CASE PRESENTATIONDr.Puskar Ghosh

3rd yr PGT,Dept. of OphthalmologyBurdwan Medical College

Name: Hasiba Khatoon Age:21 yrs,(married) Sex: Female Address: Sakta, Burdwan

Chief complaints: Dimness of vision at night for last twelve months.

History of present illness: the patient stated that she noticed the problem 12 months back while doing indoor works at night.First there was dimness of vision at night only , she felt that it would be better if there was more light . Then the difficulty begins from the sun set times. Now she is having problem in vision in the dark room even in the day time.She attended local PHC and took medicines and Vitamin oil occasionally but without any result. She had not attended any eye clinic before. There was no difficulties in vision in daylight.

There was no H/O pain, redness, watering or photophobia, floaters or flash of light. There was no H/O any eye injury.

There was no H/O deafness or indigestion.

Past History: No significant past history of illness.There was no H/O diabetes or hypertension.No H/O any prolonged drug intake.

Personal history: There was no H/O any addiction.

Family History: No family history of nightblindness.

Treatment History:nothing significant

EXAMINATION: A.GENERAL SURVEY: Pt was alert,concious,co operative.• Facies-Normal• Decubitus- of choice• Pallor- absent• Cyanosis,-absent• Icterus-Absent• Clubbing-absent• Oedema-absent• Neck vein-not engorged• Neck glands-not palpable• Pulse-84/min• BP-110/80mmHg.

OD OS

Visual Acuity1.UCVA-2.BCVA-

6/12-0.75DS (6/6)

6/18-1DS (6/9 part)

Colour Vision Normal Normal

Ocular Movements Full in all gazes Full in all gazes

Eyeball1. Position-

2. Size-NormalNormal

NormalNormal

B.Ocular Examinations

OD OS

Lid Normal Normal

Globe & adnexa Normal Normal

Conjunctiva Normal Normal

Cornea Transparent Transparent

Corneal sensation

+ + + +

+ + + +

Anterior chamber Normal depth,clear Normal depth,clear

Iris-1. Colour-2. Texture-

BrownNormal

BrownNormal

Examination of Anterior Segment

OD OS

Pupil-1. Size-2. Shape-3. Position-4. Reactions-

3mmCircularCentralDirect +,Consensual +

3mmCircularCentralDirect +,Consensual +

Gonioscopy

CBB

CBB CBB

CBB

CBB

CBB CBB

CBB

AT (12.6.15 at 11:15am)

12mm Hg 14 mm Hg

OD OS

Media Clear Clear

Disc-1. Size:

2. Shape:3. Colour:4. Margin:

5. NRR:

NormalNormal

PaleWell delineated

Pale

NormalNormal

PaleWell delineated

Pale

Macula Dull foveal reflex Dull foveal reflex

Vesseles Peripheral attenuationsheathing

Peripheral attenuationSheathing

Examination of Posterior segment(90D lense & IO)

OD OS

Numerous scattered yellowish white lesions and few bony spicule pigmentary lesions in the peripheral retina of both eyes.

Posterior and peripheral Retina:

Summery: 20year old Hasiba Khatoon presented with dimness of vision,more at night for last 1year.She had no significant past history and no family history of such problem.On general examination,within normal limit.On ocular examination,she had BCVA and normal anterior segment of both eyes.Posterior Segment examination of both eyes shows pale disc,few attenuated vesels along with periarteriolar sheathing more in the peripheral retina,dull foveal reflex and neumerous yellowish white scaterred lesion with few bony spicule pigmentary lesions in the peripheral retina.

Provisional Diagnosis: Retinitis Punctata albescens with myopia in

a 21yrs old female patient.

THANK YOU