CASE PERSENTATION 2

HORDEOLUM INTERNUM
STAGE INFILTRATE OS

Fika Anugrah Zulfathon

H1A014024
 1.
Background
Let’s start with the first set of slides
Inflammation of the
eyelid.
▪ Blepharitis,
▪ Hordeolum,
▪ Kalazion and
▪ Ophthalmic herpes zoster.

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Hordeolum is suppurative
inflammation due to
infections in the glands of
Zeis and Moll (hordeolum
externum), Meibomian
glands (hordeolum
internum). 4
Hordeolum
Internum
Internal hordeolum can lead to skin or
to the surface of the conjunctiva.
Eksternum
External Hordeolum is an infection of
the Zeis or Moll glands, which always
leads to the skin.

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▧ The most caused by Staphylococcus,
usually Staphylococcus aureus.
▧ The patients present localized area with
redness, tenderness and swelling
▧ Hordeolum to ocuur in younger people,
but are not limited to any age,gender, or
racial group

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 2.
Case Report
Patient Identity

▧ Name : Mr. AS
▧ Age : 18 years old
▧ Gender : Male
▧ Address : Kekeri-Gunungsari
▧ Religion : Muslim
▧ Date of review: November 11, 2019
▧ MR : 04 25 98 8
a. Main complaint : mass in the left eyelid
b. History of Current Disease :
Patient came to Ophthalmology Clinic of General Hospital
NTB with mass in left eyelid superior.
The mass grew since 4 days ago in the superior of the left
palpebral with pain, redness and itchy.

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▧ c. Past medical history :
○ Patient has complaint like this 1 years ago
▧ d. Family Disease History :
○ The history of diabetes, hypertension, and asthma in the
family is also denied by the patient.
▧ e. Medical History :
○ -

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▧ General condition : Fine
▧ Awareness : Compos mentis
▧ Vital signs:
• Blood pressure : 110/70 mmHg
• RR : 18 x / min
• Pulse : 68 x / min
• Temperature : 36.5 C

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 OPHTHALMOLOGY STATUS
No Examination OD OS
1. Vision 6/6 6/6

2. Eye Position Ortophoria Ortophoria

3. Eye Movement All direction All direction

4 Vision field Same with Same with examiner

examiner

5. Superior Edema (-) (+)

Palpebra Hyperemia (-) (-)

Pseudoptosis (-) (+)
Entropion (-) (-)
Extropion (-) (-)
Spasme (-) (-) 12
6. Inferior Palpebra Edema (-) (-)
Hyperemia (-) (-)
Entropion (-) (-)
Extropion (-) (-)
7. Superior Conjungtival Hyperemia (+) (+)
Edema (-) (+) In the temporal
Palpebra
section, the irregular oval
shape, pale, prominent,
hyperemia, size ± 0.5 mm
Sicatrics (-) (-)
pain (+) (-)
8. Inferior Conjungtival Hyperemia (-) (+)
Cobble stone (-) (-)
Palpebra
Cikatrics (-) (-)
Swollen (-) (-)

9. Bulb Conjungtiva Conjungtival and Siliar (-) (-)

injection
Bleeding (-) (-)
Mass (-) (-)
Edema (-) (-)
10. Cornea Shape Convex Convex

Clarity Clear Clear

Surface Smooth Smooth
Sicatrics (-) (-)
Foreign body (-) (-)
Massa (-) (-)
11. COA Depth Depth Depth
Hyfema (-) (-)
Hypopion (-) (-)
12. Iris Colour Brown Brown
Shappe Round, regular Round, regular
13. Pupil Shape Round, 3 mm Round, 3 mm
RCL (+) (+)
RCTL (+) (+)
14. Lens Transparent Transparat
Palpation N N 14
15. TIO
Okular Dextra Okular Sinistra

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 PROBLEM IDENTIFICATION

▧ OBJECTIVE
○ Visus ODS 6/6
▧ SUBJECTIVE
○ Swollen and there is
mass in the left
a. Mass in left eyelid palpebra superior with
hyperemic,and
tenderness.
○ Irregular mass with
hyperemic around in
tarsal conjungtiva.

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 Problem Analyze
• Male, 18 Yo
• Mass in left eyelid
• Hyperemic, Pain, uncomfortable
• History (+) 1 years ago

• Mass in the left eyelid superior suspected came from inflammation of hordeolum
• The mass located in the medial part of left superior palpebral direct to tarsal conjugtiva.
Inflammation is likely to occur in the meibom glands.

• The mass with white pile and hiperemic is clearly visible when the eversion test was done
•DD : Kalazion or Blepharitis

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Image 5. Meibom gland 18
Assessment
▧ Working Diagnosis : Hordeolum Internum stage infiltrat OS
▧ DD : Kalazion, blepharitis

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ADVANCED EXAMINATION
PLANNING
▪ -

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Management
▧ Medicine - Cefadroxil oral 500 mg 2x1
- warm compresses in 10 ▧ Surgery:
minutes ○ Insision and curetage
- Mefenamic Acid 500 mg 3x1
- Chloramphenicol 1% EO 4x1

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Education &
Prognosis
▧ Tell the pasient about the hordeolum diagnose and if the
medication don’t work then the dissection is needed to
remove the lump
▧ Personal hygine, always wash hands with soap and don’t
rub the eyes to avoid the bacterial spreads
▧ Prognosis in this patient : dubia ad bonam
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Conclusion
▧ Men, 18 years old came with a mass in eyelid superior,
since 4 days with pseudoptosis, hyperemic,and tenderness
▧ In physically, visus naturalis ODS 6/6. Found the mass in
left konjungtiva tarsal superior, irregular, hyperemic, size ±
0,5 cm.
▧ The work diagnosis is Hordeolum Internum stage infiltrat
OS 23
Thanks!
Any questions?

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