Konsulen Jaga Residen jaga Jaga 2 Jaga 1 Jaga magang 1 Jaga Magang 2
: dr. H. Ibrahim, SpM : : dr. Yusni : dr. Reyno : dr. Intan : dr. Mardhi & dr. Tiara
Data Dasar Tn.P/L/35 thn/ Luar Kota KU : timbul bintik putih pada bagian hitam bola mata kanan sejak 2 minggu yang lalu RPP: 3 minggu SMRS saat penderita sedang bekerja,mata kanan penderita terkena serpihan kulit pohon karet,mata kabur (+),mata merah(+),nyeri(+),keluar darah (-),seperti putih telur (-), penderita mengucek matanya,penderita kemudian memberi tetes getah pohon dan air sirih selama 1 minggu mata bertambah kabur, merah (+), kotoran mata(+), berair-air, silau dan kelopak mata sulit dibuka. 2 minggu SMRS,timbul bintik putih pd bag.hitam bola mata, penderita berobat ke dr.SpM dan diberi obat tetes gentamisin dan obat makan (as.mef,levo,ketokonazol) untuk 1 minggu. Karena tdk ada perbaikan penderita dirujuk ke RSMHpalembang. R/ peny.tiroid 1 thn yll: obat teratur R/ kacamata (-)
Permasalahan
VOD: 1/~ PSB VOS: 6/12 PH 6/6 KBM: simetris, proptosis(+) Palpebra OD: Blefarospasme (+) Palpebra OS: Retraksi (+) Konjungtiva OD: Mix injeksi (+),sekret mukoid, warna kekuningan Konjungtiva OS : Sklera Show (+) 2mm Kornea OD: Tampak defek bergaung disentral,kedalaman 1/3 stroma,batas tegas, uk.6x5mm,FT(+) tepi lesi,infiltrat(+),lesi satelit(-) sensibilitas (+) normal. Endotelial plak (+) BMD : Keruh, hipopion 1/3 BMD, Kondensasi (+) Iris : Sulit Dinilai Pupil: sulit dinilai Lensa : sulit dinilai RFOD: (-) FOD : Tidak dilakukan Hasil Scrapping : Gram (+) kokus
Assesment Ulkus kornea sentral cum hipopion OD ec bakteri + suspek Jamur Suspek thyroid Ophtalmopathy Anomali refraksi OS ICD 10 : H16.0 H 06.2 H 52
Planning
Informed consent MRS Debridement Spooling RL-Pov Iodine 0,5% 2x/ hari Levofloxacin ED 1 tetes / 2 jam Artificial Tears ED 6x1 tts OD Sulfas Atropin 1% 3x1 tts OD Ketokonazol tab 3x200 mg Cek Lab Pro USG Pro Hertel Exohthalmometer Pro Scrapping Gram & KOH ulang Pro kultur & resistensi Pro konsul ke subdivisi EED dan NO Pro konsul PDL Pro BCVA OS
Status Generalis
Status Oftalmologikus
VOD TIOD : 1/~ PSB : P : N+0 VOS : 6/12 ph 6/6 TIOS : 18,5 mmHg
KBM:
simetris, proptosis
GBM
Blefarospasme (+) Mix injeksi (+), sekret (+) mukoid, warna kekuningan Tampak defek bergaung disentral,kedalaman 1/3 stroma,batas tegas, uk.6x5mm, FT(+) tepi lesi, Infiltrat(+),lesi satelit(-)sensibilitas (+) normal. Endotelial plak (+) Keruh, Hipopion 1/3 BMD, kondensasi (+) Sulit dinilai Sulit dinilai Sulit dinilai
Segmen Posterior
Segmen Posterior : RFOD (-)RFOS (+) FOD : tidak dilakukan FOS : Papil : Bulat, batas tegas, warna merah normal,c/d 0,3,a/v :2/3 Makula : RF (+) Retina : kontur pembuluh darah baik
Corneal drawing
Follow Up
21-6-2013
22-6-2013
1/~ PSB P: : N+O Simetris Baik ke segala arah Blefarospasme Mix injeksi (+), sekret (+) mukoid, warna kekuningan Tampak defek bergaung disentral,kedalaman 1/3 stroma,batas tegas, uk.6x5mm, FT(+) tepi lesi,infiltrat(+),lesi satelit(-)sensibilitas (+) normal. Endotelial plak (+) Keruh, Hipopion 1/3 BMD, kondensasi (+) Sulit Dinilai Sulit Dinilai Sulit Dinilai FOD: tidak dilakukan
1/~ PSB P: : N+O Simetris Baik ke segala arah Blefarospasme Mix injeksi (+), sekret (+) mukoid, warna kekuningan Tampak defek bergaung disentral,kedalaman 1/3 stroma,batas tegas, uk.6x5mm, FT(+) tepi lesi,infiltrat(+),lesi satelit(-)sensibilitas (+) normal. Endotelial plak (+) Keruh, Hipopion 1/3 BMD, kondensasi (+) Sulit Dinilai Sulit Dinilai Sulit Dinillai FOD: tidak dilakukan
Follow Up
Diagnosis
21-6-2013
-ulkus kornea sentral cum hipopion ec bakteri OD + susp Jamur - Susp Tyroid Ophtalmopathy
22-6-2013
-ulkus kornea sentral cum hipopion ec bakteri OD + susp Jamur -Susp Tyroid Ophtalmopathy
Terapi
-Sppoling RL Povidone Iodine0,5 % 2X / hari -Levofloxacin ED 1 tetes/2 jam OD -Sulfas Atropin 1 % ED 3x1 tts OD - Artificial tears ED 6x1 tts OD - Ketokonazol 3x200 mg -Alih rawat Subdivisi EED Terapi : - ketakonazol distop Itrakonazol tab 2x100 mg - Spooling RL Povidone Iodine0,5 % 2X / hari -Levofloxacin ED 1 tetes/2 jam OD -Sulfas Atropin 1 % ED 3x1 tts OD -Protagenta ED 1 tetes/jam OD - Natamycin ED 1 tetes/jam OD - Timolol ED 2x 1 tetes OD - Pro aspirasi hipopion + Amfoterisin B intracameral OD
- Spooling RL-Pov Iodine 0,5% 2x1 OD - Levofloxacin ED 1 tetes / 2jam - Sulfas Atropin 1% 3x1 tts OD - Itrakonazol tab 2x100 mg - Protagenta ED 1 tetes/jam OD - Natamycin ED 1 tetes/jam OD - Timolol ED 2x 1 tetes OD - Pro aspirasi hipopion + Amfoterisin B intracameral OD
HASIL KONSUL PDL (21-06-2013) D: Hipertiroid Subklinis + Ulkus Kornea P: - PTU 2x100 mg - Propanolol 1x10 mg - EKG dan Ro thorax - Cek Free T4 - RB Dengan PDL, jika TS setuju
USG (22-06-2013)
Follow Up
23-6-2013
24-6-2013
1/~ PSB P: : N+O Simetris Baik ke segala arah Blefarospasme Mix injeksi (+), sekret (+) mukoid, warna kekuningan Tampak defek bergaung disentral,kedalaman 1/3 stroma,batas tegas, uk.6x5mm, FT(+) tepi lesi,infiltrat(+),lesi satelit(-)sensibilitas (+) normal. Endotelial plak (+) Keruh, Hipopion 1/3 BMD, kondensasi (+) Sulit Dinilai Sulit Dinilai Sulit Dinilai FOD: tidak dilakukan
1/~ PSB P: : N+O Simetris Baik ke segala arah Blefarospasme Mix injeksi (+), sekret (+) mukoid, warna kekuningan Tampak defek bergaung disentral,kedalaman 1/3 stroma,batas tegas, uk.6x5mm, FT(+) tepi lesi,infiltrat(+),lesi satelit(-)sensibilitas (+) normal. Endotelial plak (+) Keruh, Hipopion 1/3 BMD, kondensasi (+) Sulit Dinilai Sulit Dinilai Sulit Dinillai FOD: tidak dilakukan
Follow Up Diagnosis
23-6-2013
24-6-2013
-ulkus kornea sentral cum hipopion -ulkus kornea sentral cum hipopion ec bakteri OD + susp Jamur ec bakteri OD + susp Jamur - Susp Tyroid Ophtalmopathy - Susp Tyroid Ophtalmopathy
Terapi
- Spooling RL-Pov Iodine 0,5% 2x1 OD - Levofloxacin ED 1 tetes / 2jam - Sulfas Atropin 1% 3x1 tts OD - Itrakonazol tab 2x100 mg - Protagenta ED 1 tetes/jam OD - Natamycin ED 1 tetes/jam OD - Timolol ED 2x 1 tetes OD - Pro aspirasi hipopion + Amfoterisin B intracameral OD
- Spooling RL-Pov Iodine 0,5% 2x1 OD - Levofloxacin ED 1 tetes /2 jam - Sulfas Atropin 1% 3x1 tts OD - Itrakonazol tab 2x100 mg - Protagenta ED 1 tetes/jam OD - Natamycin ED 1 tetes/jam OD - Timolol ED 2x 1 tetes OD - Pro aspirasi hipopion + Amfoterisin B intracameral OD
9/19/2013
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KORNEA
Tebal:
550 m disentral, horizontal 11,75 mm dan vertikal 10,6 mm Lapisan epitel 5-6 lapis sel Lapisan bowman lapisan jernih aseluler Lapisan stroma menyusun 90 % ketebalan kornea, tdd serat-serat kolagen dengan lebar 10250m dan tinggi 1-2 m Lapisan descemet lamina basalis endotel kornea, homogen, tebal 10-12 m Lapisan endotel 1 lapis sel yg berperan mempertahankan deturgesensi stroma
terjadi imunosupresi akibat penyakit sistemik >> keganasan >> ulkus kornea
Kornea dipersarafi oleh banyak saraf sensorik terutama berasal dari saraf siliar longus, saraf nasosiliar, saraf ke V, saraf siliar longus berjalan supra koroid, masuk ke dalam stroma kornea, menembus membran Bowman melepaskan selubung Schwannya. Bulbus Krause untuk sensasi dingin ditemukan diantara. Daya regenerasi saraf sesudah dipotong di daerah limbus terjadi dalam waktu 3 bulan
Oleh karena ulkus biasannya timbul pada orang dengan keadaan umum yang kurang dari normal, maka keadaan umumnya harus diperbaiki dengan makanan yang bergizi, udara yang baik, lingkungan yang sehat, pemberian roboransia yang mengandung vitamin A, vitamin B kompleks dan vitamin C
Kebanyakan dipakai sulfas atropine karena bekerja lama 1-2 minggu. Efek kerja sulfas atropine : Sedatif, menghilangkan rasa sakit. Dekongestif, menurunkan tanda-tanda radang. Menyebabkan paralysis M. siliaris dan M. konstriktor pupil. Dengan lumpuhnya M. siliaris mata tidak mempunyai daya akomodsi sehingga mata dalan keadaan istirahat. Dengan lumpuhnya M. konstriktor pupil, terjadi midriasis sehinggga sinekia posterior yang telah ada dapat dilepas dan mencegah pembentukan sinekia posterior yang baru
1st generation 2nd generation 3rd generation 4th Fluoroquin generation olones
Cinoxacin Flumequine Nalidixic acid Oxolinic acid Pipemidic acid Piromidic acid Rosoxacin Ciprofloxacin Enoxacin Fleroxacin Lomefloxacin Nadifloxacin Ofloxacin Norfloxacin Pefloxacin Rufloxacin Balofloxacin Grepafloxacin Levofloxacin Pazufloxacin Sparfloxacin Temafloxacin Tosufloxacin Clinafloxacin Garenoxacin Gemifloxacin Moxifloxacin Gatifloxacin Sitafloxacin Trovafloxacin/Alatrofloxacin Prulifloxacin
Veterinary
Bakteri Faktor predisposisi Adhesin+Sekresi eksopolisakarida Invasi Eksotoksin Nekrosis sel PMN Pelepasan enzim lisosim (Kolagenase+Hidrolase) Kerusakan kolagen & proteoglikan
TINJAUAN PUSTAKA
It must not be mixed or administered simultaneously (within 48 hours) with calcium-containing solutions or products for patients younger than 28 days old,[2] even via different infusion lines (rare fatal cases of calcium-ceftriaxone precipitates in lung and kidneys in neonates have been described).[3] To reduce the pain of intramuscular injection, ceftriaxone may be reconstituted with 1% lidocaine.[4]
Adverse Effect Hypoprothombinaemia and bleeding are specific side effects. Haemolysis is reported. [edit]
In the original bacterial phyla, the Gram-positive organisms made up the phylum Firmicutes, a name now used for the largest group. It includes many wellknown genera such as Staphylococcus, Streptococcus, Enterococcus, (which are cocci) and Bacillus, Corynebacterium, Nocardia, Clostridium, Actinobacteria, and Listeria (which are rods and can be remembered by the mnemonic obconical). It has also been expanded to include the Mollicutes, bacteria-like Mycoplasma that lack cell walls and cannot be Gram stained, but are derived from such forms. Actinobacteria are the other major group of Grampositive bacteria, which have a high guanine and cytosine content in their genomes (high G+C group). This contrasts with the Firmicutes, which have a low G+C content.
Both Gram-positive and Gram-negative bacteria may have a membrane called an Slayer. In Gram-negative bacteria, the S-layer is directly attached to the outer membrane. In Gram-positive bacteria, the S-layer is attached to the peptidoglycan layer. Unique to Gram-positive bacteria is the presence of teichoic acids in the cell wall. Some particular teichoic acids, lipoteichoic acids, have a lipid component and can assist in anchoring peptidoglycan, as the lipid component is embedded in the membrane.
43
In most large series, gram-positive organisms continue to be the predominant cause of bacterial Staphylococcus aureus is now the most common cause of bacterial keratitis in the northern and northeastern United followed by Moraxella, P. aeruginosa, and S pneumoniae.6 In London,14 the most common causes are S. aureus, S. pneumoniae, Pseudomonas, and Moraxella.
Sikatrik ditempat lain, atau ulkus ditempat sikatrik... (ulkus ateromatosus) Bila sikatrik bentuk nebula: pasien kadang2 tidak tahu Leukoma: Putih porselen Nekrotik: radikal bebas memperberat kersakan.
Cryotherapy :
cotton bud, spray, probe
In most cases, a combination of aminoglycoside and cephalosporin is used, 1 gtt qh during first 24 hours, e.g. tobramycin 14 mg/mL and cephazolin 50 mg/mL; amikacin 25 mg/mL and ceftazidime 25 mg/mL. Vancomycin 25 mg/mL may be added
1st generation 2nd generation 3rd generation 4th Fluoroquin generation olones
Cinoxacin Flumequine Nalidixic acid Oxolinic acid Pipemidic acid Piromidic acid Rosoxacin Ciprofloxacin Enoxacin Fleroxacin Lomefloxacin Nadifloxacin Ofloxacin Norfloxacin Pefloxacin Rufloxacin Balofloxacin Grepafloxacin Levofloxacin Pazufloxacin Sparfloxacin Temafloxacin Tosufloxacin Clinafloxacin Garenoxacin Gemifloxacin Moxifloxacin Gatifloxacin Sitafloxacin Trovafloxacin/Alatrofloxacin Prulifloxacin
Veterinary
BACKGROUND
Corneal ulcer pathologic condition of cornea signed by suppurative infiltrate, excavation of cornea and corneal discontinuity from epithel to stroma Initial symptoms of corneal ulcer: - Reddish eye - Pain in eye - Glare when see bright light - Watering eye - Swelling of eye lid - Secret (+)
Optimal corneal ulcer treatment is supported by the right diagnostic The purpose of corneal ulcer treatment prevent the bacterial growth, decrease inflammation, increase the healing of epithelial defect, overcome complication and improve the visual acuity Treatment choice of corneal ulcer must be appropriate with the clinical feature of : - Degree of corneal ulcer in initial examination - Result of the gram-KOH staining - Result of culture-resistance test
Corneal ulcer treatment is stopped if there is an epithelisation and the eye looks quiet Prognosis of corneal ulcer depends on : - Degree of corneal ulcer - Time of treatment - Kind of microorganism that caused corneal ulcer - Complication of corneal ulcer
Patogenesis.
Tinjauan Pustaka
Sistem Pertahanan Mata Tulang orbita Kelopak mata Konjungtiva Tear film Epitel kornea
Faktor Predisposisi 1. Anatomi intrinsik Dry eye Mikrotrauma Defek epitel persisten Abrasi traumatik 2. Menurunnya kemampuan imunologik
ULKUS KORNEA
A. Inlay tehnik
B. Overlay tehnik
Lokasi
Progresifitas Luas daerah supurasi Kedalaman daerah supurasi Inflamasi di segmen anterior Perforasi
Non aksial
Lambat 2 mm 1/3 superfisial Ringan Tidak ada
Perifer/sentral
Sedang 2-6 mm 2/3 superfisial Sedang-berat: eksudat fibrin Tidak ada
Perifer/sentral
Cepat > 6 mm 1/3 bagian dalam Berat: hipopion Ada/ mengancam
Perbaikan
Tidak berubah/mengecil
Perburukan
Meluas
Membran amnion , lapisan terdalam dari membran fetus mengandung sejumlah faktor pertumbuhan dan protein yang berperan penting pada penyembuhan luka. Membran amnion dapat digunakn sebagai material transplantasi karena sifatsifatnya yang menguntungkan, yaitu : antibakteri, antiinflamasi, efek terapetik,aktivitas angiogenesis dan mekanisme yang mempu menghambat aktivitas proteinase.
Analisis statistika MANOVA membuktikan adanya perbedaan yang bermakna (p < 0,05) pada jumlah sel leukosit PMN, pembuluh darah baru , sel fibroblas dan ketebalan lapisan epitel antara kelopmpok MA dan K berdasarkan periode dekapitasi.Analisis statistika dengan uji Kruskal-Wallis membuktikan adanya perbedaan yang bermakna (p < 0,05) pada kepadatan serabut kolagen antara kelompok MA dan K berdasarkan periode dekapitasi.
1. BACTERIA Gram positive : Staphylococcus epidermidis, S. aureus Streptococcus pneumoniae, Bacillus sp. Gram negative Pseudomonas aeruginosa, Haemophilus influenzae, Escherichia coli, Neisseria sp., Proteus sp., Klebsiella sp., Moraxella sp.
Streptococcal keratitis Streptococcus pneumoniae >> Deep Central corneal stromal irregular Rapid progression and hypopyon Radiating folds in Descemets membrane Fibrin deposit on the endothelium
Perforation
Staphylococcal ulcers
Often occur in compromised corneas -> superinfections Round or oval White or yellow white Usually localized with distinct borders ? Diffuse S. aureus deeper and greater anterior chamber reaction than S. epidermidis
Neisseria gonorrhoeae N.
meningitidis
Cause conjunctivitis progres to keratitis sexually transmitted diseases penetrate intact corneal epithelium intense infiltrate perforation often occurs
THE CAUSES AND CLINICAL PICTURES OF KERATITIS INFECTIONS Pseudomonas corneal ulcers
Quite common and rapid progression Found in water, mascara, contaminated eye drops, skin, saliva, gastrointestinal tract
Pseudomonas secrete proteases lipases exotoxins virulence glycocalyx phagocytosis and destruction by antibody and complement
enzymes inflammatory cells contribute to tissue damage Location central or peripheral Superficial ulcer adherent mucopurulent yellowish or greenish The ulcer and stroma edematous and hazy Ring ulcer, endothelial plaques, perforation
Moraxella
More Chronic Indolent keratitis peripherel or paracentral infiltrate Compromised corneas corneal transplants over days or weeks perforations
Fungal
Stromal infiltrates feathery hyphate dry, dirty white to gray elevated above the corneal surface Other features immune ring, satellite lesions, endothelial plaque
AMPHOTERISIN B
Intracameral Amphoterisin B may be an effective adjunctive treatment of fungal unresponsive to conventional antifungal therapy, although cataract may occur
BMJ. Cornea. 2007 May ; 26(4) : 398-402