You are on page 1of 20

INFECTION AND

IMMUNOLOGY
DIVISION
DIA/ CES/ EGA/ TAN/ VAT
Mr. M/ 66 y.o.
adm. On October 16th 2018
Chief complaint: Blurred vision
Blurred vision on his right eye since 3 months ago, getting worse since 3 days
before admission. Redness (-) Pain (-) Tearing (+) Glare (-) Discharge (-). His left
eye cannot see since 5 years ago.
History of previous eye disease: Glaucoma, routinely controlled at Saiful Anwar
Hospital, herpetic keratitis since 2 weeks before admission.
History of surgery:
 Cataract surgery on the right eye: 5 months ago at Saiful Anwar hospital
(Phacoemulsification + IOL with difficulty: PCR and complication: vitreous
prolapse)
 Cataract surgery on the left eye 16 years ago
History of therapy : Timol ed 0,5% 2x1 RLE from glaucoma division, Hervis eo 5x1
RE, Vigamox ed 6x1 RE, C. Lyteers ed 6x1 RE from Saiful Anwar Hospital.
History of trauma (-)
History of wearing spectacle (+) : RLE -11.0 since 6 years ago
History of systemic disease: hypertension (-), diabetic (-)
General Condition
BP: 130/90 mmHg
HR: 88 times/mnt, RR: 18 times/ mnt
Summary Of
Database
Oct 16th 2018

RIGHT EYE LEFT EYE


1/300 Visual Acuity Light perception (+) bad projection
Pain (-) GM Pain (-)

Spasm (-), edema (-) Eyelid Spasm (-) edema (-)


CI (+) min, PCI(-),Discharge(-) Conjunctiva CI (+), PCI (-), Discharge (-)
White kp’s (+) brown kp’s (+) Cornea keratopathy (+), neovascular (+)
fl test (+) dendrit epithelial defect,
hazy (+), neovascular (+), suture Σ
5 loose, Σ 1 tga
deep, flare gr III cell gr III Anterior
Chamber
Posterior synechiae @7-11 o’clock Iris
Dte
midmidri, PR(-) Pupil
IOL in the sulcus, iris pigment (+) Lens
12 mmhg IOP 30 mmhg
RLE USG
October 16th 2018

RE USG LE USG

 Posterior capsule : intact  Posterior capsule : intact


 Vitreous anterior – media - posterior :  Vitreous anterior – media - posterior :
echodense (+), medium spike echodense (-)
 Retina : on place  Retina : on place
 Choroid : wnl  Choroid : wnl
 ONH : on place  ONH : on place
Laboratory Result
October 16th 2018

 Hb : 14,80 g/dL • RBS: 130 mg/dl

 RBC : 4,93 x 106/µL • Ureum : 20,7 mg/dL

 WBC : 7,79 x 103/µL • Creatinin : 0,98 mg/dL

 Hct : 44,0 %

 Plt : 306 x 103/µL


Diagnosis
RE chronic post operative endophthalmitis + herpetic keratitis
+ Pseudofakia
LE nearly absolute glaucoma + keratopathy

Planning
• RE intravitreal injection Vancomycin 1mg/ 0,1ml + vitreous tap + aff
corneal suture / LA
• Inf. Ciprofloxacin 2 x 400 mg IV
• Prednison 1 mg/kgBW (60 mg – 0 – 0)
• Kalk 1 x 1 tab
• Ranitidin 2 x 1 tab
• Vigamox ed 6 x 1 RE
• SA 1% ed 3 x 1 RE
• C.Lyteers ed 6 x 1 RLE
• Timol ed 0,5% 2x1 LE ~ Glaucoma subdivision
• Consult to Internal Medicine Dept.
RE intravitreal inj
vancomycin 1mg/0.1ml + Vitreous tap
+ Aff corneal suture/ LA

Performed : October 16th, 2018


Diff : -
Compl : -
Vitreous tap: minimal
Internal Medicine Dept.
There’s no contraindication of steroid
administration in this patient
FOLLOW UP DAY 1 DAY 2
RIGHT EYE October 17th, 2018 October 18th, 2018

Subjective Pain (-) Pain (-)


VA 1/60 1/60
Palpebra Spasm (-) , Edema (-) Spasm (-) , Edema (-)
Conjunc
SCH (+), chemosis (+), CI (-) PCI(-) SCH (+) ↓, chemosis (+) ↓, CI (-) PCI(-)
tiva
Cornea white kp’s (+), brown kp’s (+), white kp’s (+), brown kp’s (+), fl test (+)
neovascular (+), fl test (+) dendrite dendrite epithelial defect, punctat
epithelial defect, punctat erotions (+), erotions (+), neovascular (+),
, suture Σ 1 tga suture Σ 1 tga

AC deep, flare grade III, deep, flare grade II,


cell grade III cell grade II
Iris synechia 7-11 o’clock synechia 7-11 o’clock
pupil midmidri ec SA 1%, PR(-) midmidri ec SA 1%, PR(-)
Lens IOL in the sulcus, iris pigmen (+) IOL in the sulcus, iris pigmen (+)

IOP 8 mmHg 12 mmHg


DAY 1 DAY 2
October, 17th 2018 October 18th 2018

USG examination: USG examination:


• Posterior capsule : intact • Posterior capsule : intact
• Vitreous anterior – posterior : • Vitreous anterior – posterior :
echodense (+), low-medium spike echodense (+), low-medium spike
• Retina : on place • Retina : on place
• Choroid : wnl • Choroid : wnl
• PNII : on place • PNII : on place
FOLLOW UP DAY 1 RE USG day 1-5
LEFT EYE October 17th, 2018
VA Light perception (+) bad
projection
Palpebra Spasm (-) edema (-)
Conjunc CI (+), PCI (-), Discharge
tiva (-)
Cornea keratopathy (+),
neovascular (+)  Posterior capsule : intact
AC dte  Vitreous anterior – media -
posterior : echodense (-)
Iris dte  Retina : on place
 Choroid : wnl
pupil dte  ONH : on place
Lens dte
IOP n+1/p
DAY 1 DAY 2
October 17th, 2018 October 18th, 2018
A RE chronic post operative RE chronic post operative
endophthalmitis post intravitreal endophthalmitis post intravitreal injection
injection vancomycin 1mg/0,1ml + vancomycin 1mg/0,1ml + herpetic
herpetic keratitis + Pseudofakia keratitis + Pseudofakia
LE nearly absolute glaucoma + LE nearly absolute glaucoma +
keratopathy keratopathy

P • Inf. Ciprofloxacin 2 x 400 mg (II, III) • Inf. Ciprofloxacin 2 x 400 mg (IV, V)


• Prednison 60 mg – 0 – 0 • Prednison 60 mg – 0 – 0
• Kalk 1 x 1 tab • Kalk 1 x 1 tab
• Ranitidin 2 x 1 tab • Ranitidin 2 x 1 tab
• Vigamox ed 6 x 1 RE • Vigamox ed 6 x 1 RE
• SA 1% ed 3 x 1 RE • SA 1% ed 3 x 1 RE
• C.Lyteers ed 6 x 1 RLE • C.Lyteers ed 6 x 1 RLE
• Timol ed 0,5% 2x1 RLE ~ • Autolog serum 20% 1drop/hour RE
Glaucoma division • Timol ed 0,5% 2x 1RLE ~ Glaucoma
division
• Pro intravitreal injection Vancomycin
1mg/0,1 ml / LA
• RE intravitreal inj
vancomycin 1mg/0.1ml

Performed : October 18th, 2018


Diff : -
Compl : -
FOLLOW DAY 3 DAY 4
UP October 19th, 2018 October 20th, 2018
RIGHT
EYE
Subjective Pain (-) Pain (-)
VA 1/60 1/60

Palpebra Spasm (-) , Edema (-) Spasm (-) , Edema (-)

Conjunc SCH (+), chemosis (+), CI (-) SCH (+) , CI (+) PCI(+)
tiva PCI(-) chemosis (+) ↓ discharge (-)

Cornea white kp’s (+), brown kp’s (+), fl test (+) epithelial corneal
fl test (+) dendrite, punctat, defect size. 1,8x1mm
chemosis (+), neovascular (+), suture Σ 1 tga, white kp’s (+)
suture Σ 1 tga brown kp’s (+), neovascular (+)
AC deep, flare grade III, deep, flare grade II,
cell grade III cell grade II
Iris Posterior synechia 7-11 Posterior synechia 7-11 o’clock
o’clock
pupil midmidri ec SA 1%, PR(-) midmidri ec SA 1%, PR(-)

Lens iris pigmen (+) iris pigmen (+)


18,9 mmHg n/p
DAY 3 DAY 4
October, 19th 2018 October 20th 2018

USG examination result while


hospitalized
• Posterior capsule : intact
• Vitreous anterior – posterior :
echodense (+), low-medium spike
• Retina : on place
• Choroid : wnl
• PNII : on place
DAY 3 DAY 4
October 19th, 2018 October 20th, 2018
A RE chronic post operative RE chronic post operative endophthalmitis
endophthalmitis post intravitreal injection post intravitreal injection vancomycin
vancomycin 1mg/0,1ml+vitreous tap+ 1mg/0,1ml+vitreous tap+epithelial corneal
herpetic keratitis + secondary glaucoma defect + secondary glaucoma
LE nearly absolute glaucoma + LE nearly absolute glaucoma +
keratopathy keratopathy

P • Inf. Ciprofloxacin 2 x 400 mg (VI, • Inf. Ciprofloxacin 2 x 400 mg (VIII, IX)


VII) • Prednison 60 mg – 0 – 0
• Prednison 60 mg – 0 – 0 • Kalk 1 x 1 tab
• Kalk 1 x 1 tab • Ranitidin 2 x 1 tab
• Ranitidin 2 x 1 tab • Vigamox ed 6 x 1 RE
• Vigamox ed 6 x 1 RE • SA 1% ed 3 x 1 RE
• SA 1% ed 3 x 1 RE • C.Lyteers ed 6 x 1 RLE
• C.Lyteers ed 6 x 1 RLE • Autolog serum 20% 1drop/hour RE
• Autolog serum 20% 1drop/hour RE • Noncort ed 4x1 RE → Stop
• Noncort ed 4x1 RE • Timol ed 0,5% 2x1 LE ~ Glaucoma
• Timol ed 0,5% 2x1 LE ~ Glaucoma division
division • Consult to Vitreoretina division
• Consult to Vitreoretina division
Vitreoretina Division