OPTHALMIC RECORD

Tutor:

Prof. DR. dr. JHA. Mandang. SpM

Examinee :
Ledya Lusi Crista Simanjuntak
07- 021

DEPARTMENT OF OPHTHALMOLOGIC
MEDICAL FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA 2011

OPHTHALMIC RECORD
Name of Examiner

Ledya Lusi Crista Simanjuntak

NIM

07-021

Date of examination

December 15th 2011

Tutor

Prof. DR. dr. JHA. Mandang. SpM

Name

Mrs. S

Age

68 years old

Sex

Female

Address

Kidul Mountain, Jogjakarta

Occupation

housewife

Religion

Moslem

Nation

Indonesian

Tribe

Java

Status

Married

I. PATIENT IDENTITY

II.

INTERVIEW
Main complaint
Pain in the left eye
Additional complain
Reddish and blurred vision on the left eye, headace, nauseous,
vomitting, see a rainbow colored halo around the light
Chronology of disease
Mrs. S age 68 years old came to dr. Yap eyes hospital with
sudden pain in the left eye since 1 day ago as a main complain. She

also feel a severe headache, nauseous, vomitting, reddish and blurred

vision on the left eye and see a rainbow colored halo around the light.
Patient said that she take panadol to reduce the pain in the eye
and the headache, but there is no change in her condition. The
headache and pain in the eye is stay still.
Previous disease
She doesnt have a history of Diebetes nor Hypertension.
Patient have a history of glaucoma in her right eye and have been
operated 10 years ago.
History of family disease
There is no history of glaucoma in her family.
III.

GENERAL STATUS
General condition

mild illness appearance

Complains related symptoms : Not Found

IV.

OPHTHALMIC STATUS
a. General Examination
OD

OS

Pre ocular appearance

Quiet

Quiet

General condition of the eye

Quiet

Mild illness

Symmetric

Symmetric

Normal

Normal

OD

OS

Eyeball position
Eyeball movement
b. Systematic Examination

Visual acuity

6/6

1/300

uncorected

Cilia

Quiet

Quiet

Margo palpebra sup/inf

Quiet

Quiet

Tarsal conjunctiva sup/inf

Quiet

Quiet

Fornics conjunctiva sup/inf

Quiet

Quiet

Bulbar conjunctiva

Quiet

injection

Cornea

Clear

Edematous

Normal in depth

shallow

Radier, Brown

Radier, Brown

Pupil

Round,
Light reflex: positive

Round
Light reflex: negative
midriasis

Lens

Clear

Clear

Palpable improvement

spasm

Correction

Anterior chamber
Iris

IOP ( palpation )

V.

RESUME
Mrs. S age 68 years old came to dr. Yap eyes hospital with sudden

pain in the left eye since 1 day ago as a main complain. She also feel a
severe headache, nauseous, vomitting, reddish and blurred vision on the left
eye and see a rainbow colored halo around the light
Patient take panadol, but there is no change in her condition. The
headache and pain in the eye is stay still.

She doesnt have a history of Diebetes nor Hypertension. Patient have

a history of glaucoma in her right eye and have been operated 10 years ago.
Her father have a diabetes, but there is no history of glaucoma in her
family.
Ophthalmic Examination of the left eye
Left Eye

General Condition

Mild illness appearances

Visual acuity

1/300

bulbar conjunctiva
Cornea

Edematous

Anterior Chamber
VI.

injection

Shallow

CLINICAL DIAGNOSE
Primary Acute Closure Angle Glaucoma OS

VII.

DIFFERENTIAL DIAGNOSE
Acute iritis

VIII.

MEDICAL TREATMENT

Education

Medicamentosa
1.

Glycerine 1ml/kg p.o

2.

Pilocarpin 2% 2 drops every 15 minutes for 2hours,

after that 1 drop/hour in 6 hours

3.

Mannitol 20% iv 1.5-2 g/kg

Surgical Treatment :
1. Laser
2. Peripheral iridectomy
3. Trabeculectomy

IX.

SUGGESTIVE EXAMINATION
Tonometry

: intra ocular pressure measure

Perimetry

: measure the visual field of the eye

Ofthalmoscopy : optic nerve examination

Gonioscopy
IX.

X.

: visualization of the anterior chamber angle

PROGNOSIS
Ad Vitam

Dubia ad Bonam

Ad Sanationum

Dubia ad malam

Ad Functionum

Dubia ad malam

COMPLICATIONS
Absolute Glaucoma OS