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Ophthalmology Record

Melisa Silvia

08-184

DEPARTMENT OF OPHTHALMOLOGIC MEDICAL FACULTY

CHRISTIAN UNIVERSITY OF INDONESIA

JAKARTA, 2012

Thursday, November 29th, 2012

Examiner : Prof. J.H.A. Mandang Sp.M (K)


2/15

Patients Identity

Name : Mrs. B

Sex : Female

Age : 36 years old Address : Pete Sidomoyon Godean,

Sleman, Yogyakarta

Religion : Moslem Education : Bachelor

Occupation : Company Employee


3/15

ANAMNESES (October 23th, 2012)

Chief Complaint :

Pain in the right eye since 2 days ago

Additional Complaint :Blurred eyes, saw the rainbow colors around

lights, red eye, glare reflection ,watery,

headache, nausea, vomiting


4/15

ANAMNESES (History of Disease)

Patient came with her son to the RSM DR.YAP Yogyakarta

with complaints of pain in the right eye since 2 days ago. Pain is

felt in the right eyes and around the right eye. Pain is felt tingling

and long-lasting. Initially 1 month ago patient often complain of

headaches, especially at the right side of the head. Initially the

pain lasted about half an hour to 2 hours and then disappear,

but over time the complaint was more often and more of the

same duration, as well as pain, is increasingly growing pains.


5/15

Patient said complaint was more severe at night.

Patient taking drugs reduce complaints Bodrex and

sleep when complaints arise. However, the complaint

was only gone a while, then came back. Patient donot go to the doctor because the patient is only

considered ordinary headache.

In addition, patients also complain of nausea and

vomiting had 2 times as much, red right eye, watery,

glare, and see the rainbow colors around lights.


6/15

Previous Disease and Family History

Previous Disease :

The patient said had never had a complaint like this

before. History of Hypertension, Diabetes Mellitus, allergies

and use of drugs that contain steroids are denied.

History of trauma (-), eye pain before (-), wears glasses (-

), operations (-)

Family History :

The patients father also had this symptoms


7/15

GENERAL STATUS

General Condition : Mild illness

Consciousness : Composmentis Complains-related symptoms : Unremarkable

OPTHALMIC STATUS

GeneralRight Eye Left Eye

Surrounding of the Eye Clear Clear

General Condition of the Eye Clear Clear

Eye Position Symmetric Symmetric

Eye Movement All directions All directions


8/15

System-

atic

Right Eye Left Eye

Visual Acuity 1/300 6/6

Pinhole Correction - -

Supercillia normal, madarosis (-) normal, madarosis (-)

Cillia normal, madarosis (-), trichiasis

(-)

normal, madarosis (-), trichiasis

(-)

Superior/Inferior Palpebra Tumor (-), ptosis (-) Tumor (-), ptosis (-)

Tarsal Conjunctiva

Superior/Inferior

Follicle (-) follicle (-),

Fornices Conjunctiva

Superior/Inferior

follicle (-) follicle (-)

Bulbar Conjunctiva

Superior/Inferior

Cilliary injection (-) Cilliary injection (-)

Cornea :

Clarity clouded Clear

Infiltrate - -

Ulcer - -

Scar - -

Neovascularization - -Anterior Chamber shallow deep

Iris radier, brown radier, brown

Pupil round, central, light reflex (+)

slow reflex, 5mm, mydriatic

round, central, light reflex (+),

3mm

Lens :

Clarity Hard to be examined Clear

Field of Vision Narrow Wide

Intra Ocular Pressure 60mmH 18mmH


9/15

RESUME

The patient, female, 36 years old, came to the doctor

with chief complaint pain in the right eye since 2 days ago.

Pain is felt tingling and long-lasting. Initially 1 month ago

patient often complain of headaches, especially right. Initially

the pain lasted about half an hour to 2 hours and thendisappear, but over time the complaint was more often and

more of the same duration, as well as pain, is increasingly

growing pains. Patient said complaint was more severe at

night. Patient taking drugs reduce complaints Bodrex andsleep when complaints arise. However, the complaint was

only gone a while, then came back.


10/15

In addition, patients also complain of nausea and

vomiting had 2 times as much, red right eye, watery,

glare, and see the rainbow colors around lights. The

patient said had never had a complaint like thisbefore. History of Hypertension, Diabetes Mellitus,

allergies and use of drugs that contain steroids are

denied. History of trauma (-), eye pain before (-),

wears glasses (-), operations (-).The patients fatheralso had this symptoms


11/15

From basicophtalmologist

examinations

were found :

Right Eye Left Eye

Visual Acuity 1/300 6/6

Pinhole Correction - -

Bulbar Conjunctiva

Superior/Inferior

Cilliary injection (-) Cilliary injection (-)

Cornea :

Clarity clouded Clear

Infiltrate - -

Ulcer - -

Scar - -

Neovascularization - -

Anterior Chamber shallow deep

Iris radier, brown radier, brown

Pupil round, central, light reflex (+)slow reflex, 5mm, mydriatic

round, central, light reflex (+),3mm

Lens :

Clarity Hard to be examined Clear

Field of Vision Narrow Wide

Intra Ocular Pressure 60mmHg 18mmHg


12/15

CLINICAL DIAGNOSE

Acute Primary Glaucoma OD

DIFFERENTIAL DIAGNOSE

Acute Keratitis

Acute Uveitis

ADDITIONAL EXAMINATION

Slit lamp examination

Funduscopy

Kempimetry

Gonioscopy


13/15

TREATMENT

MedicationPilocarpin 2-4% eye drops dripped 1 drop per minute for 5minutes, followed by 1 drop every hour up to 6 hours

Asetozolamid 2x250mg then 1 tablet every 4 hours for 24hours

Timolol 0,5% 2x1Manitol 20% 1,5-2 gr/Kg body weight; 60 drops perminute (Intravenous)

SurgicalTrabeculectomy

Iridectomy


14/15

PROGNOSIS

OS

Quo ad Vitam : bonamQuo ad functionam : dubia ad bonam

Quo ad sanationam : dubia ad bonam

ODQuo ad Vitam : bonam

Quo ad functionam : dubia

Quo ad sanationam : dubia

COMPLICATION

Absolute Glaucoma OD


15/15

Thank You

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