CHAPTER I

PRELIMINARY

1.1. Background
The Sensory and Integumentum System Block is the sixteenth block in
semester V of the Medical Education Competency Based Curriculum in the
Faculty of Medicine, Muhammadiyah University, Palembang. On this
occasion a scenario case study A was carried out Mr. Roby, a 24 years old
office worker, came to ophthalmologist policlinic with a chief complain of
redness on the left eye since one week ago. The patient also complain of pain,
swollen eye lids, and fidding sensation on the left eyes since 4 days ago.
Approximately three days ago, Mr. Roby also complains of itchiness of the
eyes, sticky greenish yellow eye wax, difficulty of opening the eyelids in the
morning, blurry vision, and dazzled everytime seeing some direct light. Two
days ago, his right eyes also starting to ache, become red and producing sticky
mucus.
Mr. Roby bought some eye drops on the street vendor and use it, but theres
no improvement. History of making contact with a person with an eyes
disease (+), approximately one weeks ago.

1.2. Purpose and Objectives

The intent and purpose of this case study tutorial report, namely:
1. As a tutorial group assignment report which is part of the KBK learning
system at the Faculty of Medicine in Muhammadiyah University
Palembang.
2. Can resolve the case given in the scenario with the group discussion
learning analysis method.
3. The achievement of the objectives of the tutorial learning method.

1
 CHAPTER II
DISCUSSION
2.1.Tutorial Data
Tutor : dr. R.A Tanzila, M.Kes
Moderator : Savira Chairunnisa
Desk secretary : Ulfah Haniyah
Board secretary : Arika Shafa Nabila
Time : Monday, November 25th 2019
08.00-10.00
Wednesday, November 27th 2019
08.00-10.00

2.2. Rules
1. Switch the phone off in silent
2. Raise handi when asking question and arguments
3. Ask for permission in advance when going out of the room
4. Each tutor member is expected to wear marker

2.3. Scenario
Scenario A
“Red eyes of madness”
Mr. Roby, a 24 years old office worker, came to ophthalmologist policlinic
with a chief complain of redness on the left eye since one week ago. The
patient also complain of pain, swollen eye lids, and fidding sensation on the
left eyes since 4 days ago. Approximately three days ago, Mr. Roby also
complains of itchiness of the eyes, sticky greenish yellow eye wax, difficulty of
opening the eyelids in the morning, blurry vision, and dazzled everytime seeing
some direct light. Two days ago, his right eyes also starting to ache, become
red and producing sticky mucus.

2
 Mr. Roby bought some eye drops on the street vendor and use it, but theres
no improvement. History of making contact with a person with an eyes disease
(+), approximately one weeks ago.
Physical examination:
General Condition: aware and cooperative
Vital sign: BP: 120/80 mmHg, Pulse:92x/m RR: 18x/m, Temp: 36,7oC
Eyes:
OD : VOD 6/6, Conjungtive Injection (+), Greenish yelow secret.
OS : VOS 6/15 mixed injection (+), Greenish yellow secret, blepharospasm
(+), infiltrat on the cornea (+)

2.4. Clarification of Term

1. Blepharospasm : an abnormal involuntary blinking or spasme of the
eyelids
2. Swollen : abnormal fluid collection in the intercellular space
of the body
3. Redness eye : the dilation of blood vessels in the conjunctiva due
to inflammation in the eye.
4. Pain : feeling uncomfortable, suffering / pain caused by
stimulation at certain nerve endings
5. Mucus : free mucus in the mucous membrane consists of
glands, various salts, cells that are desquamated
6. Conjungtive Injection (hiperemia) : an specific response with enlargment
of conjungtive vessels induce by various disease
7. VOD : right eye visual acuity
8. VOS : left eye visual acuity
9. Infiltrat on the cornea :sign of acute infection on the cornea
10. Itchiness : a sensation that causes a scratching desire or reflex

2.5. Identification of Problem

3
 1. Mr. Roby, a 24 years old office worker, came to ophthalmologist policlinic
with a chief complain of redness on the left eye since one week ago. The
patient also complain of pain, swollen eye lids, and fidding sensation on
the left eyes since 4 days ago.
2. Approximately three days ago, Mr. Roby also complains of itchiness of the
eyes, sticky greenish yellow eye wax, difficulty of opening the eyelids in
the morning, blurry vision, and dazzled everytime seeing some direct light.
3. Two days ago, his right eyes also starting to ache, become red and
producing sticky mucus.
4. Mr. Roby bought some eye drops on the street vendor and use it, but theres
no improvement. History of making contact with a person with an eyes
disease (+), approximately one weeks ago.
5. Physical examination:
General Condition: aware and cooperative
Vital sign: BP: 120/80 mmHg, Pulse:92x/m RR: 18x/m, Temp: 36,7oC
Eyes:
OD : VOD 6/6, Conjungtive Injection (+), Greenish yelow secret.
OS : VOS 6/15 mixed injection (+), Greenish yellow secret,
blepharospasm (+), infiltrat on the cornea (+)

2.6.Analysis of Problem
1. Mr. Roby, a 24 years old office worker, came to ophthalmologist
policlinic with a chief complain of redness on the left eye since one
week ago. The patient also complain of pain, swollen eye lids, and
fidding sensation on the left eyes since 4 days ago
a. What is anatomy, physiology and histology in this case?
Answer:
Anatomy

4
- Cornea
The anterior surface of the cornea is somewhat elliptical
with an average horizontal diameter of 11.5-11.7 mm and 10.5 -
10.6 mm in vertical diameter while the posterior surface is circular
in shape with a diameter of 11.7 mm. In adults the thickness of the
cornea varies with an average of 0.65 - 1 mm in the peripheral part
and 0.55 mm in the middle part. This is due to differences in
curvature between the anterior and posterior corneal surfaces. The
anterior corneal curvature radius is approximately 7.8 mm while
the radius of the posterior surface curvature averages 6.5 - 6.8 mm.
The cornea becomes flatter on the peripheral part, but the leveling
is not symmetrical. The nasal and superior parts are flatter than the
temporal and inferior parts. The outer surface area of the cornea is
approximately 1.3 cm 2 or 1/14 of the total eyeball area (Snell,
2012).

- Conjunctiva

5
 The conjunctiva is a thin mucosa membrane lining the
palpebra. The following parts are conjunctival:
1. Tunica conjunctival bulbi is tunica mucosa which is loosely
attached to the sclera. Inside the bulbar conjunctiva are goblet
cells that secrete mucin, an important component of the pre-
corneal tear layer that protects and nourishes the cornea.
2. Tunica conjunctival palpebrum is a part that is covered by blood
vessels and is part of the inner surface of the palpebra.
3. The conjunctivae plica semilunaris is the meeting place of the
superior and inferior palpebrae on the medial side, the remaining
membrane nictitans located on the medial oculi angulus. Plica
semilunaris limits the lacas lacrimalis, which has a bulge in the
middle of the caruncula lacrimalis which serves to push the
lacrimal secretions to the edge of the lacus so that it can be
channeled by the lacrimales canaliculi.
4. Fornix conjunctivae superior and inferior are fold lines between
the tunica conjunctival bulbi and tunica conjunctival palpebrum.
The conjunctiva limits a sac, the conjunctival saccus which has a
gap, the pelpebrarum rhyme, the space between the superior and
inferior palpebra. This saccus is where contact lenses are inserted
and eye drops are inserted. In addition, it is into the saccus's
superior fornix that the lacrimalis secretions flow through the
ductus excretorii.
The conjunctival arteries originate from the anterior ciliary artery
and the palpebral artery. Both of these arteries are anastomosed
freely and together with many conjunctival veins which generally
follow the arterial pattern forming a myriad of conjunctival
vascular webs. The conjunctival lymph vessels are arranged in the
superficial layer and the profundus layer and connect with the
lymph vessels of the eyelids to form a rich lymphatic plexus. The
conjunctiva receives innervation from the first (ophthalmic)

6
 branching of the V nerve (trigeminal nerve, ophthalmic division -
sensory) (Snell, 2012).

Physiology
Visionary Physiology
Objects cahaya reflect light (electromganetic waves) → enter the
cornea → be forwarded to the pupil eng regulate the amount of light
entered by the pupil through the M. spincter pupile (which constricts
the pupil in a state of bright light) and M. Pupile dilator (which dilates
the pupile in a dark state) ) → light is focused on the lens →
trabeculum closes → inhibits the outflow of aquoeus → convergence
of light → shadow of objects falling right in the macula lutea
(reversed shadow) → Impulses are captured by photoreceptor cells,
stem cells (black and white) and cone cells (color) → synapse with
horizontal cells → bipolar cells → synapse with amacrine cells →
ganglion cells → propagation of impulses to the optic nerve →
chiasma opticus opt opticus tracts → fibers in the opticus synapse in

7
synaptic geniculatum laterale dorsalis → chiasma opticus → tractic
opticus → fibers in retracted opticus synapse in the geniculatum
laterale dorsalis nerve ias chiasma opticus → tractic opticus → fibers
in the opticus syntax synapse in the genus geniculatum laterale
dorsalis → chiasma opticus → tractic opticus → fibers in the opticus
syntax synapse in the genus geniculatum laterale dorsalis → chiasma
opticus → optic tract occipitalis → perception of seeing (Sherwood,
2012)

Histology
Histologically, the eyeball wall is composed by 3 layers:
- A fibrous tunic consisting of sclera and cornea.
- The vascularic tunics consisting of khoroids, the body of the
Siliaris, and the iris.
- Neurinal tunics consisting of retinal

Fibrous tunics
This coating forms a capsule that serves to support the eyeball,
composed of sclera and cornea. Sklera is located on the back of the
eyeball, is a white part while the cornea is located on the front of the
eyeball, a clear part that covers the iris. The meeting between sclera
and cornea is called Limbus.

Sclera
Sclera is a connective tissue compiled by type 1 collagen fibers and
elastin. The structure forms a sturdy wall of eyeball walls, backed by
intraocular pressure that comes from akuaeous humor and vitreus
humor. The back of the sclera penetrated by the optic nerve fibers is
called the lamina kribrosa. In sclera can be found blood vessels,
especially in the limbus.

8
Cornea
The cornea is a transparent part of the fibrous tunic, it contains no
blood vessels and is rich in nerve fiber ends. Cornea is avascular so
that nutrients are derived from the diffusion of peripheral veins in the
limbus, and through akweus humor. The cornea consists of 5 layers:

1. Corneal epithelium
- Compiled by layered geometric epithelium without horns lining.
- Is the outer cornea layer.
- Consists of 7 layers of cells.
- Contains many ends of free nerve fibers.
2. Bowman membrane
- Located under the epithelium.
- Compiled Type-1 collagen fibers.
3. Stroma Cornea
- The thickened cornea layer.

9
 - Composed of type-1 collagen fibers, the parallel running of the
collagen form lamellae.
- There are fibroblast cells among collagen fibers.
4. Membrane Descemet
- Basic membrane composed of collagen fibers
5. Endothelial cornea
- Compiled by a sprawl or cuboid epithelium.
- Synthesizes proteins for membrane descemet
- Has a sodium pump that plays an important role in keeping the
pressure in the corneal stroma.

Excess fluid in the stroma can be absorbed by the endothelial by

removing the sodium ions into the anterior oculi camera so that the
water will come out with the sodium ions. The corneal stroma should
be maintained in a slightly dehydrated state to preserve the corneal
refraction quality. The cornea becomes blurred when the corneal
endothelial fails to remove excess fluid in the stroma.

Limbus
- Is a meeting place between the cornea with sclera.
- Stromanya is the edge of sclera that blends with the cornea.
Composed of fibrous connective tissues.
- There is a SCHLEMM canal which is a ring-shaped vessel that
surrounds the eye and stems from the sclera vein plexus.
- In the corpus of ciliary there are muskulis ciliary, smooth
muscles to regulate the accommodation of the eyes.

Vaskulosa Tunika
Choroid
Khoroid is a layer that contains a lot of blood vessels and
pigmented cells that appear black. This coating is composed of rare

10
tissue connectors containing collagen and elastin fibers, fibroblast
cells, blood vessels and melanocytes. Khoroid has 4 layers:
1. Epikhoroid
The outer khoroid layer is composed of collagen fibers and elastin.
2. Lining vessels
The most thick coating and composed of blood vessels and
melanocytes
3. Lining of Koriokapiler
Composed of capillary plexus, collagen and elastin connective
tissue, fibroblasts and melanocytes
Function: supplying nutrients to the outside of the retina
4. Lamina elastic layer of khoroid which borders on retinal pigment
epithelium

Korpus ciliary
- An extension of the khoroid towards the front.
- Compiled by connective tissues that suppost elastin, blood
vessels, and melanocytes.
- The body of the ciliary forms the short bulges of the ciliary
prosessus.
- From the fact that a fibrillin thread appears that will be
insertions on the lens of the chapel, referred to as Zonula zinii.
- Zonula zinii serves as a lens suspension
- Coated by 2 layers of cuboid epithelium.
- Cell Corpus ciliary is a producer of aqueous humor.
- This fluid will flow from the Oculi camera posteriorly to the
anterior oculi camera passing through the pupil gap, then
enters the Schlemm canal on the Limbus and rises in the vein
system.
- Korpus ciliary contain 3 files of smooth muscles known as the
mukulus of ciliary.

11
 - One muscular file of the channel opens the Schlemm Canal for
the flow of akweus humor.
- 2 other files for eye accommodation.
Iris
- Iris is the frontmost part of the Vasculose tunic
- This structure is a continuation of the Siliar body and forms an
diaphragm in front of the lens.
- Iris is the anterior and posterior oculi camera separator, with
pupils in the middle.
- Iris is compiled by loose pigmented connective tissues and has
a lot of blood vessels.
- The surface of the iris facing an anterior occuli camera is
irregular with an incomplete layer of pigment.
- The posterior surface of the iris is smoother and has a lot of
pigment cells that will prevent light from passing through the
iris.
- This makes the light focus in through the pupil.
- The number of melanocytes cells found in the iris affects the
color of the eye.
- When the number of melanocytes is numerous, the eye will
appear black, conversely if slightly, the eyes will appear blue.
There are 2 types of smooth muscles, the pupil dilator muscles and the
constrictor muscle pupil.

Eye Lenses
It consists of 3 layers of lens capsules, subcapsule epithelium and
lens fibers. The capsule of the lens is a ganglia lamina consisting of
type IV collagen fibers and glycoproteins. Capsule lenses are elastic,
clear, and dense. The subcapsule epithelium is only found on the
anterior surface of the lens consisting of the cuboid epithelium. The
lens fibers are cells that lose core and other organels, then are filled by

12
a lens protein called crystallin. Cystalli will increase the lens
refrpention index.
The lens does not contain blood vessels, its nutrients are obtained
through the aqueous humor and corpus vitreus. The lens is
impermeable, but transparent.
Korpus Vitreus
It is so clear that fill the urang between the lens and retina. The
corpus vitreous is constructed 99% by water and electrolyte, as well as
collagen fibers and hyaluronic acid. In the corpus vitreous there is the
remnant of a conduit known as the Hyaloidea Canal, which originally
contained a hyalodea artery in the fetus.

Neuralis Tunics
- The Retina is the deepest layer of the eyeball, containing the
photoreceptor cells of the stem and cone.
- In the retina there is an optical plate that is the place for
Optikus the nerve.
- The nerve fibers in this area overlap form a bulge called an
opticus papilla or blind spots.
- This area does not contain photoreceptor cells so it is not
sensitive to light.
- On the optic nerve papilla there are arterial and centalist veins.
- This artery is the only artery supplying blood to the retina.
- In the lateral blind spots there is a yellow pigmented area
known as yellow spots or macular lutea.
- The middle part of the macular lutea is known as Fovea
centralist and is the most sensitive vision.
- The Vision cell on the fovea floor consists of a conical cell that
is tightly arranged and is longer than the cells in the peripheral
part of the retina.

13
 - In this fovea area also the cell layer in the retina is more
shallow, so that the light can reach the cone and stem cells
more easily.

Retina consists of 10 layers from the outside into:

1. Pigmented epithelium-> layers of polygonal cells that are rich in
grains of melanin, function to absorb light and prevent reflection,
nourish the photoreceptor cells, release cells and the impenter of
vitamin A, and where the formation of rhodopsin.
2. The stem and cone--> coating consists of the photoreceptor cells
which are the modification of the nerve cells. Stem cells contain
rhodopsin pigments that are highly sensitive to light so they can be
activated in dim light, but if they are bright, they cannot produce a
signal. Cone cells have photopsins pigment that is sensitive to red,
blue, and green color. This cell will be activated with bright light.
3. The outer membrane of the lime--> A complex set of links between
stem cells and cone cells.
4. Outer core layer--> coating consisting of stem cell core and cone
5. Outside Plesiform layers--> consist of stem and cone cell axons
and bipolar cell dendrons
6. The inner layer of the--> is formed by the nucleus and body of the
bipolar cell, horizontal cells, amakrin cells, and Muller cells (retina
Gliocytes)
7. The pleksiform layer in--> is formed due to the synapse between
the cells in the core layer in
8. Ganglion--> Lining cells consist of ganglion cells that resemble
brain neurons with long axons to opticus the nerve
9. Neural fibre coating--> Formed by ganglion cell axons
10. Membrane limiting in--> cell ganglia Muller membranes
separating the retina from vasculose corpus

14
 Auxiliary organs
Conjunctival
The conjunctiva is a clear mucous membrane lining the surface of
the eyelid and meutupi the sclera surface on the front of the eyeball.
The conjunctiva is composed of a cylindrical-patterning epithelium
with a goblet cell. A goblet cell Sekret participates in a tear curtain
that serves as a lubricant and a protective front epithelium of the eye.

Lacrimal gland
The lacrimal gland is a serous tubuloasinar gland with
Mioepithelium. The tear gland's lobe will pour its contents through
10-15 channels towards the lateral part of the superior conjunctival
fornix. The tears move towards the medial eye and the excess will
enter a lacrimal puncta, then a lacrimal canaliculus toward the
lacrimal sacus. From the lacrimal sacus, the tear will enter into the
nasolakrimal duct then excreted into the inferior meatus at the base of
the nasal cavity.

Eyelids
The eyelids consist of connective tissues and skeletal muscles in
the centre covered with skin and mucous membranes.
The skin is located on the front, which is a thin skin with various
adnexa and its own.
Under the skin is the skeletal muscle layer of orbicularis oculi. Then
in the middle of the eyelid there is a connective tissue called Tarsus.
In the tarsus there is a sebaceous gland called the Meibom gland.
(Eroschenko. V.P, 2018)

b. How is the relation between age, gender with the complaint?

Answer:

15
 Conjunctivitis can affect all ages. Conjunctivitis can affect the age
of the baby and adult. Conjunctivitis can occur in all races and
genders. Work as an office worker is a risk factor for conjunctivitis
(Ilyas, 2014)
Conjunctivitis is an inflammatory process due to infection or non-
infection characterized by vascular dilatation, cellular infiltration, and
exudation. There are certain forms of Kongjungtivitia that occur at
certain ages. In children vernal keratokongjungtivitis often occurs,
while atopic keratokongjungtivitis and allergies in young adults. Sicca
congestion is more common in women, whereas vernal conjunctivitis
and chemical-mechanical conjunctivitis are more common in men
(Ramadhanisa A, 2014)

c. What is the meaning of redness on the left eye since one weeks ago?
Answer:
The meaning of redness on the left eye since one week ago is there has
been an invasion of microorganisms that cause an inflammatory
reaction in the eye so that the eyes become red
(Ilyas, 2014)

d. What is the etiology of redness eye?

Answer:
Red eyes with normal vision :Conjunctivitis, Blepharitis, Hordeoulum,
Dacryocystitis, Trichiasis
Red eyes with decreased vision: Acute glaucoma, Keratitis
In cases of keratokunjungtivitis occuli sinistra and dextra
conjunctivitis
Etiology of keratoconjunctivitis:
Bacteria: (Hyper-fear), N. Gonorhea, N.meningtidis, (I) Pneumonia
focus, (Subacute) H. Influenza, (Chronicles) Streptocous aureus
Chlamide-virus-chemical-systemic-immunologic disease

16
 (Biswell R., Vaughan D.G., Asbury T., 2009)

The most common cause of red eye is due to dilation of blood vessels
on the surface of the eye. This is caused by :
• Hot / dry air
• Exposure to sunlight
• Dust
• Allergic reactions
• Influeza
• Bacterial or Virus Infection
• Cough
(Sudira P.U, Wardani P, 2017)

e. How is the pathophysiology of redness eye in this case?

Answer:
Risk factor: contact with a person with an eyes disease →
transmission of infectious agents → invasion of infectious agents in
the conjunctiva → penetrate tears film → conjunctival stromal injury
→ inflammatory response → vasodilation of the posterior
conjunctival arteries → increased blood flow to the posterior
conjunctival arteries → red eye
(Ilyas, 2014)

f. What is the possible disease of red eye?

Answer:
Red Eye with Normal Visus Red Eye with low visus

Konjungtivitis Keratitis

Vitamin A defficiency Ulcus Cornea

Keratokonjungtivitis Uveitis

Episkleritis Endoftalmitis

17
 Pterigium Acute Glaukoma

Pseudopterigium Panoftalmitis

Vogt Koyanagi Harada Syndrome

(Ilyas, 2014)

g. What is the meaning the patient also complaint of pain, swollen eye
lids and fidding sensation on the left eyes since 4 days ago?
Answer:
The occurrence of acute inflammation and clinical manifestations
of conjunctivitis, namely the sensation of a foreign body, that is, a
scratched or burning sensation, a full sensation around the eyes,
itching, and photophobia.
(Biswell R., Vaughan D.G., Asbury T., 2009)

h. What is the pathophysiology of pain, swollen eye lids and fidding

sensation on the left eyes?
Answer:
Risk factor : contact with a person with an eyes disease →
transmittion of infection→invasion of microorganisms in
conjunctiva→ Microorganisms penetrate tear film on the surface of
the conjunctiva serves to dissolve dirt and impurities toxic ingredients
→ inflamation of conjunctiva (Conjunctivitis)

mechanism of protecting the

irritate the nerves of the conjunctiva
surface of the eye from
that have painful nerve fibers
external substances, such as
↓
tears (containing anti-
Stimulate inflamattory mediators
microbial form of lysozyme).
↓
↓

18
 Pain ↓
In the tear film, the aqueous
element dilutes the bacterial
infection, the mucus catches
the debris and the pumping
mechanism of the palpebra
will constantly drain tears to
the tear duct.
↓
Accumulation inflamation cells,
lisozim (antimicrobial), mucus and
debris in conjungtiva
↓
Conjunctiva stroma edema (chemosis) ← injury to the conjunctival epithelium
↓ ↓
Swollen eyes papilla hypertrophy
↓
Fidding sensation
Synthesis :
Microorganisms (viruses, bacteria, fungi), allergens, irritants cause
the eyelids to become infected so that the eyelids cannot close and
open completely. Because the eyes become dry so irritation causes
conjunctivitis. Dilation of blood vessels caused by inflammation is
characterized by red conjunctiva and sclera, edema, pain and the
presence of mucopurulent secretions (Silverman, 2010).
The conjunctiva is always in contact with the outside world, but
under normal circumstances it is almost always sterile, this is trivial
because of the presence of the conjunctival defense mechanism
mainly by the presence of tear film on the conjunctival surface which
functions to dissolve dirt and toxic substances and then lacrimalis into
the inferior rice meatus. (Corwin,2009). The conjunctiva receives

19
 innervation from the first (ophthalmic) branching of the fifth nerve.
This nerve has relatively little pain fibers (Vaughan, 2011).
Conjunctiva, because its position is exposed to many organisms
and other environmental factors that interfere. There are several
mechanisms to protect the surface of the eye from external substances,
such as tears. In the tear film, the aqueous element dilutes the bacterial
infection, the mucus catches the debris and the pumping mechanism
of the palpebra will constantly drain tears to the tear duct. Tears
contain anti-microbial substances including lysozyme. The presence
of a destructive agent, causing injury to the conjunctival epithelium
followed by epithelial edema, cell death and exfoliation, epithelial
hypertrophy or granuloma. There may also be edema of the
conjunctival stroma (chemosis) and lymphoid stromal layer
hypertrophy or follicle formation. Inflammatory cells migrate through
the epithelium to the surface. These cells then merge with fibrin and
pus from goblet cells, forming conjunctival exudates that cause
palpebral edge adhesions upon awakening (Bielory, 2010&Majmudar,
2010).
The presence of inflammation in the conjunctiva causes dilation of
the posterior conjunctival eye vessels, causing hyperemia which is
most evident in the formiks and decreasing towards the limbus. In
conjunctival hyperemia is usually found swelling and hypertrophy of
the papillae which is often accompanied by a sensation of foreign
bodies and the sensation of scratches, heat or itching. This sensation
stimulates tear secretion. Mild transudation also arises from
hyperemic blood vessels and increases the amount of tears (Moore,
2009)

i. How is the relation between the complaint 4 days ago with complaints
one week ago?
Answer:

20
 The relationship is the main complaint is reddish eyes and complaints
4 days ago in the form of pain, swollen eye lids and fidding sensation
on the left eyes are the progression of inflammation / conjunctiva and
clinical manifestations of conjunctivits. Blood vessel dilation caused
by inflammation is characterized by red conjunctiva and sclera,
edema, pain and fidding sensation.(Azariet al,2013).

2. Approximately three days ago, Mr. Roby also complaints of itchiness

of the eyes, sticky greenish yellow eye wax, difficulty of opening the
eyelids in the morning, blurry vision, and dazzled everytime seeing
some direct light.
a. What is the meaning Mr. Roby also complaint of itchiness of the eyes,
sticky greenish yellow eye wax, difficulty of opening the eyelids in
the morning, blurry vision and dazzled everytime seeing some direct
light?
Answer:
The meaning of itchiness of the eyes, sticky greenish yellow eye wax,
difficulty of opening the eyelids in the morning is clinical
manifestation of conjunctivitis and blurry vision and dazzled
everytime seeing some direct light is clinical manifestation of keratitis

b. What is the etiology of itchiness of the eyes, sticky greenish yellow

eye wax, difficulty of opening the eyelids in the morning, blurry
vision and dazzled everytime seeing some direct light?
Answer:
- allergic conjunctivitis
- dry eyes
- inflammation of the eyelids
- contact lens use
- there are foreign objects
- disorders of the retina

21
 - cataracts
- post operation
(Majmudar, 2010).

c. What is the pathophysiology of itchiness of the eyes, sticky greenish

yellow eye wax, difficulty of opening the eyelids in the morning,
blurry vision and dazzled everytime seeing some direct light?
Answer:
Risk factors (contact with a person with an eyes disease) → infectious
transmission agent from the patient to another person → invasive
infectious agent in the conjunctiva → germ penetrates the tear film →
bacteria infects the conjunctival solution through the surface
epithelium → joins fibrin, neutrophils, and mucus from goblet →
make exudate → There is a thick, sticky greenish yellow eye wax →
itchiness of the eyes and difficulty of opening the eyelids in the
morning.

Risk factors contact with a person with an eyes disease →

transmission of infectious agents from patients to others through direct
contact (using hands, exposed objects) → invasion of infectious
agents in the conjunctiva → arise inflammatory response →
Conjunctivitis → inadequate treatment → infection spreads to the
cornea by diffusion because the conjunctival epithelium and cornea
are the same → inflammatory respon occurs → polymorphonuclear
secretion to disinfect germs → infiltrates formed → turbid cornea →
because the cornea functions to refract light rays → blurred eyes and
dazzled everytime seeing some direct light.
(Ilyas, 2014)

d. What is the possible disease with complaint itchiness of the eyes,

sticky greenish yellow eye wax, difficulty of opening the eyelids in

22
 the morning, blurry vision and dazzled everytime seeing some direct
light?
Answer:
The possible disease of the complaint is
- Itchiness of the eyes
Itchiness of the eyes are a complaint that is often found in eye
disorders. This complaint is found in blepharitis, conjunctivitis,
keratitis, scleritis, eye trauma, foreign body in the eye, trichasis,
allergy.
- Sticky greenish yellow eye wax
Secretions can only be removed by the epithelium which has
mucous cells or in conjunctival goblet cells. if there are excessive
secretions of complaints by this patient shows abnormalities in the
conjunctiva. This disorder is usually in the form of inflammation
of the conjunctiva or conjunctivitis
- Difficulty of opening the eyelids in the morning
Difficulty opening eyes in the morning is the result of a buildup of
secretions on the palpebra due to conjunctivitis
- Blurry vision aand dazzled everytime seeing some direct light
This is the eye's sensitivity to light, easy glare, accompanied by
pain. this complaint is found in inflammation of the eye external
(conjunctivitis and keratitis) inflammation of the eye in or uvetitis.
(Ilyas, 2014)

3. Two days ago, his right eyes also starting to ache, become red and
producing sticky mucus.
a. What is the relation of complaint two days ago with chief complaint?
Answer:
The relation between chief complaint and the complaint two days ago
is that there was transmission through direct contact

23
 b. What is the meaning his right eyes also starting to ache, become red
and producing sticky mucus?
Answer:
The meaning of his right eyes also starting to ache become red and
producing sticky mucus is clinical manifestation of conjunctivitis.
(Biswell R., Vaughan D.G., Asbury T., 2009)

4. Mr. Roby bought some eye drops on the street vendor and use it, but
theres no improvement. History of making contact with a person with
an eyes disease (+), approximately one weeks ago.
a. What is the meaning Mr. Roby bought some eye drops in the street
vendor and use it, but theres no improvement?
Answer:
The meaning of Mr Roby using eyedrops but no improvements shows
that the eyedrops is only to treat the symptoms. However,the infecting
agent (bacteria) is still present and will still cause infection.

b. What is the composition of the eye drops?

Answer:
Tetrahydrozoline HCl 0,05% b/v
Benzalkonium chloride 0,01 % b/v

c. What is the meaning history of making contact with a person with an

eyes disease (+), approximately one weeks ago?
Answer:
The meaning is a risk factor for transmission of keratoconjuntivitis
infection, which is an infection that causes inflammation of the cornea
(keratitis) and conjunctiva (conjunctivits). Conjunctiva caused by
microorganisms (especially virus and germs or a mixture of both) are
usually transmitted through contact and air (Vaughan, 2010).

24
 Bacterial conjunctivitis is easily transmitted from one eye to the
next and also easily transmitted to other people through direct contact
and objects that come in contact with the eye (Ilyas, S, 2014).

d. How is the transmition of the disease?

Answer:
Conjunctivitis based on causes can be divided into infectious and
non-infectious. Viruses and bacteria are the most common causes of
infectious infections. The most common pathogens that cause
bacterial conjunctivitis in adults are staphylococcal sp., Followed by
Streptococcus pneumonia and Haemophilus influenzae. Non-
communicable conjunctivitis includes allergies, poisons, and
conjunctivitis, and inflammation secondary to immune-mediated
diseases and neoplastic processes (Ramadhanisa A, 2014).

5. Physical examination:
General Condition: aware and cooperative
Vital sign: BP: 120/80 mmHg, Pulse:92x/m RR: 18x/m, Temp: 36,7oC
Eyes:
OD : VOD 6/6, Conjungtive Injection (+), Greenish yelow secret.
OS : VOS 6/15 mixed injection (+), Greenish yellow secret,
blepharospasm (+), infiltrat on the cornea (+)
a. What is the interpretation of the physical examination?
Answer:
General condition Reference value Mnformation
Aware and cooperative Compos mentis Normal
Vital Sign :
BP : 120/80 mmHg BP : 120/80 mmHg Normal
Pulse : 93 x/m Pulse : 60 - 100 x/m Normal
RR : 18 x/m RR : 16 - 24 x/m Normal
Temp : 36,7oC Temp : 36,7oC - 37,7oC Normal
Head: Normal
Enlargement of pre
auriculer lymph nodes(-)

25
Eyes: VOD : 6/6 Normal
Ophtalmic dekstra
VOD : 6/6
Conjuctive injection (+) Conjuctive injection (-) Abnormal (Konjuctivitis)
Greenish yelow secret No Greenish yelow secret Eksudate
Ophtalmic Sinistra VOS : 6/6 Decreased Visus
VOS : 6/15
Mixed injection (+) No Injection Konjuctivitis
Grennish yellow secret No Greenish yelow secret Eksudate
Blepharospasm (+) Blepharospasm (-) Konjuctivitis -> Over
contraction
Infiltrat on the cornea (+) Infiltrat on the cornea (-) Keratitis

b. What is the abnormal mechanism of the physical examination?

Answer:
Conjunctival injection
The existence of dilation of blood vessels in the conjunctiva

Mixed injection
bacterial infection → invade the conjunctiva → immune system
response → release of PMN cells → vasodilation of the posterior
conjunctival arteries → not treated properly → diffuse into the corneal
layer→ inflammatory reactions occur and PMN cells release→ ciliary
artery vasodilation → mixed injection

Greenish yellow secret

Microorganisms penetrate tear film → infect conjunctiva→
conjunctivitis → dilate blood vessels to increase expenditure of
inflammatory cells (neutrophils, eosinophils, basophils, lymphocytes,
plasma cells) which are often destructive agents → inflammatory cells
migrate from the conjunctival stroma through the epithelium to the
surface and join with fibrin and mucus from goblet cells forming a
greenish yellow secret

26
 Blepharospasm
Palpebral stiffness due to excessive activity of m. Orbicularis Oculi.

Infiltrate on the cornea

Infection of microorganisms in conjunctiva → conjunctivitis →
inadequate treatment-spreads to cornea- dislocation of inflammatory
cells in the cornea (PMN) → bacterial phagocytes → bacterial
degradation → removal of exudate (bacteria resulting from
phagocytes) from corneal accumulation in basal cells white spots on
cornea → infiltrates

c. How to do visus examination?

Answer:
Visual examination using a snellen card
- the patient sits facing a snelllen card with a distance of 6 meters
- installed lens grip try eyes that are not checked sharply closed
-the patient being examined reads the letters written on the snellen
card starting with the top line (the largest letter) and when it has been
read the patient is asked to read the bottom line
-define the limit of the location of the last line that can still be read
note check the sharp vision without glasses and with the glasses
noted if you get an error reading 2 letters on the sign 6 is called sharp
vision 6 / 6-2 the examination
room must have enough light
(Ilyas, 2014)

6. How to diagnose?
Answer:
Anamnesis
 redness eye
 pain

27
  swollen eye lids
 fidding sensation
 itchiness
 sticky greenis yellow eye wax
 difficulty opening the eyelids in the morning
physical examination
 OD: VOD 6/6, Conjungtive injection
 OS: VOS 6/15, mixed injectiong (+), greenish yellow secret,
blepharospasm (+), infiltrate on the cornea(+)

Sign Conjunctivitis Keratitis

Visus Normal Decrease
Dazzled - +

Pain Fidding sensation Pain

Redness eye Injection conjungtiva Injection ciliar
Secret Serous, mucos, purulent -
Sticky palpebra Mostly in the morning -
Pupil Normal Small pupil

7. What is differential diagnose in this case?

Answer:
- keratoconjunctivitis oculi sinistra and conjunctivitis dextra et
causea bacteria
- keratoconjunctivitis et causa viral

8. What is the additional examination in this case?

Answer:
- Bacterial culture
- Microscopic examination of conjunctival scraping revealed with
gram or giemsa
- Antibiotic sensitivity test

28
 (Biswell R., Vaughan D.G., Asbury T., 2009)

9. What is the working diagnose in this case?

Answer:
Keratoconjunctivitis Oculi Sinistra and Conjungtivitis Dextra et causa
Bacteria

a. What is the definition of keratoconjunctivitis?

Answer: keratoconjunctivitis is inflammation of the cornea and
conjunctiva which can be caused by various factors (Biswell R.,
Vaughan D.G., Asbury T., 2009).

b. What is the risk factor of keratoconjunctivitis?

Answer:
Risk Factors Keratitis
Factors that can increase the risk of keratitis are as follows:
1) The use of contact lenses
2) Vitamin A deficiency
3) Tear deficiency
4) Ocular surface disease
5) Corneal erosion / abrasion
6) Immunocompromise
7) History of autoimmune diseases
8) History of eye surgery
(Upadhyay MP et al, 2015)
(Green M et al, 2008.,Mascarenhas J et al, 2014)

Risk Factors Conjunctivits

Some risk factors that cause the occurrence of conjunctivitis in terms
of the environment are the level of public awareness of behavior of
clean and healthy life, distance of residence, population density,

29
 number of factories around the residence, and the level of community
education (Azizahet al, 2015).
The high occupancy density and interaction or physical contact
between individuals facilitates the transmission of disease-causing
agents. Generally the incidence of conjunctivitis is found to be high in
environments with high occupant densities and interpersonal contact
(Lopezet al, 2011).

c. What is etiology of keratoconjunctivitis?

Answer:
Viruses, bacteria (penumococci, streptococco), fungi, protozoa, and
eye trauma (Ilyas, 2014)

d. What is epidemiology of keratoconjunctivitis?

Answer:
Keratitis
Epidemiologically, keratitis is generally in the form of infectious
keratitis with the main causes of Staphylococcus and Streptococcus.
Incidence is increased in contact lens wearers.

Global
The incidence of microbial keratitis globally is around 0.4 to 5.2 per
10,000 people annually. This incidence is higher in developing
countries than in developed countries.
(Al-mujaini A, 2009)

Conjunctivitis
Epidemiological data show that conjunctivitis can be found globally
and is one of the common eye diseases. Viral conjunctivitis is the
main cause, followed by bacterial conjunctivitis in the second
position.

30
 Global
Globally, cases of conjunctivitis can occur in all age groups, from
neonates to the elderly. Cases of conjunctivitis are found in 1% of
patient visits to first-level health facilities. In the United States there
are an estimated 6 million new cases of viral conjunctivitis annually.
Viral conjunctivitis can be sporadic or epidemic (for example at
school, at the hospital, at the clinic). Adenovirus is the cause in almost
90% of cases of viral conjunctivitis. The incidence of bacterial
conjunctivitis in the United States is 135 cases per 10,000 population
per year.
(Karpecki, P. M, 2015)

The incidence of conjunctivitis in Indonesia currently occupies the

second place (9.7%) of 10 major eye diseases. There are certain forms
of conjunctivitis that occur in certain age groups. In children, vernal
keratoconjunctivitis often occurs, while atopic and allergic
keratoconjunctivitis often occurs in young adults. About 1-3% of
contact lens users are affected by giant papillary conjunctivitis and
10% of neonates have conjunctivitis with various causes. Infectious
conjunctivitis affects women and men with the same incidence.
However, sicca conjunctivitis is more common in women. In contrast,
vernal keratoconjunctivitis and chemical and mechanical
conjunctivitis are more common in men (Ramadhanisa A, 2014).

e. What is classification of keratoconjunctivitis?

Answer:
1) Bacterial Conjunctivitis: caused by bacteria (eg gonococcus,
meningococci, stapylococcus aureus, streptococcus pneumonie,
hemophilus influenza and escherichia coli. Generally, they are

31
 self-limiting, but some cases can be severe, especially if caused by
nogonorrhoeae or s. Pyogeneus or s. Pyogeneous.
2) Neonatal Gonococcal Conjunctivitis: In infants, bilateral
conjunctival discharges begin 3-5 days after birth
3) Chlamydia conjunctivitis
4) Viral conjunctivitis:
- Epidemic keratoconjunctivitis (EKC)
- Pharyngeal conjunctival fever (PCF)
5) Allergic conjunctivitis:
- Atopic keratoconjunctivitis: bilateral, hyperemia, bulbar
conjunctival chemosis, mucoid secretions, severe itching.
Patients with a history of atopy.
- Simple allergic conjunctivitis: unilateral or bilateral, mild to
moderate hyperemia, chemosis. Often due to exposure to eye
medication or contact lens solution.
- Vernal conjunctivitis: bilateral, very itchy, and mucous
discharge, numerous and cordlike.
- Bseosanal (seasonal) conjunctivitis
(Vaughan, 2011)

f. How is pathophysiology of keratoconjunctivitis?

Answer:
Risk factors for contact with a person with an eyes disease →
transmission of infectious agents from patients to others through direct
contact (using hands, exposed objects) → invasion of infectious
agents (bacteria) in the conjunctiva → arise inflammatory response →
Conjunctivitis → inadequate treatment → infection spreads to the
cornea by diffusion because the conjunctival epithelium and cornea
are the same → inflammatory respom occurs → polymorphonuclear
secretion to disinfect germs → infiltrates formed → turbid cornea →

32
 because the cornea functions to refract light rays → blurred eyes and
dazzled everytime seeing some direct light.
(Ilyas, 2014)

10. What is the governance in this case?

Answer:
Pharmacology
Topical antibiotic
Chloramphenicol 1 % : 1 drops 6x/day
Gentamycin 0.3%
Ointment can be used 3x/day for 3 days
If not respond to these antibiotic, can give to the other group, such :
Ciprofloxacin 0.3%
Ofloxacin 0.3%

Non Pharmacology
Prevention of conjunctivitis including before and after cleaning or
applying medicine, patients with conjunctivitis must wash their hands to
infect others, do not touch healthy eyes after touching a sore eye, do not
use towels or cloths with others, use contact lenses according to doctor's
instructions and the manufacturer, replacing dirty pillowcases and towels
with clean ones every day, avoiding use of pillows, towels and
handkerchiefs together, avoid rubbing eyes, and in patients suffering from
conjunctivitis, should immediately dispose of tissues or the like after
cleaning eye dirt (Ramadhanisa A, 2014).

11. What is the complications in this case?

Answer:
corneal ulceration
blepharitis
acute glaucoma

33
 retinal detachment
blindness

12. What is the prognosis in this case?

Answer:
Dubia et bonam

13. What is the competence of general practitioner for this case?

Answer:
Conjunctivitis : 4A (diagnose, manage independently and thoroughly)
General doctors are able to make a clinical diagnosis and manage
the disease independently and thoroughly.

Keratitis: 3A (Not an emergency)

General doctors able to make a clinical diagnosis based on a
physical examination and additional examinations requested by a doctor
such as a lab examination or x-ray. Doctors can decide and give
preliminary therapy, and refer to relevant specialists.

14. What is the islamic view in this case?

Answer:
Q.S. Al-Mu’minun (23):78

It means: "And He has created for you hearing, vision and conscience, but
you have very little to give thanks."

2.7 Conclusion
Mr. Roby, a 24 years old complain of redness eye, conjungtive injection,
photopobia, infiltrat on the cornea sinitra because expriencing
keratoconjugtivitis oculi sinistra and conjuntivitis dextra

34
 2.8 Conceptual Framework

Risk Factor : contact with a

person with an eyes disease

Bacteria transmition

infection of conjungtive

spread to the inlamation in conjungtive

conjungtive dextra

conjungtivitis dextra infiltrat spread to the cornea

sinistra

keratoconjunctivitis sinistra

redness of conjungtive infiltrat on the

photopobia corna sinitra
the eye injection

35
 REFERENCES

Al-mujaini A, Al-kharusi N, Thakral A, Wali UK. 2009. Bacterial Keratitis:

Perspective on Epidemiology, Clinico-Pathogenesis, Diagnosis and
Treatment.;9(August):184–95.
Azari, Amir A. & Barney, Neal P. 2013. Conjunctivitis: A Systematic Review of
Diagnosis and Treatment. doi:10.1001/jama.2013.280318. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4049531/pdf/nihms-
574949.pdf
Azizah, Z.et al. 2015. Pemodelan Jumlah Penderita Konjungtivitis di Lamongan
Berdasarkan Pendekatan Model Regresi Generalized Poisson. Vol. 1.No. 3
Bielory, Perez. 2010. Treatment of Seasonal Allergic Conjunctivitis with
Ophthaimic Cortico Steroids in the Treatment of Allergic Conjunctivities.
Lippincott Williams & Wilkins.
Biswell R., Vaughan D.G., Asbury T., 2009, Ophtalmology Umum Ed. 14.
Jakarta. EGC
Elizabeth J. Corwin. 2009.Buku Saku Patofisiologi Corwin. Jakarta: Aditya
Media
Eroschenko. V.P. 2018. Atlas Histologi di Fiore. Ed 12. EGC Jakarta
Green M, Apel A, Stapleton F. 2008. Risk factors and causative organisms in
microbial keratitis. Cornea.;27(1):22–7
Ilyas S, Yulianti SR. 2014. Ilmu Penyakit Mata. Edisi 5 Jakarta:Badan Penerbit
FKUI
Karpecki, P. M. 2015. Kanski’s Clinical Ophthalmology : A Systematic
Approach. Optometry and Vision Science, 92(10).
Lopez, H. M., Melendez, C. A. P., Flores, A. C., &de Lucio,V. M. B.
2011. Epidemiological Aspects of Infectious Conjunctivitis,
Conjunctivitis –A Complex and Multifaceted Disorder. Prof. Zdenek
Pelikan (Ed.), InTech, Available from:
http://www.intechopen.com/books/conjunctivitis-a-complex-and-
multifaceted-disorder/epidemiological-aspects-of-infectious-conjunctivitis

36
Majmudar. 2010. Conjunctivitis, Alergic, Departement of Ophthalmology: Rush.
Presbytarian-St. Luke’s Medical Center.
Mascarenhas J, Lalitha P, Prajna NV, Srinivasan M, Das M, D’Silva SS, et al.
2014. Acanthamoeba, fungal, and bacterial keratitis: A comparison of risk
factors and clinical features. Am J Ophthalmol;157(1):56–62.
Moore Keith L., Dalley Arthur F., Agur Anne M.R.. 2009. Clinically Oriented
Anatomy. Philadelphia : Lippincott Williams & Wilkins
Ramadhanisa A. 2014. Conjunctivity Bakterial Treatment In Kota Karang Village.
J Medula Unila. Vol. 3. No. 2
Sherwood, L. 2012. Fisiologi Manusia dari Sel ke Sistem. Edisi 6. Jakarta : EGC
Silverman, Sallan.2010. Buku Saku Dokter. Edisi 3. Jakarta :EGC.
Snell, R. S. 2012. Anatomi Klinis Berdasarkan Sistem. Jakarta:EGC
Sudira P.U dan Wardani P. 2017. Ilmu Kesehatan Mata. Buku Panduan Belajar
Koas : Denpasar
Upadhyay MP, Srinivasan M, Whitcher JP. 2015 Diagnosing and managing
microbial keratitis. Community Eye Heal J.;28(89) :3–6.
Vaughan, Daniel, G. dkk. 2011. Oftalmologi Umum. Dalam : Vaughan, Daniel,
G. dkk (eds) General Opthalmology. Edisi 14. Jakarta : Penerbit Widya
Medika.

37