TUTORIAL REPORT

SCENARIO A
BLOCK 16

GROUP 6
Mentor : dr. Rista Silvana, Sp. OG
Member :

Muhammad Fikri 702015035

Ahmad Muchlisin 702018003
Rahma Dhita Fitriani 702018026
Liani Khoirunissa 702018034
Hana Sulistia 702018049
Dhiya Luthfiyah Utami 702018052
Putri Nersi Rizki 702018064
Dennisa Luthfiyah Fadilah 702018074
Tarissa Rahma Dini 702018079
Della Marsellah 702018089

MEDICAL FACULTY
MUHAMMADIYAH UNIVERSITY OF PALEMBANG
2020/2021

1
 FOREWORD

We give our thanks to Allah SWT for all His blessings and gifts so
that we can complete the scenario A Block 16 Semester 5 tutorial report.
We realize that this tutorial report is far from perfect and therefore we
expect constructive criticism and suggestions, to improve future tasks.
In completing this tutorial task, we got a lot of help, guidance and advice. On
this occasion we convey our respect and thanks to:
1. dr. Rista Silvana, Sp. OG as our tutorial supervisor
2. All Members and related parties in making this report
May Allah SWT give rewards for all the deeds given to all those who have
supported us and hopefully this tutorial report will benefit us and the
development of science. May we always be protected by Allah SWT.Amin.

Palembang,
Desembe 2020

Author

TABLE OF CONTENTS

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FOREWORD..................................................................................................1
TABLE OF CONTENTS ..............................................................................2
CHAPTER 1 INTRODUCTION ..................................................................3
1.1 Background...............................................................................................3
1.2 Purpose and Objectives...........................................................................3
CHAPTER 2 DISCUSSION..........................................................................4
2.1 Tutorial Data............................................................................................4
2.2 Case Scenario...........................................................................................4
2.3 Classification of Terms ..........................................................................5
2.4 Identification of Problems......................................................................6
2.5 Priority of problem..................................................................................7
2.6 Analysis of Problems...............................................................................9
2.7 Conclusion...............................................................................................33
2.8 Conceptual Framework.........................................................................34
DAFTAR PUSTAKA...................................................................................35

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 CHAPTER I
INTRODUCTION

1.1 Issue Background

The urinary system and genetalia masculine is the 16th Block in semester 5
of the Education Competency Based Curriculum (CBC). Faculty of
Medicine, University of Muhammadiyah Palembang. On this occasion a
case study tutorial was carried out as learning material for an actual tutorial
tutorial about an upcoming opportunity. On this occasion I will explain the
case Mr. B, 55 years old, came to the RSMP emergency room with a
sudden complaint that the left eye could not see which was accompanied
by pain in and around the eye since 2 days ago. Since 3 months ago, the
patient complained of frequent headaches, nausea, vomiting and often saw
rainbow colors around the light bulb he saw. The patient takes a drug for
headaches at the stall but the complaints disappear temporarily and recur.
Since 1 year ago, Mr. B also complained of blurred vision in both eyes like
seeing smoke, and his left eye was getting worse over time. Mr. B has
never been treated for eye complaints. Mr. B was once stated that the
doctor had diabetes 10 years ago and had irregular treatment

1.2 Purpose and Objectives

The purpose and objectives of this case study tutorial, namely:

1. As a report task group tutorial that is part of KBK

learning system at the Faculty of Medicine,
Muhammadiyah University of Palembang.
2. Can solve the case given in the scenario with the
method of analysis and learning group discussion.

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 CHAPTER II
DISCUSSION

2.1 Tutorial Data

Tutor : dr. Resti Silvana, Sp. OG

Moderator : Ahmad Muchlisin
Secretary of table : Rahma Dhita Fitriani
Day and Date : Monday, Desember 7nd 2020
08.00– 10.40 am
Wednesday, Desember 9th 2020
08.00– 10.40 am
Rule of Tutorial :

1. Mutual respect among fellow tutorial participants

2. It is forbidden to eat and drink during the tutorial

3. Using good and proper communication

2.2 Case Scenario

”My Old Eyes ”

Mr. B, 55 years old, came to the RSMP emergency room with a sudden complaint that
the left eye could not see which was accompanied by pain in and around the eye since 2
days ago. Since 3 months ago, the patient complained of frequent headaches, nausea,
vomiting and often saw rainbow colors around the light bulb he saw. The patient takes a
drug for headaches at the stall but the complaints disappear temporarily and recur. Since 1
year ago, Mr. B also complained of blurred vision in both eyes like seeing smoke, and his
left eye was getting worse over time. Mr. B has never been treated for eye complaints. Mr.
B was once stated that the doctor had diabetes 10 years ago and had irregular treatment.
Physical examination:
General circumstances: conscious and cooperative
Vital sign: BP 130/80 mmHg, pulse: 82 x/minute, RR: 14 x/minut, Temperature: 36,8oC
Eye:
Basic visual examination: VOD 6/30, VOS 1/300
Ophthalmological Status:
- OD : Tonometry 17,6 mmHg, the eye lens is cloudy uneven, Shadow test (+)

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 - OS : Tonometry 40 mmHg, palpebra edema, mixed injection (+), cornea edema,
shallow front eye chambers, dilated pupil, pupil reflex (-), Shadow test hard to be
assessed
Laboratory examination:
Routine blood: Hb 14,2 g/dl; Ht 42%, platelets 280.000/mm3, leukocyte 8000/mm3 ; Blood
chemistry: BSS 210 mg/dl.

2.3 Clarification of terms

NO TERMS MEANING
1 Nausea vague unpleasant sensation in epigastrium and
abdomen with morning sickness in pregnancy
with a tendency to vomit (Dorland, 2015)
2 Pain a feeling of discomfort, pain, or pain caused
by stimulation of certain nerve endings
(Dorland, 2015)

3 Tonometry measurement of stress or pressure, especially

intraocular pressure (Dorland, 2015)

4 Headache the symptom of pain in the face, head, or neck

(Dorland, 2015)
5 Blurred the loss of sharpness of vision and the in
ability to see fine details (Dorland, 2015)
6 VOD the ability right eye to see an object within a
certain distance (Dorland, 2015)
7 Dilated pupil or mydriasis occurs when the smooth cells of
the radial muscle which are controls by the
sympathetic nervous system (Dorland, 2015)
8 Mixed injection injection cornea with intraocular, cornea
ulceration (Dorland, 2015)
9 Vomitting expulsion of gastric contents by mouth
(Dorland, 2015)
10 Cornea edema abnormal collection of fluid abnormally in the
intercellular space in the anterior part of the
eye transparent (Dorland, 2015)
11 Palpebra edema collection of fluid abnormally in the
interceluller space of the eyelid (Dorland,

6
 2015)
12 VOS the ability left eye to see an object within a
certain distance (Dorland, 2015)

2.4 Identification of problems

1. Mr. B, 55 years old, came to the RSMP emergency room with a sudden
complaint that the left eye could not see which was accompanied by pain
in and around the eye since 2 days ago.
2. Since 3 months ago, the patient complained of frequent headaches,
nausea, vomiting and often saw rainbow colors around the light bulb he
saw. The patient takes a drug for headaches at the stall but the complaints
disappear temporarily and recur.
3. Since 1 year ago, Mr. B also complained of blurred vision in both eyes
like seeing smoke, and his left eye was getting worse over time. Mr. B has
never been treated for eye complaints. Mr. B was once stated that the
doctor had diabetes 10 years ago and had irregular treatment.
4. Physical examination:
General circumstances: conscious and cooperative
Vital sign: BP 130/80 mmHg, pulse: 82 x/minute, RR: 14 x/minut,
Temperature: 36,8oC
Eye:
Basic visual examination: VOD 6/30, VOS 1/300
Ophthalmological Status;
OD : Tonometry 17,6 mmHg, the eye lens is cloudy uneven, Shadow test
(+)
OS : Tonometry 40 mmHg, palpebra edema, mixed injection (+), cornea
edema, shallow front eye chambers, dilated pupil, pupil reflex (-), Shadow
test hard to be assessed
5. Laboratory examination:
Routine blood: Hb 14,2 g/dl; Ht 42%, platelets 280.000/mm3, leukocyte
8000/mm3; Blood chemistry: BSS 210 mg/dl.

2.5 Priority problem

Identification number 1 because if not treatment right, can interfere with
activities and threaten the patient, also increased mortality and morbidity

2.6 Problem analysis

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1. Mr. B, 55 years old, came to the RSMP emergency room with a
sudden complaint that the left eye could not see which was
accompanied by pain in and around the eye since 2 days ago.
a. What are the eye anatomy, physiology and the function refraction ?
Answer:
EYE ANATOMY

The eye has several parts, including:

1) Sclera
The sclera is the wall of the eyeball which consists of tissue
a strong tie that is not clear and not elastic with a thickness of ± 1
mm. On the sclera is the insertion or attachment of 6 muscles that
move the eyeball.
2) The muscles that drive the eyeball
The functions of the muscles that move the eyeball are different,
namely:

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  Abduction movement, using the muscles of m.rectus bulbi
lateralis, m.obliquus bulbi superior, m.obliquus bulbi
inferior.
 Cranial movements, using muscles of the superior m.rectus
bulbi, m.obliquus bulbi inferior.
 Caudal movement, using the muscles of the inferior
m.rectus bulbi,m.obliquus bulbi superior.
 Movement of rotation in accordance with clockwise using
the muscle-m.rectus bulbi superior and m.obliquus bulbi
superior muscles.
 Rotational movements counterclockwise using the muscles
of the inferior m.rectus bulbi and m.obliquus bulbi inferior.
3) Cornea
The normal cornea is a transparent membrane located on the the
surface of the eyeball (Ilyas, et al., 2010). Cornea in central part
has a thickness of 0.5 mm. The cornea has no blood vessels, but it
is very rich in nerve fibers. This sensory nerve originates from the
ciliary nerve which is the ophthalmic branch of the trigeminal
nerve (nerve V) (Ilyas, 2008).
4) Eye Fluid (Humor Aquosus)
Aqueous humor is a flowing intraocular fluid free that is in front
of the lens. This fluid is formed by the ciliary processus at an
average of 2-3 μL / min which flows through the pupil into the
anterior ocular camera. From here, fluid flows into the front of the
lens and into the angle between the cornea and iris, then through
the trabecular reticulum, and finally into the Schlemm's canal,
which then flows into the extraocular veins (Guyton & Hall,
2008).
5) Ciliary Body
The ciliary body is a triangular shaped network lies attached to the
sclera. The ciliary body supports the lens, contains muscles that
allow the lens to accommodate and function to secrete eye fluid.
6) Iris
The iris is part of the anterior uvea and is attached to the part
peripheral with ciliary bodies. The front of the iris has no
epithelium, while on the back there is a pigmented epithelium that
gives the iris its color. There is a slit in the iris called the pupil.

9
 The pupil plays a role in regulating the amount of light that enters
the eye. The pupil will be enlarged or mydriasis when there is less
light, and shrink or miosis when it is overexposed.
7) Lens
The lens is in the form of a translucent clear bikonvek. located
behind the iris and in front of the corpus vitreosus about 5 mm
thick and 9 mm in diameter in adults. The posterior lens surface is
more curved than the anterior (Ilyas, et al., 2010). The lens has a
total refractive power of only 20 diopters or one-third of the total
refractive power of the eye. However, the lens is very important
because in response to nerve signals from the brain, its curved
surface can be bulging, allowing accommodation to occur (Guyton
& Hall, 2008).
8) Body of Glass (Corpus Vitreosus)
The glass body is clear in color, soft consistency, avascular or has
no blood vessels, and consists of 99% water and the rest is a
mixture of collagen and hyaluronic acid. The glass body plays a
major role in maintaining the shape of the eyeball, this is because
the glass body fills most of the eyeball which is located between
the lens, retina and optic nerve papillae (Ilyas, 2008).
9) Retina
The retina is a thin membrane consisting of sensory nerves vision
and optic nerve fibers. The retina is a network of nerves in the eye
which on the outside corresponds to the choroid. The choroid
provides nutrition to the outer retina or cone and stem cells. The
inner retina is metabolized by the central retinal artery. The retina
consists of 3 main layers that make up the retinal sensible nerve
synapses, namely cone and stem cells, bipolar cells and ganglion
cells.
10) Macula Lutea
It is the central visual nerve where it is acuity maximum vision.
The macula lutea is located on the retina.
11) Yellow Spot (Fovea)
Is a part of the retina that contains cone cells that are very
sensitive and will produce maximum visual acuity or 6/6. If there
is damage to the central fovea, visual acuity will decrease.
12) Blind Spot (Optic disc)
Is an area of the optic nerve that leaves the inside eyeball.

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The bones forming the orbital cavity:
1) Os. Frontalist
2) Os. Maxillaris
3) Os. zygomaticum
4) Os. Sphenoidalis
5) Os. Lakrimalis
6) Os. Ethmoidalis
7) Os. Palate

The eyeball (Bulbus oculi) has 3 layers:

1) Fibrous tunica:
From front to back, namely the cornea → sclera
The cornea functions to reflect light that enters the eye
2) Tunica vasculosa pigmentosa
From front to back, namely the iris and pupil → corpus ciliaris →
choroidea. The pigmented iris gives the eye its color. Pupil to
adjust the amount of light entering. Regulated by involuntary
muscle fibers i.e. radial to dilate the pupil and circular to shrink
the pupil). Corpus ciliaris for the production of aquos humor
which serves as a food member on the cornea and lens. Choroidea
is pigmented and heavily vascular
3) Tunica nervosa
Retina (sheet of nerve tissue). There are both stem cell and cone
cell photoreceptors, cells bipolar and ganglion cells

PHYSIOLOGY OF VISION
Object → reflects light (electromagnetic waves) → enters the cornea
→ is transmitted to the pupil → adjusts the amount of light that enters
the pupil through the m.sphincter pupillae (which constricts the pupil
in light) and m. → light is focused by the lens → convergence of light
→ the image of a falling object is right on the macula lutea (reverse
image) → impulses are captured by photoreceptor cells, rod cells
(black and white) and cones (color) → synapse with horizontal cells
→ bipolar cells → synapse with amacrine cells → ganglion cells →
propagation of impulses to the optic nerve → chiasma opticum →
tractus opticus → fibers in the optic tractus synapse in the nucleus
geniculatum laterale dorsalis → tractus geniculocalcarina → primary

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 visual cortex in the calcarina of the occipital lobe → see
(Guyton,2014)

PHYSIOLOGY OF AQUEOUS HUMOR FLOW

The aqueous humor is formed by the ciliary process → camera oculi
posterior (COP) → pupil → camera oculi anterior (COA) →
trabecular reticulum → Schlemm's canal → episclera vein →
extraocular vein → systemic vein (Guyton, 2014)

b. What is the meaning Mr. B, 55 years old, came to the RSMP

emergency room with a sudden complaint that the left eye could not
see which was accompanied by pain in and around the eye since 2
days ago ?
Answer:
The meaning Mr. B sudden complaint that the left eye could not see
which was accompanied by pain in and around the eye since 2 days
ago is a clinical sign of acute glaucoma. Glaucoma is damage to the
optic nerve characterized by curvature of the optic disc, decreased
visual field, and accompanied by increased intraocular pressure. In
glaucoma, there is an increase in intraocular pressure which causes
nerve damage and apoptosis of retinal ganglion cells. This results in
reduced axons in the optic nerve and optic atrophy resulting in
impaired visual sensory perception, in which Mr. B couldn't see
suddenly since 2 days ago. Then, an increase in intraocular pressure,
causing TNF-L activation then stimulates the release of bradykinin
and histamine so that it stimulates efferent nerve nociceptors and
causes pain around Mr.B’s left eye (Ilyas, Sidarta & Sri Rahayu
Yulianti, 2017)

c. What are the possible diseases of sudden complaint that the left eye
could not see which was accompanied by pain in and around the eye ?
Answer:
1. Acute glaucoma
2. Optic neuritis: inflammation of the optic nerve with visual
symptoms descending on the affected nerve.
3. Retinal detachment: vision drops suddenly when detachment of
the retina hits the macula lutea (Ilyas and Yulianti, 2017)

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d. What is the correlation gender and age in this case ?
Answer:
We estimated the global prevalence of glaucoma to be 3.54%, with
the highest prevalence in Africa. The number of people with
glaucoma worldwide (aged 40-80 years) will increase from 64.3
million in 2013 to 111.8 million in 2040, disproportionally affecting
people residing in Asia and Africa. men were 36% more likely to have
POAG than women. The age-adjusted prevalence rate of cataract
(including cataract surgery) was 23.0% (95% confidence interval,
20.8–25.2). The most common type of cataract for both genders
(adjusted for age) was mixed (13%) followed by nuclear only (5.7%),
and cortical only (4%). The prevalence rate of any cataract for adults
aged 21 to 29 was 1.1%, increasing to 82.8% for those aged older than
60 years. Similar trends with age were noted for nuclear, cortical, and
PSC cataract. Women had higher prevalence rates than men for all
types of cataract except cortical (Giangiacomo & Coleman, 2009).
Based on research by Yesi Nurmalasari and Muhammad Rizki
Hermawan (2017) regarding the characteristics of glaucoma patients
based on interinsic factors, glaucoma often occurs in the elderly and
adults (40-62 years). This is because at that age there is a degeneration
process of eye tissue and there are also comorbidities that are a risk
factor for glaucoma, such as diabetes mellitus. The correlation gender
in this case there is no significant relationship between the sexes of
women and men. But in some studies there are those who say that
women experience glaucoma more often because it is influenced by
biological factors, where in women there is a protective hormone on
the optic nerve which when women enter the age of menopause, the
hormone will decrease, so that the incidence rate of glaucoma
increases in women at menopause . In addition, it is also seen from the
risk factor for glaucoma, which is diabetes mellitus. Where diabetes
mellitus occurs more frequently in women than men (Shekhar J dkk.
2010)

e. How is the pathophysiology of sudden complaint that the left eye

could not see which was accompanied by pain in and around the eye ?
Answer:
Left eye could not see:

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Risk factors Age (degenerative process  new fibers appear on the
lens  buildup of old fibers in the eye lens) + Risk factors for DM
(DM  Increased glucose in the blood  increased blood glucose
while the pancreas has decreased function to produce insulin  build
up of glucose in the blood  unbalanced body metabolism 
hyperglycemia  glucose into the lens through a diffusion process
without the help of insulin  glucose breakdown through 3 pathways,
namely anaerobic glycolysis, pentose phosphate and polyol pathways
 in the polyol pathway glucose is converted into sorbitol by the
enzyme aldose reductase  in a hyperglycemic state , there is a
decrease in the polyol dehydrogenase enzyme so that sorbitol cannot
be converted into fructose  sorbitol accumulation in the lens  lens
turbidity  increased osmotic pressure on the lens  attracts aqueous
humor into the lens  convex lens  pushes the iris forward  COA
angle becomes shallow  occlusion trabecular webbing by the
peripheral iris  inhibits the flow of aqueous humor  accumulation
of aqueous humor  increases in intraocular pressure  pushes the
boundary between the optic nerve and the retina behind the eye 
blood supply to the optic nerve decreases  decreased visual field 
the left eye cannot see (Richard et all, 2018)
Pain in around eyes:
Risk factors Age (degenerative process  new fibers appear on the
lens buildup of old fibers in the eye lens) + Risk factors for DM
(DM  Increased glucose in the blood  increased blood glucose
while the pancreas has decreased function to produce insulin 
buildup of glucose in the blood  unbalanced body metabolism 
hyperglycemia glucose into the lens through a diffusion process
without the help of insulin  glucose breakdown through 3 pathways,
namely anaerobic glycolysis, pentose phosphate and polyol pathways
 in the polyol pathway glucose is converted into sorbitol by the
enzyme aldose reductase  in a hyperglycemic state , there is a
decrease in the polyol dehydrogenase enzyme so that sorbitol cannot
be converted into fructose  sorbitol accumulation in the lens  lens
turbidity  increased osmotic pressure on the lens  attracts aqueous
humor into the lens  convex lens  pushes the iris forward  COA
angle becomes shallow  occlusion trabecular webbing by the

14
 peripheral iris  inhibits the flow of aqueous humor  accumulation
of aqueous humor  increases in intraocular pressure  compresses
nerve nodes in the corneal area which is a branch of N. trigeminus 
pain around the eyeball (Richard et all,2018).

2. Since 3 months ago, the patient complained of frequent headaches,

nausea, vomiting and often saw rainbow colors around the light bulb
he saw. The patient takes a drug for headaches at the stall but the
complaints disappear temporarily and recur.
a. What is the meaning since 3 months ago, the patient complained of
frequent headaches, nausea, vomiting and often saw rainbow colors
around the light bulb he saw ?
Answer:
The meaning since 3 months ago the patient complained of frequent
headaches, nausea, vomiting and often saw rainbow colors around the
light bulb he saw is since 3 months ago Mr.B has experienced early
symptoms of acute glaucoma. Acute glaucoma has obvious
symptoms, namely headache, nausea, vomiting, blurred vision and
seeing halos or rainbow colors around lights. In glaucoma there is an
increase in intraocular pressure which causes disruption of the corneal
function as light habituation, this causes Mr. B looks at the rainbow
colors around the lights. Increased intraocular pressure in glaucoma
patients, causes stress of retinal ganglion cells and glial cells in the
retina, this causes retinal ischemia which stimulates trigeminal nerve
fibers and causes headaches as well as nausea and vomiting (Ilyas,
Sidarta & Sri Rahayu Yulianti, 2017)

b. What is the meaning the patient takes a drug for headaches at the stall
but the complaints disappear temporarily and recur ?
Answer:
It means that the drug consumed only relieves complaints, not treats
them, so these complaints can come back at any time (Mita & Husni,
2017)

c. What are the possible drugs that Mr. B consumption ?

Answer:

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 Analgesics are drugs used to relieve pain. Analgesic drugs are divided
into two groups, namely opioid drugs and NSAIDs. The opioids work
on the central nervous system, while the NSAIDs work on the
receptors for the peripheral nervous system and the autonomic
nervous system. Paracetamol, salicylates, (acetasol, salicilamide, and
benorylate), Prostaglandin inhibitors (NSAIDs) ibuprofen,
anthranylate derivatives (mephenamylate, glafenin niflumic acid,
floctafenin, pyrazolinone derivatives (aminophenazone, isoprophyl)
penazone, in this case, Mr. B took NSAIDs type paracetamol that are
often found in stalls (Mita & Husni, 2017).

d. What is the correlation between additional complaints since 3 months

ago with the main complaints ?
Answer:
The correlation between additional complaints since 3 months ago
with the main complain is symptoms of acute glaucoma. Acute
glaucoma has obvious symptoms, namely headache, nausea, vomiting,
blurred vision and seeing halos or rainbow colors around light. And
then there was progressive glaucoma experienced by Mr. B because
when the glaucoma symptoms appeared 3 months ago it was not
treated immediately so that the complaints in the left eye were getting
worse and Mr. B could not see suddenly accompanied by pain
(Kowalak, 2017)

e. What is the etiology of headache, nausea, vomiting and often saw

rainbow colors around the light bulb he saw ?
Answer:
- Headache: ↑ intraocular pressure, ↑ intracranial, ischemia,
hypoxia, hypoglycemia.
- Nausea, vomiting: intracranial disorders (tumors, etc.),
extracranial disorders (digestive tract).
- Seeing the rainbow (hello): uncorrected refractive error, streaking
of the eyeglass lenses, excessive dilation of the pupil, cloudy eye
media, corneal edema (Kowalak, 2017)

f. How is the mechanism of headache, nausea, vomiting and often saw

rainbow colors around the light bulb he saw ?
Answer:

16
 Nausea - Vomiting – Headache
Old age, DM Uncontrolled → High Oxidate stress→ Aldose
Reductase induced osmotic stress and low lens glutathione →
degenerative process of the eye lens → denaturation of the lens
protein → cloudy eyepiece → senile cataract → increased lens
osmosis → fluid infiltration into the lens → the lens swells →
pushing the iris forward → the angle of the camera oculi anterior
becomes shallow → closure of the trabeculum (canalis shlemm) →
impaired aqueous humor drainage → accumulation of aqueous humor
→ increasing intraocular pressure → compression of the optic nerve
papules → stimulation of the autonomic nervous system → nausea
and vomiting and headaches (Price & Wilson, 2014)

Like Seeing Rainbow Colors Around Light Bulbs

Old age, DM Uncontrolled → High Oxidative stress→ Aldose
Reductase induced osmotic stress and low lens glutathione →
degenerative process of the eye lens → denaturation of the lens
protein → cloudy eye lens → senile cataract → increased osmotic
lens → infiltration of fluid into the lens → the lens swells → pushing
the iris forward → the angle of the camera oculi anterior becomes
shallow → closure of the trabeculum (canalis shlemm) → impaired
aqueous humor drainage → accumulation of aqueous humor →
intraocular pressure ↑ → damaged endothelium → fluids enter the
corneal stroma → corneal edema → loose cell structure and cloudy
color → cloudy cornea → disturbed function of the cornea as light
refraction → like seeing rainbow colors (Price & Wilson, 2014)

3. Since 1 year ago, Mr. B also complained of blurred vision in both eyes
like seeing smoke, and his left eye was getting worse over time. Mr. B
has never been treated for eye complaints. Mr. B was once stated that
the doctor had diabetes 10 years ago and had irregular treatment.
a. What is the meaning Since 1 year ago, Mr. B also complained of
blurred vision in both eyes like seeing smoke, and his left eye was
getting worse over time ?
Answer:
The meaning Mr. B complained of blurred vision in both eyes like
seeing smoke, and his left eye was getting worse over time is Mr. B
had senile cataract since 1 year ago. Senile cataracts are cataracts that

17
 occur at the age of over 50 years. This cataract is cloudiness in the
lens of the eye due to the accumulation of sorbitol and protein
denaturation, causing reduced transparency of the eye lens, this causes
blurred vision such as seeing smoke. Senile cataract experienced by
Mr. B since 1 year ago, became the cause of acute glaucoma
experienced by Mr. B now. Where in senile cataracts, sorbitol and
fructose accumulate in the eye lens. This will cause a hypertonic state
in the eye lens so that fluid will enter the eye lens, then will close the
trabeculum and inhibit the drainage of the aquous humor. This will
cause an increase in intraocular pressure and cause symptoms of acute
glaucoma experienced by Mr. B since 3 months ago until now (Ilyas,
Sidarta & Sri Rahayu Yulianti, 2017)

b. What are the etiology of blurred vision in eye ?

Answer:
There are multiple reasons for blurry vision. Blurred vision can be
temporary or permanent, with the condition worsening over time. The
precise geometry for image formation is lost due to readjustment of
optic muscles which hold the eyeball and cause refraction errors. Due
to refraction errors, such as nearsightedness, farsightedness, and
astigmatism, one may have blurring vision. May be related to eye
disease such as dry eyes, scratched cornea, reti- nal detachment,
macular degeneration, cataracts, and glaucoma are disorders of the
functional eye and its processing units. Blurry vision may also be
there due to pregnancy, this is due to oversaturation of estrogen
receptors in the lens. If this is the only reason, one can take it lightly
(Gupta, 2019)

c. What are the classification of cataract ?

Answer:
Based on age, cataracts can be classified into:
1) Congenital cataracts: are cataracts that start before or soon after
the baby is born and the baby is less than 1 year old. Congenital
cataracts are often found in babies born to mothers who suffer
from rubella, galactosemia, homocysteine, diabetes mellitus. In
the pupil of a baby suffering from congenital cataracts will appear
white spots or a leukocoria.

18
 2) Juvenile catrak, cataracts that occur after 1 year of age. Juvenile
cataracts are flaccid cataracts and occur in young people, which
begin to form at the age of less than 9 years and more than 3
months. Is a continuation of congenital cataracts
3) Senile cataracts are all lens opacities present in the elderly,
namely over 50 years of age
4) Complicated cataracts: are cataracts caused by other eye diseases
such as inflammation, and degenerative processes such as retinal
detachment, retinitis pigementosa, glaucoma, intraocular tumors,
ocular ischemia, anterior segment necrosis, buftalmos, due to
trauma and post eye surgery. Complicated cataracts give a special
sign where the cataract starts forever in the area under the capsule
or in the cortex layer, opacities can be diffuse, punctate or linear.
5) Diabetic cataract: is a cataract that occurs due to diabetes mellitus
6) Secondary cataract: occurs due to the formation of fibrosis tissue
in the remaining lens, the earliest this condition is after 2 days of
ECCE (extra capsular cataract extraction)

d. What are the stadium of cataract ?

Answer:
1. Iminens / insipiens
At this stage, the lens is swollen because it includes water, the
opacity of the lens is still light, the vision is usually> 6/60. On
examination, it can be found normal iris, normal front chamber,
normal eye chamber angle, and negative shadow test.
2. Immature
In the next stage, the lens opacity increases and the vision starts
to decrease to 5/60 to 1/60. The lens fluid increases as a result of
pushing the iris and the front chamber into a shallow, narrow
chamber angle, and glaucoma is common. On examination, a
positive shadow test was found.
3. Matur
If the cataract is left unchecked, the lens will become completely
cloudy and the vision drops drastically to 1/300 or can only see a
hand waving within 1 meter. On examination, a negative shadow
test was found.
4. Hypermatur

19
 In the final stage, the cortex liquefies so that the nucleus falls and
the lens drops from its capsule (Morgagni). The lens looks
completely cloudy, the vision has decreased so much that it can
reach 0, and complications can occur in the form of uveitis and
glaucoma. The examination showed iris tremulans, inner front
chamber, open corner of the eye chamber, and a false positive
shadow test. (Astari, 2018)

e. What is the meaning of Mr. B has never been treated for eye
complaints ?
Answer:
Cataract is a state of gradual clouding of the eye lens. Which if not
treated immediately can progress to the next stage and risk of
complications from glaucoma (Kowalak, 2017)

f. What is the meaning Mr. B was once stated that the doctor had
diabetes 10 years ago and had irregular treatment ?
Answer:
The meaning is Mr. B had uncontrolled diabetes mellitus since 10
years ago. Where uncontrolled diabetes mellitus is a risk factor for
cataracts and glaucoma experienced by Mr. B.

g. How is the pathophysiology of blurred vision in both eyes like seeing

smoke, and his left eye was getting worse over time ?
Answer:
Risk factors for age 55 years  degeneration process  forming a
new layer of cortex fibers that are concentrically formed  the eye
lens is aging, heavy and thick and there is a decrease in
accommodation  the lens nucleus is compressed and becomes heavy
protein high molecules  protein aggregation occurs  the protein
fluctuates  the lens is cloudy but uneven (immature)  reduces the
transparency of the lens  the refractive medium is disturbed  the
incoming light is blocked  blurred vision and smoky (Price &
Wilson, 2014)

h. What the correlation between additional complaints since 1 year ago

with the main complaints ?
Answer:

20
 The relationship is a symptom of the last 1 year indicating that Mr. B
has cataracts. where cataracts in this case can be caused by age and a
history of diabetes mellitus. With increasing age, the size of the lens
can increase with the emergence of new lens fibers. With increasing
age, the clearness of the lens in the eye decreases. in this case the
patient has a history of diabetes, where this glucose will enter the eye
lens through the diffusion process without the help of insulin. Both of
these can cause cloudiness in the lens of the eye which can cause
cataracts. This cataract can cause further complaints, namely
glaucoma. when glaucoma occurs, there will be an increase in
osmosis and absorbing fluid so that the lens of the eye appears
convex. In glaucoma, obstruction occurs because the peripheral iris
closes the corner of the eye at the front chamber. As a result, there
will be obstruction to the flow of the aqueous humor which will cause
an increase in intraocluar pressure. this increase in pressure causes
symptoms such as pain around the eyeball and decreased visual field
so that Mr. B couldn't see suddenly (Blanco, 2012)

4. Physical examination:
General circumstances: conscious and cooperative
Vital sign: BP 130/80 mmHg, pulse: 82 x/minute, RR: 14 x/minut,
Temperature: 36,8oC
Eye:
Basic visual examination: VOD 6/30, VOS 1/300
Ophthalmological Status:
OD : Tonometry 17,6 mmHg, the eye lens is cloudy uneven, Shadow test
(+)
OS : Tonometry 40 mmHg, palpebra edema, mixed injection (+), cornea
edema, shallow front eye chambers, dilated pupil, pupil reflex (-), Shadow
test hard to be assessed
a. What are interpretation of physical examination ?
Answer:
OD OS
VOD 6/30 decreased vision VOS 1/300 decreased vision, can
only see the wave of the hand
Tonometri 17,6 mmHg. normal Tonometri 40 mmHg  ocular
hypertension

21
the eye lens is cloudy uneven  Edema palpebral abnormal
abnormal, cataract
Shadow test (+) cataract immature Mixed injeksi (+) abnormal
cornea edema abnormal
shallow front eye chambers 
abnormal
dilated pupil  Abnormal
pupil reflex (-)  Abnormal
Shadow test hard to be assessed 
abnormal

b. How is the abnormal mechanism of physical examination ?

Answer:
VOD 6/30 (decreased vision):
Risk factors for age 55 years  degeneration process  forming a
new layer of cortex fibers that are concentrically formed  the eye
lens is aging, heavy and thick and there is a decrease in
accommodation  the lens nucleus is compressed and becomes heavy
protein high molecules  protein aggregation occurs  the protein
fluctuates  the lens is cloudy but uneven (immature)  reduces the
transparency of the lens  the refractive medium is disturbed  the
incoming light is blocked  blurred vision  VOD 6/30

Shadow test (+) on the left eye / Cataract immature:

Risk factors for age 55 years  degeneration process  forming a
new layer of cortex fibers that are concentrically formed  the eye
lens is aging, heavy and thick and there is a decrease in
accommodation  the lens nucleus is compressed and becomes heavy
protein high molecules  protein aggregation occurs  the protein
fluctuates  the lens is cloudy but uneven (immature)  Shadow test
(+)

VOS 1/300 (decreased vision, can only see the wave of the hand):
Senile cataract → increased lens osmosis → infiltration of fluid into
the lens → swollen lens → pushing the iris forward → the camera
angle of the anterior oculi becomes shallow → closure of the
trabeculum (canalis shlemm) → impaired aqueous humor drainage →

22
accumulation of aqueous humor → intraocular pressure ↑ →
compression of the arteries retina & optic nerve papillae → reduced
supply of nutrients to the retina → apoptosis of retinal ganglion cells
→ thinning of the nerve fiber layer and inner lining of the retina and
reduced axons in the optic nerve (optic nerve papillae) → reduced
impulse transmission to the brain → decreased vision (1 / 300).

Tonometry 40 mmHg on the left eye:

Senile cataract → increased lens osmosis → infiltration of fluid into
the lens → swelling of the lens → pushing the iris forward → the
camera angle of the anterior oculi becomes shallow → closure of the
trabeculum (canalis shlemm) → impaired aqueous humor drainage →
accumulation of aqueous humor → intraocular pressure ↑ →
tonometry 40 mmHg.

Palpebral edema:
Senile cataract → increased lens osmosis → fluid infiltration into the
lens → swollen lens → pushing the iris forward → the camera angle
of the anterior oculi becomes shallow → closure of the trabeculum
(canalis shlemm) → impaired aqueous humor drainage →
accumulation of aqueous humor → intraocular pressure ↑ → damaged
endothelium → fluid enters the corneal stroma → corneal edema → ↑
hydrostatic pressure → fluid transudation into loose connective tissue
→ palpebral edema.

Mixed injection (+):

senile cataract → increased lens osmosis → infiltration of fluid into
the lens → swelling of the lens → pushing the iris forward → the
camera angle of the anterior oculi becomes shallow → closure of the
trabeculum (canalis shlemm) → impaired aqueous humor drainage →
accumulation of aqueous humor → intraocular pressure ↑ → ball
strain eye → compression of the posterior conjunctival artery and
anterior ciliary artery → compensation → dilation of the posterior
conjunctival artery and anterior ciliary artery → mixed injection (+)

Superficial abnormal front chamber:

23
 Senile cataract → increased osmotic lens → fluid infiltration into the
lens → swollen lens → pushing the iris forward → the angle of the
camera oculi anterior becomes shallow (front chamber shallow).

Dilated pupils:
Senile cataract → increased lens osmosis → fluid infiltration into the
lens → swollen lens → pushing the iris forward → the camera angle
of the anterior oculi becomes shallow → closure of the trabeculum
(canalis shlemm) → impaired aqueous humor drainage →
accumulation of aqueous humor → intraocular pressure ↑ → damaged
endothelium → fluid enters the corneal stroma → corneal edema →
loosening of the cell structure and the color is cloudy → cloudy
cornea → little light enters → compensation mechanism → ↑ work m.
dilator pupillae → dilation of the pupil in an attempt to let more light
enter.

Pupillary reflex (-):

Senile cataract → increased lens osmosis → fluid infiltration into the
lens → swollen lens → pushing the iris forward → the camera angle
of the anterior oculi becomes shallow → closure of the trabeculum
(canalis shlemm) → impaired aqueous humor drainage →
accumulation of aqueous humor → intraocular pressure ↑ → damaged
endothelium → fluid enters the corneal stroma → corneal edema →
loosening of the cell structure and the color is cloudy → cloudy
cornea → (checked with a flashlight), incoming light is blocked →
light does not reach the pupil → pupillary reflex (-)

Shadow test cannot be assessed:

senile cataract → increased lens osmosis → fluid infiltration into the
lens → swollen lens → pushing the iris forward → the camera angle
of the anterior oculi becomes shallow → closure of the trabeculum
(canalis shlemm) → impaired aqueous humor drainage →
accumulation of aqueous humor → intraocular pressure ↑ → damaged
endothelium → fluid enters the corneal stroma → corneal edema →
loosening of the cell structure and the color is cloudy → cloudy
cornea → the shadow test cannot be assessed

c. What are the function of intraocular examination (tonometry) ?

24
 Answer:
Its function is to determine the "normal" value of eye pressure, which
is 2 levels up and down from the average, which is around 10-21
mmHg (AAO). If the pressure is 21 mmHg, preferably controlled C/
D ratio, check the central field of view, find a wide blind spot and a
scotoma around the fixation point. If the pressure is 24-30 mmHg,
control more tightly and perform the above checks. (Budhiastra et al,
2017)

d. How to do pupil examination?

Answer:
1) Light-reflex test
- What it assesses – The integrity of the pupillary light reflex
pathway
- How to perform – Dim the ambient light and ask the patient to
fixate on a distant target. Shine on the right eye from the right side
and on the left eye from the left side
- Normal response – A brisk, simultaneous, equal response of both
pupils in response to light shone in one or theother eye.
2) Near-reflex test
- What it assesses – The miosis component of near fixation
- How to perform it – In a normally lit room, instruct the patient to
look at a distant target. Bring an object into the near point and
observe the pupillary reflex when their fixation shifts to the near
target
- Normal response – Brisk constriction of pupils.
3) Swinging Flashlight-test
- What it assesses – Relative afferent papillary defect
- How to perform it – In a dimly lit room, a light source is
alternatively switched from one eye to the other and back, thus
stimulating each eye in rapid successionResponse – A right
relative defect is characterized by the following (Cor, 2019)

e. How to do Intraocular pressure examination (tonometry) ?

Answer:
1. Instil the local anaesthetic drops and then the fluorescein. Only a
very small amount of fluorescein is needed

25
 2. For measuring the IOP in the right eye, make sure the slit beam
is shining onto the tonometer head from the patient’s right side;
for the left eye, the beam should come from the patient’s left side
3. Move the filters so that the blue filter is used to produce a blue
beam
4. Make sure the beam of light is as wide as possible, and that the
light is as bright as possible. This makes visualising the
fluorescein rings easier (with the slit diaphragm fully open)
5. Ask the patient to look straight ahead open both eyes wide, fix his
or her gaze and keep perfectly still
6. With the thumb, gently hold up the patient’s top eyelid, taking
care not to put any pressure on the eye
7. Direct the blue light from the slit lamp or the Perkins tonometer
onto the prism head
8. Make sure that the tonometer head is perpendicular to the eye
9. Move the tonometer forward slowly until the prism rests gently
on the centre of the patient’s cornea, with the other hand, turn the
calibrated dial on the tonometer clockwise until the two
fluorescein semi-circles in the prism head are seen to meet and
form a horizontal ‘S’ shape. (Note: the correct end point is when
the inner edges of the two fluorescein semi-circle images just
touch)
10. Note the reading on the dial and record it in the notes
11. Withdraw the prism from the corneal surface and wipe its tip
12. Repeat the procedure for the other eye
13. Wipe the prism with a clean, dry swab and replace it in the
receptacle containing the disinfectant (Stevens et al., 2012)

f. How to do eye chambers ?

Answer:
- The flat iris will be illuminated evenly, this means that the corner
of the front eye chamber is open.
- The iris is only partially lit, bright in the flashlight but forming a
shadow in other parts, possibly the corner of the eye chamber is
narrow or closed (Paul & John, 2009)

5. Laboratory examination:

26
 Routine blood: Hb 14,2 g/dl; Ht 42%, platelets 280.000/mm3, leukocyte
8000/mm3; Blood chemistry: BSS 210 mg/dl.
a. What is interpretation of laboratory examination ?
Examination Interpretation Range normal
Hemoglobin (Hb): 14,2 g/dl Normal 13-17 g/dl
Hematocrit (Ht): 42 % Normal 40-50 %
Platelets: 280.000/mm3 Normal 150.000-450.000/mm3
Leukocyte:8000/mm3 Normal 5000-10.000/mm3
BSS: 210 mg/dl Hiperglikemia < 200 mg/dl

b. How is the abnormal mechanism of laboratory examination ?

Answer:
DM  Increased glucose in the blood  increased blood glucose
while the pancreas has decreased function to produce insulin 
buildup of glucose in the blood  unbalanced body metabolism 
hyperglycemia  BSS 210 mg/dl (Richard et all, 2018).

c. What is the correlation between BSS 210 with Mr.B’s complaints ?

Answer:
The relationship is in a state of hyperglycemia, glucose can enter the
lens of the eye by diffusion without the help of insulin. in the lens of
the atax, this glucose will be at the rate of polyol to be converted into
sorbtiol by the enzyme aldose reductase. Under normal circumstances,
this sorbitol will be converted into fructose by the enzyme polyol
dehydrogenasw. However, in hyperglycemia this enzyme has
decreased so that sorbitol will accumulate in the eye lens. Then, in the
presence of hyperglycemia, glucose has a carbonyl reactive compound
that will bind to the crystalline lens protein amino group which will
reduce the solubility level of the protein (Turk, 2016).

6. How to diagnose ?
Answer:
Anamnesis results obtained:
1) The left eye could not see suddenly and was accompanied by pain
around the eye since 2 days ago
2) Since 3 months ago headache, nausea, vomiting, and seeing rainbow
colors around the lights

27
 3) Since 1 year ago, both eyes blurred like smoke and the left eye is
getting heavier.
4) Have a history of uncontrolled diabetes mellitus since 10 years.
Physical examination results obtained:
1) on the right eye:
- vos 6/30: decreasing
- the eye lens is cloudy
- shadow test (+)
2) on the left eye:
- vod 1/300: decreased
- increased intraocular pressure in the left eye: 40 mmHg
- palpebral edema
- cornea edema
- pupil dilation
- pupillary reflex (-)
- shadow test cannot be assessed
- mixed injection
- shallow front eye chambers
Laboratory examination results obtained:
BSS 210: hyperglycemia

7. What are the differential diagnosis in this case ?

Answer:

Glaukoma sudut tertutup Katarak Uveitis

anterior
Penglihatan   
Nyeri periocular Nyeri berat - Sangat nyeri
Mata kemerahan + - +
Mual dan muntah + - +
Penglihatan berasap - + -
Ketajaman   
penglihatan
Tekanan intraocular  normal Normal/
Pupil Middilatasi normal Konstriksi
Kamera okuli dangkal normal Normal

28
anterior
Shadow test - +/- -
Mengenai sisi unilateral Unilateral/bilateral Unilateral

8. What are the additional examination in this case ?

Answer:
1) Gonioscopy: to distinguish glaucoma caused by angle closure or not.
2) Funduscopy with dilated pupil: to assess the optic disc.
3) Color blind examination: to rule out neuropathy other than glaucoma.
4) Perimetry or visual field examination
5) Field view test
6) HbA1C examination: to confirm the diagnosis of diabetes mellitus as
a risk factor for glaucoma (Kanski JJ dan Bowling B, 2011)

9. What is the working diagnose in this case ?

Answer:
The Right eye: Immature Senile Cataract
The left eye: Glaukoma Acute et causa Immature Senile Cataract

10. How is the treatments in this case ?

Answer:
Pharmacology
Glaucoma: opens corners
1) Beta-blockers: Timolol maleate 0.25 - 0.50%, 1-2 drops a day
(inhibits the production of aqueos humor).
2) Carbonic anhydrase inhibitor (systemic): Acetazolamide 250 mg, 4
times 1 tablet (inhibits the production of aqueos humor)
3) Kcl 0,5gr 3x / daySymptoms therapy
Education
1) Do not drink too much water immediately, as this can increase the
pressure
2) Do not get emotional (confused and afraid) can cause acute attack
3) Do not read closely resulting in miosis or small pupils will attack
glaucoma with pupil block
4) Refer an eye specialist for surgery
Non-pharmacological
Cataract Surgery

29
 1) ECCE (Extra Capsule Cataract Extraction).
2) Phaco Emulsification (can be used in immature cataracts).
Glaucoma Surgery
If the maximum medication fails to hold the eye pressure below 21 mmHg
and the field of vision continues to reverse, surgery is performed. The type
of surgery used is Elliot's trepanation or Scheie sclerotomy surgery.
Recently, the operation that has become popular is trabeculectomy. This
surgery requires a microscope (Ilyas S, Yulianti SR, 2015)

11. What are the complication in this case ?

Answer:
1) Chronic glaucoma: Inadequate management can lead to a progressive
course of glaucoma.
2) Damage to the optic nerve: Nerve damage in glaucoma generally
occurs due to increased intraocular pressure. The higher the
intraocular pressure, the more severe the nerve damage that occurs.
3) Blindness: Poor control of intraocular pressure will cause further
damage to the optic nerve and decrease vision leading to blindness

12. What is the prognosis in this case ?

Answer:
Cataract
Quo ad vitam : dubia ad bonam
Quo ad fungsionam : dubia ad bonam
Glaukoma
Quo ad vitam : dubia ad bonam
Quo ad fungsionam : dubia ad malam
Prognosis of glaucoma sufferers by disease, degree of optic nerve damage,
IOP, fragility of the optic nerve papillary disc, whether or not other
systemic diseases, speed and accuracy of treatment and treatment of
treatment given. Patients who are old, high IOP who are not responsive to
treatment, sufferers of other systemic diseases, patients who are late
receiving treatment, patients who do not comply with drug use have a
worse prognosis so they are more likely to experience blindness
(Giangiacomo & Coleman, 2009).

13. What is the SKDU in this case ?

Answer:

30
 Cataract
Capability Level 2: diagnose and refer Doctor graduates are able to make a
clinical diagnosis of the disease and determine the most appropriate
referral for further patient management. Doctor graduates are also able to
follow up after returning from referral.
Glaukoma
Capability Level 3: diagnose, perform initial treatment, and refer 3B
(Emergency): Doctor graduates are able to make clinical diagnoses and
provide preliminary therapy in an emergency to save lives or prevent
severity and / or disability in patients. Doctor graduates are able to
determine the most appropriate referral for further patient management.
Doctor graduates are also able to follow up after returning from referral.

14. What are the islamic point of view in this case ?

Answer:
“If I test my servant with a disease in both eyes, then he is able to be
patient, then I will replace him with heaven. intent (habibataihi) is his two
eyes” [HR. Bukhari No.5221] So the meaning, Mr. B who suffered from a
disease in his eye was one of the tests from Allah, so Mr. B is expected to
be sincere and patient and always pray and try to be given healing.

2.7 Conclusion
Mr. B 55 years old, complained blurred vision in both eyes due to Immature
Senile Cataract and complained the left eye couldn’t see, pain, headache,
nausea, vomiting, and often saw rainbow colors around the light bulb he saw
due to Acute Glaucoma of the left eye et cause Immature Senile Cataract in
both eyes

31
 2.8 Conceptual framework
History of Diabetes Melitus 10 years ago Age factor of 55
years old

Collection of sorbitol in the lens eye Degenerative

process

The eye lens is cloudy

blurred and smoky vision Immature Senile Cataract in both eyes

Increased intraocular pressure

Pressing the optic nerve from the papilla

Stimulates the autonomic nervous system

Acute glaucoma of the left eye

Pain Headache Nausea Vomitting The left eye

couldn’t see

32
 DAFTAR PUSTAKA

Basak SK. Essentials of Opthalmology, 6th edition. New Dehli: Jaypee Brothers Medical
Publisher; 2016. P. 427-447

Blanco AA. 2012. Surgery of angle closure glaukoma in basic and clinical science course.
USA: American Academy of Opthalmology

Cor, P. G. (2019). Pupil : Assessment and diagnosis. 167–171

Faradilla N. (2009). Glaukoma dan Katarak Senilis. Riau: Fakultas Kedokteran University
of Riau

Giangiacomo, A., & Coleman, A. L. (2009). The Epidemiology of Glaucoma. Glaucoma,

13–21. https://doi.org/10.1007/978-3-540-69475-5_2

Guyton, A. C., Hall, J. E. 2014. Buku Ajar Fisiologi Kedokteran. Edisi 12.Jakarta : EGC

Ilyas S, Yulianti SR. 2015. Ilmu penyakit mata, edisi 5. Jakarta:Badan Penerbit : FKUI

Kiziltoprak, H., Tekin, K., Inanc, M., & Goker, Y. S. (2019). Cataract in diabetes mellitus.
World Journal of Diabetes, 10(3), 140–153. https://doi.org/10.4239/wjd.v10.i3.140

Kowalak. 2017. Buku Ajar Patofisiologi. Jakarta: EGC

33
Lam D, Rao SK, Ratra V, Liu Y, Mitchell P, King J, Tassignon MJ, Jonas J, Pang CP,
Chang DF. Cataract. Nature Reviews Disease Primers. 2015 Jun 11;1:15014

McMonnies CW. Glaucoma history and risk factors. J Optom. 2017;10(2):71-8

Mita, R. S., & Husni, P. (2017). Pemberian Pemahaman Mengenai Penggunaan Obat
Analgesik Secara Rasional Pada Masyarakat. Aplikasi Ipteks Untuk Masyarakat, 6(3),
193–194

Pan Y, Varma R. Natural history of glaucoma. Indian J Ophthalmol. 2011;59:519-523

Price Sylvia A, Wilson Lorraine M. Patofisiologi: Konsep Klinis Proses-Proses Penyakit.

Jakarta: EGC; 2012

Richard S, et all. 2018. Tissue-specific effects of aldose reductase inhibiton on fluorescence

and cross-linking of extracelullar atrix in chronic galactosemia. Relationship to
pentosidine cross-link. 1049-1056

Sari, E., & Aditya, M. (2016). Acute glaucoma with immature cataract oculi right et left. J
Medula Unila, 4 (3), 46–50

Snell, Richard S.,M.D,PhD. Anatomi Klinis:Berdasarkan Sistem. Jakarta: EGC;2012

Stevens, S., Gilbert, C., & Astbury, N. (2012). How to measure intraocular pressure:
Applanation tonometry. Community Eye Health Journal, 25(79–80), 60

Turk.2016. Temporal Association between Lens Protein Glycation and Cataract

Development in Diabetic rats.Acta Diabetol. 49-54

Vaughan, Asbury. Oftalmologi Umum. Glaukoma. Optik dan Refraksi. Edisi ke- 17.
Jakarta: EGC; 2010. hal.212-398.

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