STATUS UJIAN

ILMU PENYAKIT MATA

Penguji :

dr. Gilbert. W. Simanjuntak, SpM

Disusun Oleh :

Imam Hertian Maryanto

(0861050077)

KEPANITERAAN ILMU PENYAKIT MATA

PERIODE 27 MEI 2013 – 22 JUNI 2013

FAKULTAS KEDOKTERAN

UNIVERSITAS KRISTEN INDONESIA

JAKARTA 2013

OPHTALMIC RECORD

Examiner : Imam Hertian Maryanto

NIM : 0861050077

Date of exam : 17 June 2013

Tutor : dr. Gilbert. W. Simanjuntak, SpM

I. PATIENT IDENTITY

Name : Mr. S

Age : 74 years

Sex : Male

Religion : Christian

Address : Mayjen Sutoyo , Jogjakarta

Occupation : Retired

II. ANAMNESIS

Main complaint : Blurred vision on left eye

Additonal complaint :

Feeling of lump in the left eye.

Chronology of disease :

A 74 years old male came to dr. YAP Eye’s hospital with the main complaint

of blurred vision on left eye since 1,5 years ago. Blurred vision progressively

deteriorated since first onset of complaints. The patient had tried to come to the

ophthalmologist and get eye drops and tablets, but the complaint still getting worse from day to

day.

Previous disease :

In March 1999 the patient suffered blindness in his right eye due to glaucoma.

In August 2010 the patient underwent keratoplasty surgery in his left eye. Post

keratoplasty patients can see well over 5 months until finally the complaints begin to

emerge slowly.

History of family disease :

In families of patient has never suffered like him.

III. GENERAL STATUS

General condition : Mild illness appearance

Symptom or illness related to the complaint : Not found

IV. STATUS OFTALMOLOGI

A. General examination

Parameter OD OS

Periocular Appearance Quiet Quiet

General Condition of The eye Quiet Quiet

Eyeball position Simetric Simetric

Eyeball movement Normal Normal

B. Sistematic Examination

Parameter OD OS

Visual Acuity 0 0,25/60

Supersilia Quiet Quiet

Silia Quiet Quiet

Palpebra

Superior/inferior

Quiet Quiet

Tarsal conjungtiva

Superior/inferior

Normal Normal

Forniks conjungtiva

Superior/inferior

Normal Normal

Bulbi conjungtiva Normal Normal

Cornea

Clarity

Infiltrate

Ulcus

Clear

No

No

Cloudy

No

No

Anterior Chamber Deep difficult to assess

Iris Radier

Chocolate

difficult to assess

Pupil Light reflex (+)

Round

difficult to assess

Lens Clear difficult to assess

V. RESUME

A 74 years old male came to dr. YAP Eye’s hospital with the main complaint

of blurred vision on left eye since 1,5 years ago. In addition, patient also complaint of a

feeling of lump in the left eye. The patient had tried to come to the ophthalmologist and

get eye drops and tablets, but the complaint still getting worse from day to day.

General condition : Mild illness appearance

From the ophtalmologic examination on both eyes founded

Parameter OD OS

Visual Acuity 0 0.25/60

Cornea

Clarity

Infiltrate

Ulcus

Clear

No

No

Cloudy

No

No

Additional Arcus senilis Arcus senilis

Leukoma

Keratoplasty suture

VI. CLINICAL DIAGNOSE

OD :

- Blindness (visual acuity 0)

OS :

- Leukoma e.c corneal allograft rejection

- Blindness (visual acuity 0,25/60)

VII. DIFFERENTIAL DIAGNOSE

- Graft failure

- Uveitis

- Reactivation of HSV

VIII. MEDICAL TREATMENT

OD : -

OS :

- Re – keratoplasty

- Topical steroid (Dexamethasone phosphate 0,1 %)

- Systemic steroid (Prednisolone 1mg/kg/day in devided doses)

IX. PROGNOSE

OD OS

Ad Vitam Malam Dubia et malam

Ad Sanasionum Malam Dubia et malam

Ad Fungsionum Malam Dubia et malam

X. COMPLICATION

- Blindness