Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with progressive central vision loss, metamorphopsia, and scotoma in the affected eye. Onset is insidious, duration [X] months. No history of ocular trauma or recent intraocular surgery. Amsler grid testing confirms central distortion.
Clinical Examination Findings
BCVA [X/X]. Slit-lamp exam: anterior segment quiet. Dilated fundus exam: presence of a full-thickness macular hole (FTMH) at the fovea. OCT macula confirms disruption of the foveal contour, cystic changes at the edges, and presence of operculum. Stage [1-4] macular hole noted.
Treatment Protocol
Plan: Pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling and gas tamponade (C3F8/SF6). Patient advised on strict face-down positioning for [X] days to ensure tamponade efficacy. Post-operative topical antibiotics and corticosteroids prescribed.