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Cataract Patient Physical Examination

The patient presented with diminished vision in the right eye that had gradually worsened over years. On examination, visual acuity was hand motions in the right eye and 6/18 in the left eye. Examination of the right eye showed signs of a mature or immature cortical cataract. The left eye showed evidence of previous cataract surgery. Based on the history and examination, the provisional diagnosis was a mature or immature cortical cataract in the right eye and a pseudophakic left eye.

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Siddireddy Yogeeswara Reddy
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101 views4 pages

Cataract Patient Physical Examination

The patient presented with diminished vision in the right eye that had gradually worsened over years. On examination, visual acuity was hand motions in the right eye and 6/18 in the left eye. Examination of the right eye showed signs of a mature or immature cortical cataract. The left eye showed evidence of previous cataract surgery. Based on the history and examination, the provisional diagnosis was a mature or immature cortical cataract in the right eye and a pseudophakic left eye.

Uploaded by

Siddireddy Yogeeswara Reddy
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

CATARACT

Name -
Age -
Gender-
Occupation -
Address -

Chief complaints :
Diminished vision in the Right (or left) eye since ___ years

History of present illness :


Patient was apparently normal ___ years ago, then he developed
diminished vision, which is insidious in onset and gradually progressing.
The patient attained the present state of vision such that he is not able
to even perform his daily activities.
No history of pain
No history of redness
No history of glare
No history of coloured halos
No history of polyopia
No history of black spots
No history of floaters
No history of photopsia
No history of watering
No history of associated trauma

Past history :
No similar complaints in the past
Not a known case of diabetes, hypertension, tuberculosis and bronchial
asthma
History of cataract surgery performed ____ years ago. (if pseudophakia)

Family history :
No other family members have similar complaints

Personal history :
Good appetite
Mixed diet
Adequate sleep
Normal bowel and bladder movements
No addictions

1
General Examination:
Patient is conscious, coherent and co operative;
Oriented to time, place and person
Moderately built and nourished
No Pallor
No Icterus
No Cyanosis
No Clubbing
No Lymphadenopathy
No Edema

Vitals:
Blood pressure -
Pulse rate -
Respiratory rate -
Temperature -

Local Examination :
Facial symmetry - Normal
Head posture - Normal
Forehead - Normal

Ocular Examination : Right eye Left eye


Visual Acuity HM + (if mature) 6/18
6/36 (if immature) On pinhole : 6/9
(if pseudophakia)
Eyebrows
Level Normal Normal
Cilia Normal Normal
Orbits
Inspection Normal Normal
Palpation Normal Normal
Eyelids
Position Normal Normal
Lid margins Normal Normal
Eye lashes Normal Normal
Skin on lids Normal Normal
Lid crease Normal Normal
Movements Normal Normal

2
Palpebral fissure
Horizontal width 28 mm 28 mm
Vertical width 10 mm 10 mm
Conjunctiva
Congestion Absent Absent
Chemosis Absent Absent
Cornea
Size Normal Normal
Shape Normal Normal
Surface Smooth and regular Smooth and regular
Sheen Normal Normal
Sensations Normal Normal
Transparency Clear Clear
Anterior Chamber
Depth Normal Slightly deeper (if
Contents Clear pseudophakia)
Clear
Iris
Colour Normal Normal
Pattern Normal Normal
Or Iridodonesis (if
pseudophakia)
Pupil
Site Central Central
Shape Circular Circular
Size Normal Normal
Colour Pearly white (if mature) Blackish (if
Greyish white (if pseudophakia)
Immature) Or Black (Normal)
Pupillary reactions
Direct Normal
Consensual Normal Normal
Iris shadow Present (if immature) Normal
Absent
Shimmering reflex Absent Absent
Present (if
pseudophakia)

3
Lens
Position Normal —
Transparency Normal —
Colour Pearly white (if mature) — (if pseudophakia)
Greyish white (if Or Normal
immature) Normal
Black (if normal)
Ocular movements Normal Normal
Lacrimal system
Congestion Absent Absent
Swelling Absent Absent
Regurgitation test Negative Negative
Digital Tonometry Normal Normal
Perception of Light + +
Projection of Rays

Provisional Diagnosis :
Right eye Senile Cortical Mature (or Immature) cataract
Left eye Pseudophakia (or___)

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