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Pterigium - DR - Gilbert
Pterigium - DR - Gilbert
PTERYGIUM
Examiner :
Observer :
NIM : 1261050282
I. PATIENT IDENTITY
Name : Mr. E
Age : 41 years old
Sex : Male
Religion : Islam
Address : Cililitan Besar RT. 01 RW. 014, East Jakarta
Occupation : Entrepreneur
Status : Married
II. ANAMNESIS
Anamnesis done at February 20th, 2017
Additonal complaint :
Itchy and watery eyes.
Chronology of disease :
A 41 years old male came to the Department of Eye Disease at UKI Hospital
with the main complaint about something like a fat grew on both eyes since 5 months
ago. Patient actually felt this fat even more spreading to the center of his eyes recently.
Patient also complained of redness appearance and itchy eyes sometimes. Patient
admitted, his sight is still good and there is no vision problems at all.
Previous disease :
The patient never felt the same symptoms before. Patients never wore contact
lenses or eyeglasses. Patients denied the presence of a high blood pressure, allergy and
diabetes mellitus.
Parameter OD OS
Periocular Appearance Quiet Quiet
General Condition of The eye Mild Mild
Eyeball position Simetric Simetric
Eyeball movement All direction All direction
Visual field Wide Wide
B. Sistematic Examination
Parameter OD OS
Visual Acuity 1,0 1,0
Supersilia Grow evenly Grow evenly
Silia Grow evenly, good Grow evenly, good
position position
Palpebra Normal Normal
Color matches the color of Color matches the color of
Superior/inferior
the skin the skin
edema (-) edema (-)
Cornea
Clarity Fibrovascular (+) Fibrovascular (+)
Cicatrix
Sclera White White
Cicatrix (-) Cicatrix (-)
Anterior Chamber Medium in depth Medium in depth
Hypopyon (-) Hypopyon (-)
Hyphema (-) Hyphema (-)
Iris Radier Radier
Brown Brown
Synechia (-) Synechia (-)
Pupil Round, isokor, diameter 3 Round, isokor, diameter 3
mm, Direct light mm, Direct light
refleks(+), Indirect light refleks(+), Indirect light
refleks (+) refleks (+)
V. RESUME
A 41 years old male came to the Department of Eye Disease at UKI Hospital
with the main complaint about something like a fat grew on both eyes since 5 months
ago. Patient actually felt this fat even more spreading to the center of his eyes recently.
Patient also complained of redness appearance and itchy eyes sometimes. Patient
admitted, his sight is still good and there is no vision problems at all.
GENERAL STATUS
General condition : Mild illness appearance
Conciousness : Compos mentis
Parameter OD OS
Visual Acuity 1,0 1,0 (Add +1.00)
Cornea
Clarity Fibrovascular (+) Fibrovascular (+)
Cicatrix
Bulbi conjungtiva Hyperemic (-) Hyperemic (-)
X. PROGNOSE
OD OS
Ad Vitam Bonam Bonam
XI. COMPLICATION
- Recurrent pterygium
- Diplopia