CASE REPORT

KERATITIS
By :
Eriska Ratnawati
18360196
 CASE REPORT

I. IDENTITY
 Name : Mr. S
 Age : 78 years old
 Gender :Male gender
 Job :-
 Address : Kemiling - Bandar Lampung
 MR : 11.72.47
 ANAMNESIS

Done on November 16 2018 obtained automatically.

 Main Complaints : Blurred vision in the left eye
 Additional complaints : Patients also complain of red eyes,
feeling glare when they see light,
and tears that flow continuously
 Past medical history : No history of hypertension and
diabetes mellitus
 Treatment history : beforehand go to a health center
 PHYSICAL EXAMINATION

A. Status Generalis
 General Condition : Good
 Awareness : Compos mentis
Status of Ophthalmology
OD OS
6/20 Visus 1/300
Orthoforia Status of Ophthalmology
bulbus oculli Orthoforia
Trichiasis (-) Madarosis (-) Silia Trichiasis (-) Madarosis (-)
Hiperemis (-) tenderness (-) Palprbra superior Hiperemis (-) tenderness (-)
Edema (-) Edema (-)
Hiperemis (-) tenderness (-) Palpebra inferior Hiperemis (-) tenderness(-)
Edema (-) Edema (-)
Hiperemis (-) Papil (-) Folikel (-) Conjungtiva palpebra Hiperemis (-) Papil (-) Folikel (-)

Hiperemis (-) Papil (-) Folikel (-) Conjungtiva fornices Hiperemis (-) Papil (-) Folikel (-)

Injeksi konjungtiva (-) Conjungtiva bulbi Injeksi konjungtiva (-)

Injeksi (-) Sklera Injeksi (-)
infiltrate (-) Cornea infiltrate (+)
Medium, pus (-) blood (-) Camera okuli anterior Medium, pus (-) blood (-)
Arcus sinilis Iris Arcus sinilis

light reflex (+) Pupil light reflex (+)

Cloudy Lensa Cloudy
Normal Retina Normal
 RESUME

Patients came to RSPBA ophthalmology clinic with

blurred eye complaints since 1 month ago. Patients also
complain of red eyes, feeling glare when they see light, and
tears that flow continuously. From the results of the
ophthalmology examination, VOD 6/20 (non-advanced
correction) andVOS 1/300 were obtained.
 RECOMMENDATIONS

 Gram coloring
 DIAGNOSIS DIFFERNTIAL

 Bacterial keratitis Os
 Distrofi kornea
 Uveitis
 DIAGNOSIS

 Bacterial keratitis e. Os os cornea dystrophy

 MANAGEMENT

 Medical
- Citrol 3x1 drops
- Cendo lyter 3x1 drops
- 2x1 doxycycline
 PROGNOSA

 Quo ad vitam : dubia ad bonam

 Quo ad fungsionam : dubia ad bonam
 Quo ad sanationam : dubia ad bonam.
THANK YOU