History

: Both eyes blur since three days ago. Both eyes felt red (+),
tenderness (+), aqueous (+) and painful (+). A history of
:
trauma was found, the patient was splashed with cold liquid
by the husband of a patient 3 days ago. Patients complain of
difficulty opening the eyes accompanied felt sick after
exposure to liquids and the patient immediately rinse with
normal tap water. However, the patient’s symptoms remain
the same. The patient has been taken to a hospital outside
and treated by an ophthalmologist with Acetazolomin tablet,
Methyilprednison tablet, and eye drops.

Line of sight : 1/60, count Line of sight : 0.5 / 60, count

fingers, there is (left eye) fingers, there is
(right eye )
no no
improvement improvement

PRESENT STATUS

Sensorium : compos mentis anemis : (-)

Blood pressure : 120/80 mmHg jaundice : (-)
Heart rate : 88 x / minute Dyspnoe : (-)
Respiratory rate : 20 x / min cyanosis : (-)
Temperatures : 36,7C° edema : (-)

Ophthalmology Examination
EXAMINATION Right eye Left eye

Vision 1/60 (finger count) 0.5 / 60 (count fingers)

Position Ortoforia Ortoforia

Superior eyelid Hyperemia (+), edema (+), Hyperemia (+), edema (+),
lacerations (-) lacerations (-)
Inferior eyelid Hyperemia (+), edema (+), Hyperemia (+), edema (+),
lacerations (-) lacerations (-)

Conj. Tars. Superior Hyperemia (+), Hyperemia (+),

discharge (-), edema (+), discharge (-), edema (+),

Conj. Tars Inferior Hyperemia (+) Hyperemia (+)

Secretions (-) Secretions (-)

Edema (+) Edema (+)

Bulbar conjunctiva Ciliary injection (-), Ciliary injection (-),

Conjunctival injection (+), Conjunctival injection (+),

Chemosis (+) Chemosis (+)

Necrosis (+) Necrosis (+)

cornea cloudy cloudy

COA moderate moderate

pupil difficult Assessed difficult Assessed

slice difficult to assess difficult to assess

Lens difficult Assessed difficult Assessed

Corpus vitreous No assessment No assessment

fundus oculi No assessment No assessment

Picture