KEMENTERIAN KESIHATAN MALAYSIA Tel : 05 - 689 6600

HOSPITAL SERI MANJUNG Faks : 05 - 688 4013

32040 SERI MANJUNG Web : http://hsmanjung.moh.gov.my
Email : hsmanjung.moh.gov.my
PERAK DARUL RIDZUAN

To,
                                                                                                                      
Vitreoretinal Surgeon,
Ophthalmology Department,
Hospital Raja Permaisuri Bainun,
Ipoh, Perak                                                                                                                                    28th June 2022
                                                                                                                 

Dear Doctor, 

REF                    : DARESEMI BT KASILAN

I/C                     : 641221-71-5182
H/P                   : 05-6884686
IMPRESSION :
1.       RE RUBEOTIC GLAUCOMA SECONDARY TO ADED WITH FULL VH
2.       LE ADED WITH DME AND ERM
3. ? RE TRD SECONDARY TO ADED
4. BE CATARACT
 
 
               Thank you for seeing this patient, a 57 years old Malay female with underlying Diabetes Mellitus
type 2, and Hypertension. Patient has been under our follow up since June 2020. Patient presented with
both eyes blurring of vision for 2 months. RE VA: 6/24 (PH: 6/18), LE VA: 6/60 (PH: 6/60). BE anterior
segment was unremarkable with BE cataract and BE IOP 14mmHg. RE fundus examination showed PDR
with VH and maculopathy, LE optic disc pink, ADED with VH, DME, and ERM. She was given multiple BE
PRP laser.

On 23 March 2021, patient came to eye clinic for regular follow up. RE VA: 6/36 (PH: 6/24), LE
VA: 6/36 (PH: 6/36). She claims vision is clearer than last TCA and no eye pain or eye redness. On
examination, RE anterior segment unremarkable with presence of rubeosis iridis at 12 o’clock with IOP
23mmHg. LE anterior segment is unremarkable with IOP 12mmHg. BE gonioscopy shows open angle
with no new vessels at angle. Fundus examination RE showed full VH and LE optic disc pink, ADED with
DME and ERM and laser marks, no VH. She was given BE PRP laser and started with G. Maxidex 4 hourly
RE, G. Atropine TDS RE, and G. Xalatan ON RE. She was subsequently started with G. Timolol BD RE on
December 2021 due to IOP not decreasing more than 20mmHg.

On 21 March 2022, patient came for regular follow up with complaint of RE blurring of vision
gradually worsening for 2 months. On examination, RE VA: HM, LE VA: 6/36 9PH 6/36). BE anterior
segment was unremarkable with BE cataract and IOP RE 18mmHg, and LE 14 mmHg. RE fundus no view
due to VH, LE optic disc pink, fundus fibrous tissue overlying optic disc superiorly and inferiorly, macula
+HE and retinal thickening of macula with old VH. B-scan of RE: VH with flat retina. OCT LE: ERM, central
fovea thickness 291μm, +IRF, unable to comment on ellipsoid layer due to poor image. She was
continued on G. Atropine 1% OD RE, G. Timolol BD RE, and G. Xalatan ON RE and off G. Maxidex.
 Last review on 28 June 2022, patient came for regular follow up. She claimed her RE vision is
static with LE vision improving. No eye pain or eye redness, no floaters, no flashes. On examination, RE
VA: HM, LE VA: 6/36 (PH: 6/36). Reverse RAPD negative, BE anterior segment is unremarkable with
immature cataract and BE IOP 18mmHg. Gonioscopy BE shows open angle with no new vessels at angle.
Fundus examination RE: no view due to full VH, LE LE fundus optic disc pink, fibrous tissue overlying
optic disc superiorly and inferiorly, macula DBH and ERM, vessels, tortuous but not dilated. Noted
patient has right thumb onychomycosis and started with T. Itraconazole 100mg OD 7 days monthly for 3
months and miconazole cream LA BD. She was continued on G. Atropine 1% OD RE, G. Timolol BD RE,
and G. Xalatan ON RE. Total PRP shots RE: 7523 shots, LE: 5977 shots.

Patient has been counseled for VR surgery and she is keen for operation under local
anaesthesia. We have attached patient's blood investigations, ECG, and biometry. Kindly review this
patient and for further management. Your expertise is fully appreciated.
 
 
Thank you.
 
Sincerely,

------------------------------------------- 
Dr Mohamad Hafiz bin Mohd Azmi
Medical Officer
Opthalmology Department
Hospital Seri Manjung