Melissa Valdellon

Patient case for June 5, 2023

A 27 year old Hispanic female came in for her comprehensive eye exam, complaining of blurred distance and near vision without glasses. Her last eye exam was a year ago elsewhere – she was not prescribed anything at that time.

Her medical history includes irritable bowel syndrome, depression, and migraines. She takes amitriptyline, sumatriptan, trazadone, and is using a birth control implant.

Incoming vision is OD 20/20-1, OS 20/25-3. Pupils and EOMs are normal.

Retinoscopy is plano in both eyes with visual acuity OD 20/20, OS 20/40+1. Refraction doesn’t yield any change for the left eye and it seems to be fluctuating throughout refraction.

Anterior segment is clear before drops, IOPs are 17 mmHg, 15 mmHg OD/OS, respectively. Posterior segment is clear with moderate cups of 0.65 round OD, 0.60 round OS and a vitreoretinal tuft in the left eye. Another look at anterior segment shows diffuse epithelium disruption left eye and clear right eye after dilation.

Auto-refractor after dilation shows:
OD: -0.25-0.75×173  20/20-1
OS: -1.25 -0.75×164  20/30

Retinoscopy after dilation shows:
OD: +1.50-0.50×180
OS: +1.00-0.50×035

What are your differentials for the decreased vision in the left eye? What extra tests would you like to perform to rule your differentials in or out? How would you manage and counsel this patient at the end of today’s exam based on your different differentials?

I look forward to hearing your thoughts.

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