Clinical Case Report: Ophthalmic Evaluation
1. Patient Information
Age/Gender: 24-year-old female
Clinical Setting: Ophthalmology outpatient evaluation
2. Chief Complaint
The patient presented with occasional twitching of both eyes, more prominent in the right eye, associated with mild watering and redness for approximately 1 week.
3. History of Present Illness
The patient had been wearing spectacles for approximately 20 years, with the previous prescription updated around 2.5 years earlier.
She reported prolonged digital screen exposure of approximately 10 hours per day.
There was no history of ocular or head trauma and no recent ophthalmic consultation.
4. Past Ocular History
History of bilateral congenital cataract.
Underwent bilateral cataract extraction with posterior chamber intraocular lens (PCIOL) implantation approximately 10 years ago.
No other significant ocular history reported.
5. Family History
Family history of glaucoma in the maternal grandmother.
Family history of congenital cataract in the mother.
6. Medication and Allergy History
No regular medications before the current visit.
No known drug allergies.
7. Ophthalmic Examination
Visual Acuity
Distance unaided: 20/30p in both eyes
Best-corrected distance visual acuity: 20/20 in both eyes
Near vision: N6 in both eyes
Intraocular Pressure
Applanation tonometry performed at 10:35 AM:
Right eye: 10 mmHg
Left eye: 12 mmHg
Ocular Alignment and Motility
Ocular alignment was normal.
Extraocular movements were full and free in both eyes.
Anterior Segment Examination
Cornea: Clear bilaterally
Conjunctiva and sclera: Quiet
Anterior chamber: Normal depth and contents
Pupils: Round and reactive
RAPD: Absent
PCIOLs: Well centered bilaterally
Fundus Examination
Optic discs: Medium-sized
Cup-to-disc ratio: 0.3 in both eyes
Retinal vessels: Normal
Macula: Normal
Retina: Attached bilaterally
Overall fundus examination: Within normal limits
8. Clinical Assessment
Bilateral pseudophakia following congenital cataract surgery with PCIOL implantation.
Mixed astigmatism in both eyes.
Ocular asthenopia/digital eye strain with ocular surface irritation, likely associated with prolonged digital screen exposure.
9. Management
Non-Pharmacological Measures
Continue regular use of prescribed corrective spectacles.
Reduce prolonged digital screen exposure.
Take regular visual breaks during screen use.
Medications
Zincovit (multivitamin and multimineral preparation with grape seed extract): 1 tablet orally once daily for 1 month.
Refresh Tears (carboxymethylcellulose 0.5%): 1 drop in both eyes four times daily as required for ocular surface lubrication.
10. Follow-Up
Follow-up was advised on an SOS/as-needed basis.
11. Summary
A 24-year-old female with a history of bilateral congenital cataract surgery and PCIOL implantation presented with a 1-week history of intermittent bilateral ocular twitching, predominantly affecting the right eye, with mild watering and redness. Examination showed good best-corrected visual acuity, normal intraocular pressure, well-centered PCIOLs, and an otherwise unremarkable anterior and posterior segment examination. The clinical assessment included bilateral pseudophakia, mixed astigmatism, and symptoms consistent with digital eye strain and ocular surface irritation.
References
American Academy of Ophthalmology. Computer Vision Syndrome (Digital Eye Strain). EyeWiki.
American Academy of Ophthalmology. Cataract in the Adult Eye Preferred Practice Pattern.
American Academy of Ophthalmology. Refractive Errors and Astigmatism.
Medical Disclaimer: The information provided in this article is strictly for educational, study, and exam-preparation purposes. It does not constitute professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider for clinical decisions.
