AP.박영훈/R2 이민아 망막 컨퍼런스

Case 2010.4.12 ER M/48 Chief complaint: FB sense(OU) Onset:2010.4.11 상기 환자 2010.4.11 고압전선(25000V)이 머리카락에 닿으면서 electrical burn 입은 후 상기 증상 발생하여 응급실 내원함. Face & neck : 4% 2nd degree burn Sole: 0.5 % 3rd degree burn LOC(+) 약 10분

Past history DM/HBP (-/-) Ocular op/trauma(-/+) 2010.4.11 고압전선에 electrical burn Gls (-) Eye drop (-) brain CT: WNL

Ocular exam VA OD 0.4 (n-c) OS 0.5 (n-c) IOP OD 13 mmHg OS 13 mmHg EOM straight at 1 position by ACT, no LOM Orbit no exophthalmos Lid no swelling Conj. not injected Cornea OD 5 x 3mm sized epi defect at center OS clear AC deep & cell(-) Pupil round & nl sized, LR(+), RAPD(-/-), NVI(-/-) Lens mild cortical opacity /(OU)

2011.4.11 A) corneal abrasion(OD) P) O-LVF x 4, O-OF x hs/OD 5일후 외래 fu

2011.4.16 VA 0.4(n-c) /0.5 (n-c) Lid No swellling Conj. not injected Cornea OD clear(decreased epidefect) AC deep & cell(-) Pupil round & nl sized, LR(+) Lens mild cortical opacity Fds nl. optic disc c flat post.pole /OU

2011.4.28 VA OD 0.02( 0.1 x +0.75Ds=-2.00Dc Ax 90) OS 0.04(0.15 x 0.00Ds=-1.25Dc Ax90) IOP 16/14 mmHg Ishihara test: OD 1/12 OS 1/12 ( 원래색약) Lid No swellling Conj. not injected Cornea clear AC deep & cell(-) Pupil round & nl sized, LR(+) Lens mild cortical opacity /OU

Fundus(OU) 2010.4.28 sl.edematous optic disc c yellow ring at parafovea

Clue list -Electrical burn Hx. -Underlying(-) -FDs : R/O M. Hole(OU) sl. edematous optic disc

Electrical injury(involve of retina) <Posterior segment> -Vitreous hemorrhage -Retinal detachment -Retinal edema (resembles commotio retinae) -Chorioretinal rupture -Pigmentary disturbances—lightning maculopathy -Macular hole -Central retinal vein occlusion <Optic nerve> -Thermal papillitis -Optic disc edema and optic neuropathy -Retrochia

Cause of M.hole -High myopia -Retinal detachment -DM -Best disease -Injury to eye ;blunt trauma, burn P) MOCT, FAG

MOCT 2010.5.7 Finding: partial thickness M.hole(OU) OD OS 약간의 cystic change를 보이면서 foveolar lesion 에서 약간의 RPE와 sensory retina가 떨어져 있는 양상의 Stage 1 정도의 M.Hole 소견 보입니다 Finding: partial thickness M.hole(OU)

FAG 2010.5.7 Fluorescein angiography

Dx) R/O M.Hole c d/t electrical burn(OU) Plan) observation for 3wks -> 호전 없을 경우 수술고려

2010.7.7 opd VA OD FC/50cm / OS FC/50cm IOP 15/15 mmHg

2010.7.7 OD OS

20110.8.19 의정부 성모 병원 ppV기계 고장으로 본원 전원됨 VA(N) OD 0.02 (n-c) OS 0.02 (n-c) IOP OD 14 mmHg OS 13 mmHg EOM straight at 1 position by ACT, no LOM Orbit no exophthalmos Lid no swelling Conj. not injected Cornea clear AC deep & cell(-) Pupil round & nl sized, LR(+), RAPD(-/-), NVI(-/-) Lens mild cortical opacity/OU

Fundus (OU) nl optic disc c 1/2DD sized M.hole

MOCT 2010.8.19 Phaco+ppV+ILM peeling+IOL+gas inj (OD) 우안 macular hole 증가된 소견 보이며 좌안 sontaneous closed 된 소견 보임 Phaco+ppV+ILM peeling+IOL+gas inj (OD)

Progress 2010.10.6 <POD #1> VA : HM(N-C) IOP(AP) 11 mmHg Conj.) well-approximated wx. Cornea) mild edematous c iris pigment on the endothelium AC) deep & cell(++) , iris pigment(+), viscoelastics(+) Pupil) round & mild dilated d/t mydriatics Lens) PCL in situ Fds) nl.optic disc c flat post.pole, glistering app. gas-fluid interface/OD

Progress 2010.11.1 <POD #1mon> VA HM/0.04(n-c) IOP 20/11 mmHg OD

Progress 2010.12.3 <POD 2#mon> S) 시력이 점점 나빠지는것 같아요 VA HM/0.02(n-c) IOP 19/14 mmHg R/O traumatic optic neuropathy(OU) P) VEP 신경안과 consult

VEP Ddelayed P100 Ddelayed P100

Progress 2011.6.13 VA OD HM OS FC/50cm