Case Challenge 06 – November 2018

Optometric Education Consultants Clinical Case Challenge

A 21 year old male plumber called in requesting an urgent appointment. He was working on a job and trying to dislodge a drain coupling by hammering it with the blunt end of a screw driver. He missed, recoiled, and hit himself in the eye, presumably with the sharp end of the screw driver. He reported over the phone that he was tearing and that fluid was running down his cheek. He took some Tylenol and the pain was subsiding a bit. He noticed a “loose flap of skin” on his eye that he was trying to manually remove. Discussing his adventures over the phone led to a myriad of possible consequences and he was told to come in immediately.

Fortunately, he came in immediately as he had a full thickness corneal laceration with a flat chamber and bubbles in his anterior chamber (which is not a good sign of corneal patency). His adventures relayed over the phone were easily explained. The fluid running down his cheek was aqueous, the loose flap of tissue that he was trying to pull off was, in fact, his cornea, and Tylenol didn’t relieve the pain as much as severing his corneal nerves did.

Dealing with open globe injuries such as this can be challenging. Potential findings may include pain, lacrimation, decreased vision, and (+) Seidel’s sign; additionally you may also see hyphema, anterior chamber inflammation, a flattened anterior chamber, even air bubbles in the chamber as in this case. Iris prolapse possible and may actually plug the wound in some cases. Do not perform tonometry or otherwise manipulate the eye due to the possibility of extruding uveal tissue and worsening the situation. The least done the better. Shield the eye (but do not patch), instruct the patient not to eat or drink (in case surgery will be imminently performed), and refer immediately for surgical repair.

Some perforations can self-seal and may not manifest a positive Seidel test. Even if this happens, there still exists the possibility of an infective organism gaining access to the internal eye with subsequent endophthalmitis. Always consider any high speed injury to be a globe perforation until proven otherwise and perform a dilated exam and, if possible, B scan ultrasonography. Progressive vision loss, redness, sensitivity to light, pain, inappropriate inflammation, hypotony, and a shallow anterior chamber should alert to the possibility of an open globe injury and endophthalmitis, necessitating emergency referral to a retinal specialist.

In the case of this 21 year old plumber, surgical repair was delayed over half-a-day due to insurance reasons and an inability to locate a surgeon agreeable to taking on the case. Ultimately, he had a surgical repair done by a general ophthalmologist through a local emergency room at 11:30 pm that night. He did not develop endophthalmitis and ultimately had a final visual acuity of 20/30+ in that eye. He was reminded that there is a right tool to use for every job.

New Workshops!

Florida required courses: Florida Jurisprudence and Prevention of Medical Errors and Increase Patient Loyalty and Overcome Purchasing Hesitation & The Invisible Truth about UV Protection

Meet Our Speakers

This year we are pleased to bring in Drs. Caldwell, Sowka, Steen, Pelino, and Onofrey.


Click on the toggles below to read previous case challenges.

Case Challenge 05, Explained – October 2018

  A 47-year-old man presented complaining of gradually decreasing vision and monocular diplopia in his right eye for approximately the past 18 months. He had undergone LASIK vision correction over 13 years earlier with an excellent emmetropic...

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Case Challenge 05 – September 2018

A 65 year old woman previously diagnosed with primary open angle glaucoma presented for ongoing care. She was using latanoprost in each eye and had bilateral selective laser trabeculoplasty performed two years earlier. Her medical history was significant for hypertension, elevated cholesterol, and arthritis.  Her vision was 20/20 OD and 20/25 OS. She had an inferior retinal nerve fiber layer defect in the right eye and significant superior rim damage in the left eye. Threshold perimetry showed the above corresponding visual field defects.

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Case Challenge 04 – August 2018

The first patient is a 16 year old male whose vision has been fluctuating for 6 weeks. He also complains about headaches. His primary care physician feels it’s a normal growth spurt and Mom feels it’s migraines as there is a strong family history, but she still wants eyes checked. His vision is 20/20 OD/OS uncorrected and he has bilateral optic disc edema.

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Case Challenge 03 – July 2018

A 35 year old man presents wanting another opinion due to “blood on my right eye”. He says that everything happened 3 days ago after violently vomiting, reportedly due to food poisoning from chicken Caesar salad. He still feels a little nauseated and somewhat “not himself”. He saw another practitioner 3 days ago, was told he had a ‘bruise’ on his eye and it should go away in 1-2 weeks. From the outward appearance, he seems to simply have just a subconjunctival hemorrhage…or does he?

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Case Challenge 02 – June 2018

A 13 year old female was referred for painless reduced vision (20/40) in her left eye with a concurrent abnormal screening visual field, reportedly elevated intraocular pressure (IOP), and an afferent pupillary defect. Her previous exam was 3 weeks earlier and she had been previously referred to an ophthalmologist over a year earlier by another optometrist, but her mother did not know why and did not take her. When presented with painless vision loss in a young patient with these findings, there are numerous diagnostic possibilities.

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Case Challenge 01 – June 2018

A 27 year old woman presents urgently complaining of painful vision loss in her right eye. She has no known medical history and this has never occurred before. She has an edematous optic nerve with hemorrhaging, an afferent pupil defect, superior arcuate scotoma, pain when she moves her eye, and 20/70 visual acuity. A clear-cut case of optic neuritis possibly as the first manifestation of multiple sclerosis? Perhaps…perhaps not.

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Quebec City, Quebec, Canada
August 31-September 2, 2018