Inmate Ross Case Study Answers

Inmate Ross is new to me. He has a history of a basal cell excision in 2014 and underwent a Hughes flap reconstruction on the right side at UNC. He has had a revision of the flap since I have seen him last and presents in reassessment. He has had decreased vision in his right eye for about a year.

PHYSICAL EXAMINATION
Vision with correction is hand motion in the right, 20/70 in the left. Applanation pressures are 12 both eyes. External exam shows a small notch in his inferior temporal lid with some fullness over the lid. The cornea is clear both eyes. The anterior segment is otherwise clear and quiet. The right eye shows a 3-4+ cortical cataract. The left eye shows 1-2+ nuclear sclerosis. Posterior segment in the right eye demonstrates no view through the dense cataract. The left eye has a cup-to-disc ratio of 0.4. The macula, vessels, and periphery otherwise within normal limits. …show more content…
The mature cataract meets the BOP criteria for cataract extraction. I would recommend a cataract evaluation at North Carolina Eye, Ear, Nose and Throat in the next 4-6 weeks time. I would also recommend a B-mode ultrasound at that time to rule out any posterior segment pathology. He also has a history of a basal cell excision of his right lower lid which is doing well status post Hughes flap