By:

U s wat u n H a s a n a h
19360154
Preceptor:
d r. R a h m a d Sy u h a d a , S p . M ( K )
 Patient identity
Name : Mrs. H
Gender : Woman
Age : 56th years old
Occupation : Housewife
Marital status : Merried
Religion : Non Muslim
 Anamnesis
Performed by autoanamnesis on 13 November 2019

Additional Complaints
Main complaint
Sticky eyelid, itchy eyelid,
The right eyelid is swollen and
frequent eye discharge, and
red
watery eye
Current Disease History

Os came to Eye Polyclinic at

Pertamina Bintang Amin Hospital
with complaints the right eyelid
was swollen and red since 3 days.
Os also complained Sticky eyelid,
sometimes the eyelid was itchy,
frequent eye discharge and watery
eye at OD. Os had similar
symptoms about 4 month ago and
its intermitten. Os has a habit of
using make up.
Past medical history: Hypertension (-), DM (-)

Family history: none

Allergy history: none

Treatment history: Os ever consumption drugs when she had the

first symptomps like this. The drugs are cendovital, diclofenac
sodium, cendohyalub and dexametason.
Physical examination
Status Present
• General circumstances : Good
• Awareness : Composmentis
• Vital sign
- Blood pressure: 120/80 mmHg
- Pulse : 80 times / minute
- Temperature : 36℃
- Breathing : 20 times / minute
Generalist status
• Head : normal
• Thoraks : normal
• Abdomen : normal
• Upper limb : normal
• Lower extremity : normal
Ophtalmology status
OD OS
20/50 Visus 20/70
Hyperemis (+) tenderness (-) Palpebra Superior Hyperemis (-) tenderness (-)
Edema (+) Edema (-)
Hyperemis (-) tenderness (-) Palpebra Inferior Hyperemis (-) tenderness (-)
Edema (-) Edema (-)
Papil (-) Folikel (-) Konjungtiva palpebra Papil (-) Folikel (-)
Papil (-) Folikel (-) Konjungtiva fornices Papil (-) Folikel (-)
Injection Konjungtiva (-) Injection siliar (-) Secret (+) Konjungtiva bulbi Injection konjungtiva (-), Injection siliar (-) Secret (-)

white, clear Sclera white, clear

Clear, Edema (-), Sikatriks (-), keratic Kornea Clear, Edema (-), Sikatriks (-), keratic persipitate (-)

persipitate (-)
Hipopion (-), hifema (-), flare (-) Camera oculi anterior Hipopion (-), hifema (-), flare (-)

Blackish brown color, sinekia posterior (-) Iris Blackish brown color, sinekia posterior (-)

Round, light reflex (+) Pupil Round, light reflex (+)

Clear Lensa Clear
Supporting investigation

Tonometry to determine intaocular

pressure
TIOD : 14,5
TIOS : 13,2
 Medical Resume
Mrs. H came to Eye Polyclinic at
Bintang Amin Hospital with complaints
the right eyelid was swollen and red
since 3 days. Os also complained Sticky
eyelid, sometimes the eyelid was itchy,
frequent eye discharge, and watery eye at
OD.
Generalist Status: All of Normal
Ophthalmology status was found OD
with 20/50 vision (Not progress using
pinhole) and OS with 20/70 (correction
with lens -1,25 be 20/30), Edema and
hyperemis at palpebra superior dextra.
 Diagnosis

Differential Work Diagnosis

Diagnosis
Blepharitis OD
Blepharitis OD

Chalazion OD

Palpebra’sTumor OD
 Management
• Warm compresses
Non Farmakologik • Keep hygene of eyes
• Avoid the trigger factors

R/ Ceftriaxon tab no. X

S 2 dd 1
Farmakologik
R/ Cendo mycos eye ointment no. I
S 4 dd UE OD

R/ Cetirizine tab no. X

S 2 dd 1

R/ Metilprednisolon tab no. X

S 2 dd 1
Prognosis

Quo ad vitam
Ad bonam

Quo ad functionam
Ad bonam

Quo ad sanationam
Ad bonam
 Definition
Literature common inflammation of the eyelids that is marked by
Review red, scaly, crusting eyelids and a burning, itching, grainy
feeling in the eye.

Etiology

•Allergic :
Dust, smoke, cosmetics, irritative chemicals

• Bacterial :
Streptococcus alfa or beta, pneumococcus and pseudomonas

• Viral :
Herpes zoster, Herpes simplex

• Fungal :
Actinomyces, Nocardia
 Classification
Based on the site
a. Anterior
b. Posterior

Based on the cause

a. Bacterial Blepharitis
b. Viral Blepharitis
c. Fungal Blepharitis
d. Allergic Blepharitis
 Supporting investigation

1. Slit lamp

2. Skin swab
 Management
• Warm compresses
Non
• Keep hygene of eyes
Medikamentosa • Avoid the trigger factor

• Blepharitis Allergic : Steroid, Antihistamin

• Blepharitis Bacterial : Local and sistemic Antibiotic
Medikamentosa • Blepharitis Viral : Asiclovir and IDU
•Blepharitis Fungal : Griseofulvin, Amfoterisin B
 Prognosis

Blepharitis prognosis is generally good.

Blepharitis very rarely causes vision
problems and significant morbidity.
Thank You