CASE REPORT

CORNEA AND REFRACTIVE SURGERY SUBDIVISION

JEHAN FAUZI Rr
 CHIEF COMPLAINT
Pain on the right eye
HISTORY OF PRESENT ILLNESS
 ±3H BDOV
 Patient cleaned up his yard, suddenly his right eye stucked
by twig. Felt pain and blurred vision.
 ±2H BDOV
 Went to District Hospital, referred to SGH
 DOV
 Corneal laceration on the left eye, blurred vision, pain +
 HISTORY OF PAST ILLNESS
 History of Eye Diseases : (-)
 History of Diabetes Mellitus: (-)
 History of Hypertension : (-)
 History of Surgery : (-)
 History of Wearing Spectacles : (-)
 History of Eye and Head Trauma: (-)
PHYSICAL EXAMINATION
 General condition : Good, alert

 Vital Sign
 BP : 118/71 mmHg

 HR : 72 x/minute

 RR : 20 x/minute

 T : 36◦C

 VAS : 5
 RE EXAMINATION
VISUAL ACUITY 6/6
EYE LID Within normal limit
CONJUNCTIVA Within normal limit
CORNEA clear
ANTERIOR CHAMBER Deep and clear

IRIS / PUPIL Round, Central, 3 mm, light reflex +/+

LENS Clear
VITREUS BODY Clear
PAPIL Distinct margin, CD 0.3
MACULA Reflex (+)
RETINA a/v 2/3
IOP N
 LE EXAMINATION
1/60 VISUAL ACUITY
Spasm gr I EYE LID
Hyperemis gr II, CI (+) CONJUNCTIVA
Full thickness laceration + 4x1 mm with prolapsed iris CORNEA
Deep ANTERIOR CHAMBER
Not round, central, 3 mm, light reflex +/+ IRIS / PUPIL
Dense opacity, phacodenesis (-) LENS
VITREUS BODY
PAPIL
Couldn’t be assesed
MACULA
RETINA
N- IOP
Free OM
LE EXAMINATION
 DIAGNOSIS
LECorneal Laceration Full
Thickness with Prolapsed Iris
MANAGEMENT AND PLAN
 RE Pro Emergency Corneal Laceration Repair under General
Anesthesia
 ATS 1500 IU im
 Ceftriaxone 1 gram/12 hours iv
 Ketorolac 30mg/8 hours iv
 Levofloxacin ED/1 hours LE
 Ceftazidim ED/1 hour LE
 RE EXAMINATION D+1
HM G/G VISUAL ACUITY
Spasm gr II EYE LID
Hyperemis gr II, CI (+) CONJUNCTIVA
Mild edema in the central to infero temporal, graft + CORNEA
Deep and clear ANTERIOR CHAMBER
Not round, central, posterior synechia IRIS / PUPIL
Dense opacity LENS
VITREUS BODY
PAPIL
Macular reflex (+)
MACULA
RETINA
N IOP
Free OM
LE EXAMINATION D+1
ULTRASONOGRAPHY
MANAGEMENT AND PLAN
 Ciprofloxacin 500 mg/12 hours
 Mefenamic acid 500 mg/8 hours
 Levofloxacin ED/2 hours LE
 C.eftazidim ED/2 hours LE
 Betamophtal ED/2 hours LE
 Methylprednisolone 16mg 1-1-0
 LE EXAMINATION D+6
HM G/G VISUAL ACUITY
Spasm gr I EYE LID
Hyperemis gr I, CI (+) CONJUNCTIVA
corneal graft + CORNEA
Deep and clear ANTERIOR CHAMBER
Not round, central, , Ø 7mm ,posterior synechiae IRIS / PUPIL
Dense opacity LENS
VITREUS BODY
PAPIL
Coudn’t beasessed
MACULA
RETINA
N IOP
Free OM
LE EXAMINATION D+6
 DIAGNOSIS
LE Post Repair Corneal
Laceration D+6 + Traumatic
Cataract
MANAGEMENT AND PLAN
 Ciprofloxacin 500 mg/12 hours
 Mefenamic acid 500 mg/8 hours
 Levofloxacin ED/2 hours LE
 C.eftazidim ED/2 hours LE
 Betamophtal ED/2 hours LE
 Methylprednisolone 16mg 1-1-0
 PROGNOSIS
 RIGHT EYE
 Ad Visam : Dubia ad Bonam
 Ad Sanam : Dubia ad Bonam
 Ad Vitam : Bonam
 Ad Cosmeticam : Dubia ad Bonam
 THANK YOU
ADVICES AND SUGGESTIONS ARE VERY WELCOME