61 year old
OD +0.75 -0.75 x 100 +2.25
OS +0.75 -1.25 x 075 +2.25"
Initially upon intake, the patient reported dry, itching, burning eyes and no other symptoms. During the review, he reported seeing a dark spot most of the time in his superior vision (eye unknown). He had mentioned it to a relative who is a paramedic, who rated it of low concern; therefore, he’s ignored it since. He was correctable to 20/20 OD, OS, and OU with minor hyperopic, astigmatic, and presbyopic correction. His extraocular muscles, confrontations, color vision, and stereopsis testing was all within normal limits. Anterior segment evaluation performed with Eyefficient Firefly S390L revealed scalloped lid margins OU, aligning with his symptoms on intake. Also, he was noted to have early 1+ NS cataracts OU. All other anterior segment findings were determined to be within normal limits. IOP is usually determined by NCT, but was deferred during this examination due to COVID-19 guidelines. The patient performed a visual field test on the OCULUS Easyfield C. His right eye was significant for high false positives; however, there is a notable superior defect, aligning with the dark spot in his vision. The visual field in his left eye was also unreliable, but overall unremarkable. His posterior segment was examined with a photo from Centervue DRS. His nerves were pink and healthy with a 0.25 cup-to-disc ratio in both eyes. His right eye was significant for a 1.5DD CHRPE in the superior temporal arcade. There was also an area from 4:30 to 8:00 of retinal whitening, indicating poor perfusion.
The patient’s symptoms, visual field, and posterior pole all aligned suggesting a problem. The patient was diagnosed with a branch retinal artery occlusion of the right eye. He was referred out to an OMD for confirmation and evaluation of possible treatment options. He was also referred to his PCP for a stroke evaluation and work-up. No follow-up has been received.