Grand Round Case Dated:27/12/12 Patient’s Name – Reshu, 6yrs./ Male, R/o Luchnow
Chief Complaints – Diminution of vision with whitish discolouration of central clear part of BE’s noticed 2 months back
History of present illness- History is given by the patient’s father and seems to be reliable. According to him the child was apparently asymptomatic 2 mths back when he accidentally collided with a wall following which they noticed diminution of vision and whitish discoloration of central clear part of both eyes. The next day parents took the patient to a Govt. hospital in Lucknow where he was prescribed some topical medications and was advised surgery. The parents refused surgery at that time due to economic problems.
In the meantime, there has been no progression in diminution of vision or the whitish discoloration.
2 days back, the patient came to KGMU and has been admitted for further management.
No H/o pain, redness, watering
No H/o photophobia
No H/o trauma
No H/o any drug intake by the patient
No H/o fever, diarrhea, any systemic illness
No significant family history
Birth history- No H/o any drug intake by mother during antenatal period
No H/o fever or rash during antenatal period
No significant perinatal historyFull term normal vaginal delivery in hospital
Normal cry after delivery
Examination
Patient is conscious, co-operative and well oriented to time, place and person.
General Examination
Temperature : Afebrile Pulse: 88/min. Resp. rate: 16/min. BP: 1100/70 mm of Hg
Local Examination
Slit Lamp Examinaion
Retinosopy
RE- No glow LE- No glow
Fundus examination
RE- Not visible LE- Not visible
InvestigationsHb – 13 gm% , TLC- 6800/cumm, DLC- N70 L26 E01 M03 B00, Platelet count- 2.8 lakhs/cumm, RBS- 82 mg/dl
HIV-NR, HBsAg- NR, HCV-NR
B-Scan:
Cataract both eyes. Rest WNL.
