupillary light Sluggish Sluggish

reaction
 Ocular examination cont…:
Slit-lamp Examination

R/E L/E
Eye lid margin Normal Normal
& Eye lashes
Conjunctiva Normal Normal
Cornea Clear Clear
Anterior Chamber Normal in depth Normal in depth

Pupil Round, regular and Round , regular

sluggish and sluggish
 Ocular examination cont…:

Slit-lamp Examination

R/E L/E
Iris Normal Normal
Crystalline lens Opaque (NS 2) Opaque(NS 2)
Intra ocular 12 mm Hg 12 mm Hg
pressure
On 05/11/19
at11 am
 Ocular examination cont…:

Fundoscopic Examination
R/E
Media : vitreous haemorrhage present
 Optic disc-size,shape,color-normal , new vessels present more then 1/3
disc area
 Microaneurysm , dot and blot hge-all four quadrant
 Pre retinal hemorrhage present.
 Hard exudate with in 500 µm of centre of macula and distributed all over
the macula
 Foveal reflex dull
 NVE present
 Ocular examination cont…:

•Optic Disc : colour, size and shape could not be delineated

properly
• Media : Hazy due to Vitreous haemorrhage
•There was a tractional fibrovascular band extending over the disc
along the inferotemporal vascular arcade upto the temporal part of
macula.
•Pre retinal clotted blood situated in the inferotemporal and
inferonasal quadrant approximately 20-22 DD
•Hard exudates present with in 500 µm centre of macula and
temporal part of macula .
•Presence of dot and blot haemorrhage all quadrants
•NVE present
Salient feature

Momotaz Begum , 55yrs old, hailing from Jamalpur came to

NIO&H with the complaint of gradual dimness of vision of
both eyes for 2years . Which was more deteriorated for last
2months associates with floaters more marked in left eye.
It was not associate with pain, redness, photophobia,
Patient is known diabetic for 12years which is uncontrolled
and taking hypoglycemic agent. Patient is also hypertensive
and taking antihypertensive for 8yrs.
Patient did not give history of recurrent fever,
spontaneous bleeding , and trauma.
On ocular examination VA(unaided) 6/60 and BCVA
6/60 in both eyes. Pupillary light reaction is sluggish
and lental opacity (NS grade 2) present in both eyes.
 On Fundoscopic examination – R/E
Vitreous haemorrhage present, new vessels disc more
than 1/3 disc area
Microaneurysm, dot and blot hge present-all four
quadrant
Pre retinal hemorrhage present.
Hard exudate with in 500 µm of centre of macula
NVE present, foveal reflex dull
Fundoscopic examination – L/E
Optic Disc : colour, size and shape could
not be delineated properly
Media : Hazy due to Vitreous haemorrhage
There was a tractional fibrovascular band
extending and over the disc along the
inferotemporal vascular area.
Pre retinal clotted blood situated in the inferotemporal and
inferonasal quadrant approximately 20-22 DD
Hard exudates present with in 500 µm centre of macula and
temporal part of macula .
Presence of dot and blot haemorrhage all quadrants
NVE present
PROVISIONAL DIAGNOSIS:

Advanced diabetic eye disease with Age related

cataract B/E
DIFFERENTIAL DIAGNOSIS:

 HYPERTENSIVE RETINOPATHY

 VASCULITIS RTINAE
INVESTIGATIONS:

 Systemic

 CBC- Normal

 RBS: 13.4 mmol/L

 HbA1c-8.4mg/dl

 Serum Creatinine – 1.1 mg/dl

 ECG-Normal

 LIPID PROFILE - Normal

Investigations

Ocular :
1. Colour Fundus Photography(B/E)
2. B Scan (B/E)
3. Optical coherence Tomography (B/E)
4. Fundus Fluoroscence Angiography (B/E)
FFA of R/E
FFA of L/E
B Scan Of R/E
B Scan of L/E
OCT OF (R/E)
OCT OF(L/E)
Confirmatory Diagnosis:

Advanced Diabetic eye disease with age related

cataract (B/E)
Treatment

General :
Strictly control diabetes and hypertension by
consulting with endocrinologist and cardiologist
Life style modification
Counselling for surgical outcomes
Definitive :
R/E Anti VEGF 3-5 doses + Pan retinal photocoagulation with
meticulous follow up
L/E preparatory anti VEGF followed by Pars Plana
Vitrectomy + Peeling of tractional band +Endo laser +/-
Silicon oil implant with Guarded visual prognosis
(Phacoemulsification + vitrectomy may be needed if
fundus not clearly visible)