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Make your diagnosis

Case presentation by Dr Dirk Booysen

March 2018

34 year old Asian man referred for RGP consultation due to high astigmatism and poor acuity in the right eye since he received his new specs two months previously (apparently many remakes done). Healthy, kick boxing as main sport, lots of stress, non-smoker.

Refraction.

R -1.50/-4.50×172 20/40 (6/12)
L. -1.75/-4.50×5 20/20 (6/6)
Pupil 1+ APD right
IOP 15 mm Hg OU
Large discs, C/D R.060 and L.0.70

Pentacam scans, fundus photos, FAF, and retinal OCT below.

Pentacam scans (figure 3) show regular corneal astigmatism without any evidence of ectasia, fundus photos (figure 1) and FAF (figure 2) show small nevus left eye superior arcade and an elevated lesion (hyper fluorescent with FAF) central in the left eye. This is confirmed by the retinal OCT (figure 4)

  1. What other exams do you suggest?
  2. What is your diagnosis and what treatment is available for this patient?

 

Figure 1. Fundus photo left & right

Figure 2. FAF left & right

Figure 3. Pentacam left & right

Figure 4. Retinal OCT right eye

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