Name of examinee NIM Date of examination Examiner

: Ajeng Rizki Paramita Sari : 05-071 : February 21th, 2011 : Prof.DR.Dr J.H.A MANDANG SpM

I.

PATIENT IDENTITY Name Age Address Occupation Religion : Mr. R : 43 Years old : Bercak Jagotirto , sleman - jogjakarta : sand miners : Moslem

II.

ANAMNESIS Main complains : Sudden pain, redness, blurred vision on the right eye. Additional complains : Headache and nausea.

History of Disease Patient came to Dr. Yap Eyes Hospital Yogyakarta with main complains sudden pain, redness, and blurred vision on his right eye. The pain felt deep in the eye ball and spread to forehead. Besides that, its also followed by headache and nausea too. These complain had been happening for 2 days. Patient taken an eye drop (Visine) and Paramex to reduce those symptoms but it didnt getting better and then he decided to go to the hospital to receive better treatment. This similar complains had not found on the rest of his family member.

Previous disease The patient said that there is no history of trauma on his right eye and he never had the same symptoms like this before.

III.

GENERAL STATUS General condition : Appearance of severe illness Complains-related symptoms : not found

IV.

OPHTALMIC STATUS A. General Examination

Right Eye Around Eye Appearance General Condition of
Quiet Severe illness

Left Eye
Quiet Well

The Eye Ball Eye ball position Eye ball movement

Symmetric Normal Symmetric Normal

B. Systematic Examination
Right Eye Visual Acuity Correction
1/60 Cant be corrected

Left Eye
6/6 -

Palpebra Superior/Inferior Tarsal Conjunctiva Bulbar Conjunctiva Cornea Anterior Chamber

Edematous

Quiet

Hyperemic Ciliarys injection Edematous Narrow anterior chamber angle

Quiet Quiet Clear Normal

Iris Pupil

Radier

Radier

Round,Isokor, Light Reflex (+)

Round,Isokor, Light Reflex (+)

Clear 18,5 mmHg

Lens Schiotzs tonometer

Turbid 45,8 mmHg

V.

RESUME Patient, Mr. R, 43 years old came to Dr. Yap Eyes Hospital with main complains sudden pain, redness, and blurred vision on his right eye. The pain felt deep in the eye ball and spread to forehead. Besides that, its also followed by headache and nausea too. These complain had been

happening for 2 days. Patient taken an eye drop (Visine) and Paramex to reduce those symptoms but i t didnt getting better and then he decided to go to the hospital to receive better treatment. This similar complains had not found on the rest of his family member.

From General Examination on The Right Eye Founded: General condition of eye ball: Appearance of severe illness

From Systematic Examination on The Right Eye Founded: Visual acuity : 1/60, cant be corrected

Palpebra superior/inferior : Edematous Tarsal conjunctiva Bulbar conjunctiva Cornea Anterior chamber Pupil Lens Schiotzs Tonometer : Hyperemic : Ciliarys injection : Edematous : Narrow anterior chamber angle : Dilated, light reactive (-) : Turbid : 45,8 mmHg

VI.

CLINICAL DIAGNOSE Right Eye Acute congestive /primary angle closure Glaucoma Left Eye Normal

VII.

DIFFERENTIAL DIAGNOSE

Right Eye Acute anterior uveitis

Left Eye -

VIII. MEDICAL TREATMENT For The Right Eye Acetazolamite 500 mg I.V. then 250 mg tablet, 1 tablet orally 4 times daily Timolol 0,25 %,1 drop 2 times daily Pilocarpine 2 %, 1 drop/minute in 5 minutes, then 1 drop/hour in 6 hours

If necessary: Oral glycerin 50 % in a dose 2-3 ml/kg of body weight Vitamin K 300 mg tablet, 1 tablet orally 3 times daily

If the intraocular pressure remains increased and the visual field show progressive loss, surgery might be advised (Iridectomy)

For The Left Eye Preventive peripheral I ridectomy Screening examination: every 1 year or less.

IX.

PROGNOSIS Right Eye Ad vitam Ad sanationum Ad functionum Bonam Dubia ad bonam Dubia ad malam Left Eye Bonam Bonam Bonam

X.

COMPLICATION

Right Eye Absolute Glaucoma Blindness

Left Eye Acute Glaucoma

ACUTE GLAUCOMA

EXCAVATIO GLAUCOMATOSA DEXTRA

EXCAVATIO GLAUCOMATOSA SINISTRA

TONOMETER

GONIOSCOPY

IRIDECTOMY

10