1. An ATYPICAL CASE OF DISC EDEMA (DUE TO POSTERIOR SCLERITIS) Dr Samuel Ponraj Post graduate Department of Ophthalmology MMC & RI

2. History Mrs Valli ,42 yr old ,Home maker Chief Complaints : Headache of left side - 1 week Diminshed vision of left eye - 1 week 3. History of Presenting illnessComplaints of sudden loss of vision of left eye for 1 week associated with headache ,dull character and left sided . Complaints of cough and cold for 2 days. No complaints of photophobia , floaters,diplopia,watering,frequent change of glasses,joint pains, skin rashes , fever. No complaints of weakness or sensory disturbance . 4. Past history :History of intermittent pain and redness of left eye since 2 years which subsided after instillation of Ciplox D eye drops in left eye . History of Hypertension - 6 months on treatment. History of contact with pet dogs for 2 years. Not a diabetic or Asthmatic. 5. General Examination :Patient is cooperative,conscious, oriented Vital Parameters Blood pressure : 130/80 mm/Hg Pulse : 84/min No Pallor ,Icterus, Cyanosis , Clubbing , Lymph node enlargement , Edema. 6. Ocular Examination Head Posture Normal Gaze in Primary Position Orthophoric Facial Symmetry Normal Orbital Symmetry Normal Extra Ocular Movements Full in both eyes 7. FUNDUS RIGHT EYE EYE LEFT 8. RED FREE FILTER RELE 9. Ocular Examination 16/11/2013 Right EyeLeft EyeDistance Vision6/61/60 No improvement with pinholeNear VisionN6N60EyelidsNORMALNORMALConjunctivaNORMALNORMALCorneaClearClearAnterior ChamberDepth Normal Clear Anterior ChamberDepth Normal Clear Anterior ChamberIrisColour Normal Pattern NormalColour - Normal Pattern - NormalPupilReacting briskly to lightRAPD +LensClearClear 10. RIGHT EYELEFT EYEColour VisionNormalDefectiveIOP17.3 mmHg17.3 mmHgFundusMedia Clear Media Clear Disc Size Normal Disc Size - Normal Colour -- Normal Colour Pallor Cup/Disc 0.4 No Vessels - Normal hyperemia Fovea Normal Margin - Blurry Peripapillary Edema Vessels Normal Fovea Edema Serous detachement few exudates + superior to macula 11. B scan of Left Eye 12. B Scan of left eye 13. Neurological Examination Other cranial nerves Normal Motor System - Normal Sensory System Normal Cerebellar system NormalRespiratory System Normal breath sounds heard No added soundsCardiovascular System S1 ,S2 heard No murmur 14. B Scan of Right Eye : NormalLeft Eye : Vitreous Cavity Normal Edema around Optic nerve head RC complex thickened Macula Serous detachment T Sign present No Visible Orbital mass lesion. 15. Differential Diagnosis- Posterior Scleritis - Idiopathic Orbital inflammatory disease - Optic Neuritis - Neuroretinitis - Vogt Koyanagi Harada Syndrome - Central Serous Chorio Retinopathy - Non Arteritic Anterior Ischaemic Optic Neuropathy - Hypertensive Retinopathy 16. Investigations : Hb : 8.6 gm % PCV : 29 % RBC : 4.27 million/cumm MCV : 68 fl MCH : 20 pg MCHC : 30 ESR : 39 after 1 hr TC: 12,300 cells/cumm N : 87 % E : 4 % , L : 9 % AEC : 492/cumm HIV : Non reactive VDRL : NegativePlatelet : 4.85 lakh/cumm RBS :98 mg/dl ANA : negative RF : negative CRP : within limits Mantoux Test Negative Chest X Ray Normal MRI Brain - Normal 17. Treatment started on 16/11/2013Tablet Predmet 16 mg 2 0 2 Tablet Rantac 150 mg 1 - 0 1 Tablet Doxycycline 100 mg 1-0-1 x 1 week On review 18/11/2013 Right EyeLeft EyeDistance Vision6/66/18 NIPNear VisionN8N8PupilRTLRTLFundusNormalMedia Clear Disc Normal Vessels Normal Fovea Exudates present 18. FUNDUS LEFT EYE 19. Admission on 25/11/2013Started on Inj IV Methyl Prednisolone 1 gm in 200 ml 5 days and Mutltivitamins then was Discharged , Oral Tab Predmet 16 mg 2-0-2 Review after 1 week. Condition at time of discharge Left eye - Vision improved to 6/9 - Colour vision continued to be defective 20. On Review following 2 weeks , Patient camewith congestion in her left eye and a history of frequent use of steroids.