CASE REPORT

Vitreoretina
Subdivion
Jehan Fauzi Rakhmandani
PATIENT’S IDENTITY
• Name : Mr. M
• Age : 70 years old
• Address : Pacitan
• Occupation : Farmer
• MR : 01.92.04.48
• Day of Visit : January 13th, 2020
Chief Compaint
Blurry vision of Left Eye
HISTORY OF PRESENT ILLNESS

2W BDOV 1W BDOV Days DOV

• Blurred vision • He Use the eye • Blurred vision

on eyes when drop from persisted. He
he woke up. Pharmacy saw an
Redness (-), • And blurred ophtalmologist
tearing (-), vision and referred to
persisted.
Pain (-) SGH
History of Past Illness
(and Risk Factors)

• Hypertension (+)
• Diabetes Mellitus (-)
• Dyslipidemia (?)
• Active smoker (-)
• Cardiovascular disorder (-)
• Blood clotting disorder (-)
• Glaucoma (-)
History of Family Illnesses
• Hypertension (- )
• Diabetes (-)
• Cardiovascular diseases (-)
 RIGHT EYE EXAMINATION
6/15 PH 6/7.5 VISUAL ACUITY
Within normal limit EYE LID
Within normal limit CONJUNCTIVA
Clear CORNEA
Deep, Clear CAMERA OCULI ANTERIOR
Round, Central, Ǿ 8 mm, LR -/- (on tropicamide 0.5%) IRIS / PUPIL
Clear LENS
Clear VITREUS BODY
Sharp demarcation, CD 0,3 PAPIL
Reflex (+) MACULA
a/v ratio: 1/3,av crossing + RETINA
13 IOP
Free OM
8
Visual Acuity HM G/G
Eye Lid Within normal limit
Conjunctiva Within normal limit
Cornea clear

Ant. Chamber Deep, Clear

Iris / Pupil Round, Central, Ǿ 8 mm, LR -/- (on tropicamide 0.5%)

Lens clear
Vitreus Body Clear
ONH Sharp demarcation, CD 0.3
Makula Reflex (+) , edema (+)
a/v ratio: 1/3, flame shape haemorrage (+), cotton wool spot, slightly
Retina
turtous vein, ghost vessel (+)
IOP 14 mmHg
10
OM Free