DEPARTEMEN ILMU KESEHATAN MATA

FAKULTAS KEDOKTERAN UMI

DEPARTEMENT OF OPHTHALMOLOGY

UVEITIS
IDENTITAS PASIEN
Nama : Ms. S
Jenis kelamin : Perempuan
Usia : 55 tahun
Alamat : Darsalam 04/02 Kudus
Agama : Islam
suku/ bangsa :-
Pekerjaan : IRT
Medical Record : 485140
Tanggal pemeriksaan : November, 2019
 ANAMNESIS
Keluhan Utama: redness on the left eye

The patient came to the Eye Clinic at Kudus District Hospital with complaints redness on
the left eye since 2 days ago. The redness on the Left eye felt continuously, getting worse
day by day. The patient said that she always wanted to close her left eye like she was
sleepy. The eye feels a little better when resting and getting worse when activities such as
reading and writing. Excessive tearing (+) blurred vision (+) dizziness on the left head (+)
a day ago. Itchy on eye (-). History of the same complaint 2 years ago but healed.
 ANAMNESIS
Riwayat Penyakit:
Riwayat penyakit mata :
A history of similar symptoms (+)
Riwayat penyakit sistemik : DM (+) , Hipertensi (+)
Riwayat trauma : (+)

Riwayat pengobatan :
There is a history of getting treatment for similar complaint

Riwayat keluarga : there are no family with similar complaints

 OD Visus OS

6/6 Visus jauh tanpa koreksi 2/60

- koreksi -
PEMERIKSAAN
VISUS
Visus jauh dengan
- -
koreksi terbaik

- Visus dekat -

- koreksi -

- Visus dekat dengan koreksi -

 OD OS
Palpebral Edema (-) Massa (-) Edema (+) Pain (+)
Hiperemis (-)
Cilia Secret (-), trikiasis (-) Scuama (-), Secret (-),
Madarosis (-) Madarosis (-)
Lacrimal Lacrimasi (-) Lacrimasi (+)
Apparatus
Conjunctiva Hyperemia (-) Injectio (-) Hyperemia (+), Injectio (+)
PEMERIKSAAN SEGMENT Chemosis(-) Chemosis (-)
ANTERIOR Cornea clear Clear
Anterior Normal Depth Normal Depth
Chamber
Iris Brown, Crypt (+) Brown, Crypt (+), Syneki (+)
Pupil Round, Central Round, Central
Direct / +/+ +/+
Inderct Light
Reflex
RAPD - -
Lens Clear Clear
 EXAMINATION
OD OS
METHODS

PALPASI Tenderness (-) (-)

Tumor/Mass (-) (-)

Pre Auriculer gland Tidak teraba Tidak teraba

 EXAMINATION
OD OS
METHODS
TEKANAN
INTRAOCULAR
Palpation Tn Tn

Non Contact
- -
Tonometry/ schiotz
 Oculus Dextra & Sinistra

DOKUMENTASI
KLINIS PASIEN
 • DIAGNOSIS
DIAGNOSIS OS : Uveitis Anterior Akut

• DIFFERENTIAL DIAGNOSIS
OS Konjungtivitis
OS Keratitis
OS Glaukoma akut
 Rencana Terapi :

Inmatrol 5 x 1 tetes/hari OS
C-Mydriatil 2 x 2 teete/hari OS
TERAPI Cyprofloxacin 500 mg 3 x 1 tab

EDUCATION :

Regularly use the drugs

PROGNOSIS Quad Ad Vitam : Dubia ad Bonam
Quad Ad Functionam : dubia ad Bonam
Quad Ad Cosmetican : Bonam
Quad Ad Sanationam : dubia ad Bonam