Case Report

External Eye Disease Subdivision

Karina Adistiarini
 PATIENT’S IDENTITY
 Name : Mr. B
 Age : 29 years old
 Address : Purworejo
 Occupation : Private employee
 MR number : 01.99.88.17
 DoV : 27th April 2022
 Chief Complaint
 Foreign Body Sensation on both eyes
 Exp RE
 History of present illness
• 1. The patient often feels that his joint is
aching
2 Years • 2. The patient feels easily tired when doing
BDOV activities
• 3. The patient's mouth becomes dry and
often canker sores

• The patient checked himself into an internal

medicine doctor and was referred to the
rheumatology department
 History of present illness
Rheumatology department

A series of autoimmune tests

were carried out according to
the SOP

1. Patient was diagnosed by

Sjogren Syndrome
2. Monthly evalutiation routine
 INTERNAL MEDICINE TAKEN
 Candesartan 8 mg / once a day
 Imuran 50mg / 12 hours
 Methylprednisolone 4mg / once a day
 Prove D 1000 UI/ once a day
2 weeks • Both eyes feels foreign body sensation
• Redness of both eyes accompanied by

BDOV
excessive tearing
• The patient treated it by buying eye
drops at the drug store but did not
improve

Symptoms was
Dov persisted
 History of Past Illness
 History of eye trauma (-)
 History of eye infection (-)
 History of systemic disease (+) Hypertention
 Wearing speaktacles (-)
 History of diabetes (-)
 History of autoimmune disease (+) SSD
 Other systemic conditions

 Allergy (-)
 DM (-)
 Hypertension (??)
 Smoking (-)
 Routine medicine (+) monthly evaluation for SSD at Rheumatology dept
 Herbal medicine (-)
 General examination
 Vital Sign :
 BP : 140/73 mmHg Body Height :
163 cm
 HR : 89 x/minutes Body Weight :
78 kg
 RR : 20 x/minutes
 T : 36,2 C
 VAS : 2-3
 6/6 Visual Acuity

Mild spasm Eye lid

Hyperemic grade 2 + Conjunctiva
Clear Cornea

Deep and clear Anterior Chamber

RE
Round, Central, Ø 3mm, LR +/+ Iris/ Pupil Ophthalmologica
clear Lens l Status

clear Vitreous Body

Distinct Margin +. CD 0.3 ONH
Ref + Makula
a/v 2/3 Retina
13 IOP
free Ocular Movement
 LE Ophthalmological Status
Visual Acuity 6/7,5 ph 6/6
CC S-0,25  6/6
Eye lid Within normal limit
Conjunctiva Within normal limit
Cornea Clear
Anterior Chamber Deep and clear

Iris/ Pupil Round, central, Ø 3mm, LR +/+

Lens Clear
Vitreous Body Clear
ONH Distinct margin, CD 0,3

Makula Ref +
Retina a/v 2/3
IOP 15
Ocular Movement Free
RLE Photograph
RLE Slit Photograph
 CCT calculation
RE LE
43.00 K1 43.44
43.81 K2 43.10
2709 CD 2713
35 CV 33
556 CCT 546
Fundus Photograph of RLE
1 TBUT of RLE
st
1 schrirmers Test
st

OD : 5 mm/ 5 minutes
OS : 5,5 mm/ 5 minutes
RLE Pachymetric Test
Anterior Chamber OCT Test/RE
Anterior Chamber OCT Test/LE
 Diagnose
 RLE DRY EYES SYNDROME due to
Sjogren Syndrome Disease (mild
Symptom)
 LE Simplex Myopia
 Plan :

1. Cendo Lyteers / 6 hours RLE

2. Cendo Hyalop/ 6 hours RLE
3. Betamophtal/ 6 hours RLE
4. Warm compresses and eye lid massage
5. Monitoring of IOP cause of steroid usage
6. Re evaluate symptom for next month
After 1 Month Of Therapy
 6/6 Visual Acuity
Within normal limit Eye lid
Within normal limit Conjunctiva
Clear Cornea

deep, clear Anterior Chamber RE

Ophthalmological
Round,Central, diameter 3 mm rc +/+ Iris/ Pupil Status D+30
Clear Lens
Clear Vitreous Body
Distinct margin, CD 0,3 ONH
Ref + Makula
a/v 2/3 Retina
11 IOP
free Ocular Movement
 LE Ophthalmological Status
Visual Acuity 6/7,5 ph 6/6
CC S-0,25  6/6
Eye lid Within normal limit
Conjunctiva Within normal limit
Cornea Clear
Anterior Chamber Deep and clear

Iris/ Pupil Round, central, Ø 3mm, LR +/+

Lens Clear
Vitreous Body Clear
ONH Distinct margin, CD 0,3

Makula Ref +
Retina a/v 2/3
IOP 12
Ocular Movement Free
D+1 Month RLE Photograph
D+1 Month RLE Slit Photograph
2 TBUT after D+30
nd
2 Schrirmers test D+30
nd

 OD : 10mm/ 5 minutes
 OS : 10 mm/5 minutes

Result : Improved
 Diagnose
 RLE DRY EYES SYNDROME due to
Sjogren Syndrome Disease (mild
Symptom)
 LE Simplex Myopia
 Plan :

1. Cendo Lyteers / 4 hours RLE

2. Cendo Hyalop/ 8 hours RLE
3. Evaluate symptom for 3 month
 Prognosis

RE
 Ad visam : ad bonam
 Ad sanam : ad bonam
 Ad cosmeticam : bonam
 Ad vitam : bonam
 LE
 Ad visam : ad bonam
 Ad sanam : ad bonam
 Ad cosmeticam : bonam
 Ad vitam : bonam
 Thank you
advices and suggestions are very welcome
DASAR DIAGNOSIS
NON OCULAR
DRY EYES SYNDROME
BIOMOLECULE OF TEAR FILM
TBUT TEST
OSDI SCORE