Thursday, November 29th, 2012

Examiner : Prof. J.H.A. Mandang Sp.M (K)

Ophthalmology Record
Melisa Silvia 08-184
DEPARTMENT OF OPHTHALMOLOGIC MEDICAL FACULTY CHRISTIAN UNIVERSITY OF INDONESIA JAKARTA, 2012

Patients Identity
Name Sex Age Address : Mrs. B : Female : 36 years old : Pete Sidomoyon Godean, Sleman, Yogyakarta : Moslem : Bachelor : Company Employee

Religion Education Occupation

ANAMNESES (October 23th, 2012)

Chief Complaint : Pain in the right eye since 2 days ago Additional Complaint : Blurred eyes, saw the rainbow colors around lights, red eye, glare reflection ,watery, headache, nausea, vomiting

ANAMNESES (History of Disease)

Patient came with her son to the RSM DR.YAP Yogyakarta

with complaints of pain in the right eye since 2 days ago. Pain is
felt in the right eyes and around the right eye. Pain is felt tingling and long-lasting. Initially 1 month ago patient often complain of

headaches, especially at the right side of the head. Initially the

pain lasted about half an hour to 2 hours and then disappear, but over time the complaint was more often and more of the same duration, as well as pain, is increasingly growing pains.

Patient said complaint was more severe at night. Patient taking drugs reduce complaints Bodrex and sleep when complaints arise. However, the complaint was only gone a while, then came back. Patient do not go to the doctor because the patient is only considered ordinary headache. In addition, patients also complain of nausea and vomiting had 2 times as much, red right eye, watery, glare, and see the rainbow colors around lights.

Previous Disease and Family History

Previous Disease :
The patient said had never had a complaint like this before. History of Hypertension, Diabetes Mellitus, allergies and use of drugs that contain steroids are denied. History of trauma (-), eye pain before (-), wears glasses (), operations (-)

Family History :
The patients father also had this symptoms

GENERAL STATUS General Condition : Mild illness Consciousness : Composmentis Complains-related symptoms : Unremarkable OPTHALMIC STATUS General
Right Eye
Surrounding of the Eye Eye Position Eye Movement Clear Symmetric All directions Clear Clear Symmetric All directions General Condition of the Eye Clear

Left Eye

Right Eye Visual Acuity Pinhole Correction Supercillia Cillia Superior/Inferior Palpebra Tarsal Conjunctiva Superior/Inferior Fornices Conjunctiva Superior/Inferior
1/300

Left Eye

6/6 normal, madarosis (-) normal, madarosis (-) normal, madarosis (-), trichiasis normal, madarosis (-), trichiasis (-) (-) Tumor (-), ptosis (-) Tumor (-), ptosis (-) Follicle (-) follicle (-), follicle (-) Cilliary injection (-) follicle (-) Cilliary injection (-)

Systematic

Bulbar Conjunctiva Superior/Inferior Cornea : Clarity Infiltrate Ulcer Scar Neovascularization Anterior Chamber Iris Pupil

clouded shallow radier, brown round, central, light reflex (+) slow reflex, 5mm, mydriatic Hard to be examined
Narrow 60mmHg

Clear deep radier, brown round, central, light reflex (+), 3mm Clear
Wide 18mmHg

Lens : Clarity
Field of Vision Intra Ocular Pressure

RESUME
The patient, female, 36 years old, came to the doctor with chief complaint pain in the right eye since 2 days ago. Pain is felt tingling and long-lasting. Initially 1 month ago patient often complain of headaches, especially right. Initially the pain lasted about half an hour to 2 hours and then disappear, but over time the complaint was more often and more of the same duration, as well as pain, is increasingly growing pains. Patient said complaint was more severe at night. Patient taking drugs reduce complaints Bodrex and sleep when complaints arise. However, the complaint was only gone a while, then came back.

In addition, patients also complain of nausea and vomiting had 2 times as much, red right eye, watery, glare, and see the rainbow colors around lights. The patient said had never had a complaint like this before. History of Hypertension, Diabetes Mellitus, allergies and use of drugs that contain steroids are denied. History of trauma (-), eye pain before (-), wears glasses (-), operations (-).The patients father also had this symptoms

Right Eye Visual Acuity Pinhole Correction Bulbar Conjunctiva Superior/Inferior Cornea : Clarity Infiltrate clouded shallow radier, brown round, central, light reflex (+) slow reflex, 5mm, mydriatic Clear deep
1/300

Left Eye 6/6 Cilliary injection (-)

Cilliary injection (-)

From basic ophtalmologist examinations were found :

Ulcer Scar Neovascularization Anterior Chamber Iris Pupil

radier, brown round, central, light reflex (+), 3mm

Lens : Clarity
Field of Vision Intra Ocular Pressure

Hard to be examined
Narrow 60mmHg

Clear
Wide 18mmHg

CLINICAL DIAGNOSE Acute Primary Glaucoma OD

DIFFERENTIAL DIAGNOSE Acute Keratitis Acute Uveitis

ADDITIONAL EXAMINATION Slit lamp examination Funduscopy Kempimetry Gonioscopy

TREATMENT
Medication Pilocarpin 2-4% eye drops dripped 1 drop per minute for 5 minutes, followed by 1 drop every hour up to 6 hours Asetozolamid 2x250mg then 1 tablet every 4 hours for 24 hours Timolol 0,5% 2x1 Manitol 20% 1,5-2 gr/Kg body weight; 60 drops per minute (Intravenous) Surgical Trabeculectomy Iridectomy

PROGNOSIS OS Quo ad Vitam Quo ad functionam Quo ad sanationam OD Quo ad Vitam Quo ad functionam Quo ad sanationam

: bonam : dubia ad bonam : dubia ad bonam

: bonam : dubia : dubia

COMPLICATION Absolute Glaucoma OD

 Thank You