OPHTALMOLOGY RECORD

PTERIGIUM

Examiner :

Dr. dr. Gilbert. W. Simanjuntak, SpM(K)

Observer :

Vebio Romatua Pangidoan

(1765050081)

DEPARTMENT OF EYE DISEASE

PERIOD OF DECEMBER 10th 2019 - JANUARY 19th 2019
MEDICAL FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA
2019
 OPHTALMOLOGY RECORD

Examiner : Vebio Romatua Pangidoan

NIM : 1765050081

Tutor : Dr. dr. Gilbert. W. Simanjuntak, SpM(K)

I. PATIENT IDENTITY
Name : Mrs.S
Age : 46 years old
Sex : Female
Religion : Moslem
Address : Pewayangan 1 street, bantul, yogyakarta
Occupation : housemaid
Status : married

II. ANAMNESIS
Anamnesis done at January 2th, 2019

Chief complaint : The left eye feels something is blocking

Additonal complaint : Itching especially in the left eye, the eyes feel sticky, red eyes

Chronology of disease :
Patients come to Dr. Yap eye hospital, Yogyakarta with complaints that the left
eye feels fid like a membrane has grown since ± 1 year ago. The Beginning a membranes
grow a small triangular-shaped, reddish in the corner near the nose on the left eye first.
The more days pass a membrane widens to the center of the eyeball. The patient said, if
the complaint is accompanied by red eyes, itching and watery eyes arise and usually
comes when patient is working. Patient’s job as housemaids, results in frequent exposure
of patients to sunlight and dust. The patient said, the size of a membrane is expanding
but the sight of patients not reduced or interrupted while viewing the far and near vision,
 foggy denied, out dirt from the eyes, pain in the eye denied, headaches denied. The patient
is afraid if the membrane will interfere with his eyesight later on. The patient has been
treated at the puskesmas before, but the patient does not feel any improvement. Previous
disease :
The patient never felt the same symptoms before. Patient’s denied the presence
of a high blood pressure, allergy and diabetes mellitus.

History of family disease :

Patient’s family have never suffered the same symptom like her.

III. GENERAL STATUS

General condition : Mild illness appearance
Conciousness : Compos mentis

IV. STATUS OFTALMOLOGI

A. General examination
Parameter OD OS
Periocular Appearance Quiet Quiet
General Condition of The Mild Mild
eye
Eyeball position Simetric Simetric
Eyeball movement All direction All direction
Intraoccular pressure 14 mmHg 14 mmHg

B. Sistematic Examination
Parameter OD OS
Visual Acuity 6/6 6/6
Field of view Large Large
Supersilia Grow evenly Grow evenly
Silia Grow evenly, good Grow evenly, good
position position
Palpebra Normal Normal
Superior/inferior
 Color matches the color of Color matches the color of
the skin the skin
edema (-) edema (-)
tumor (-) tumor (-)
Tarsal conjungtiva Hyperemic (-) Hyperemic (-)
Superior/inferior Cicatrical (-) Cicatrical (-)

Papilar (-) Papilar (-)

Forniks conjungtiva Hyperemic (-) Hyperemic (-)

Superior/inferior
Bulbi conjungtiva Hyperemic (-) Hyperemic (+)

Injection conjungtiva (-) Injection conjungtiva (-)

Injection ciliar (-) Injection ciliar (-)

Fibrovascular in triangular Fibrovascular in triangular

shape (-) shape (+)

Cornea
 Clarity Clear, arcus senilis (-) Clear, arcus senilis (-)
 Infiltrate (-) (-)
 Ulcus (-) (-)

 Erosion (-) (-)

 Cicatrix (-) (-)

 Neovascularization (-) (-)

Normal Normal
 Sensibility
(-) (-)
 Corpus Alienum
Sclera Hyperemic (-) Hyperemic (-)
Cicatrix (-) Cicatrix (-)
Anterior Chamber Depth 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 (+)

Lens Clear Clear

V. RESUME

Patients come to Dr. Yap eye hospital, Yogyakarta with complaints that the left eye feels
fid like a membrane has grown since ± 1 year ago. The Beginning a membranes grow a small
triangular-shaped, reddish in the corner near the nose on the left eye first. The more days pass
a membrane widens to the center of the eyeball. The patient said, if the complaint is
accompanied by red eyes, itching and watery eyes arise and usually comes when patient is
working.. The patient has gone to the clinic but has not improved. The patient never felt the
same symptoms before. Patient’s denied the presence of a high blood pressure, allergy and
diabetes mellitus.

GENERAL STATUS
General condition : Mild illness appearance
Conciousness : Compos mentis
STATUS OFTALMOLOGI
Sistematic Examination
Parameter OD OS
Visual Acuity 6/6 6/6
Field of view Large Large
Supersilia Grow evenly Grow evenly
Silia Grow evenly, good Grow evenly, good
position position
Palpebra Normal Normal
Superior/inferior Color matches the color of Color matches the color of
the skin the skin
edema (-) edema (-)
tumor (-) tumor (-)
Tarsal conjungtiva Hyperemic (-) Hyperemic (-)
Superior/inferior Cicatrical (-) Cicatrical (-)

Papilar (-) Papilar (-)

Forniks conjungtiva Hyperemic (-) Hyperemic (-)

Superior/inferior
Bulbi conjungtiva Hyperemic (-) Hyperemic (+)

Injection conjungtiva (-) Injection conjungtiva (-)

Injection ciliar (-) Injection ciliar (-)

Fibrovascular in triangular Fibrovascular in triangular

shape (-) shape (+)

Cornea
 Clarity Clear, arcus senilis (-) Clear, arcus senilis (-)
 Infiltrate (-) (-)
 Ulcus (-) (-)

 Erosion (-) (-)

 Cicatrix (-) (-)

 Neovascularization (-) (-)

Normal Normal
 Sensibility
(-) (-)
 Corpus Alienum
Sclera Hyperemic (-) Hyperemic (-)
Cicatrix (-) Cicatrix (-)
Anterior Chamber Depth 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 (+)
 Lens Clear Clear

VI. CLINICAL DIAGNOSE

OS Pterigium
VII. DIFFERENTIAL DIAGNOSE

OS Pinguekula

OS Pseudopterigium

MEDICAL TREATMENT

- Education :
 Explain to the patient about the disease
 Explain to the patient about the recommendations for action to be taken.
 Explain to patients to avoid exposure to direct sunlight, wind, and dust from the
eyes.
 Explain to patients to use headgear such as a hat or eye protection such as dark
glasses to avoid exposure to UV light directly to the eyes
 Explain to patients for routine control to an ophthalmologist
Medicamentosa :
 Atrificial Tears (Topical Lubricating Drops)
 Anti Inflammatory Non-Steroid Agents Drops
 Surgery
-

VIII. RECOMMENDED EXAMINATION

 Topografi kornea
 Sonde Tes

IX. PROGNOSE

OD OS
Ad Vitam Bonam Bonam
 Ad Sanasionum Dubia ad Bonam Dubia ad Bonam

Ad Fungsionum Dubia ad Bonam Dubia ad Bonam

X. COMPLICATION
 Dry eye syndrome
 Conjungtival and corneal scar