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LAPORAN JAGA RESIDEN Bagian Ilmu Kesehatan Mata Kamis 20-6-2013 pkl 07.

00 WIB s/d Jumat 21-6-2013 pkl 07.00 WIB

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

Keadaan Umum sedang Sensorium TD Nadi Respiratory rate Temperatur

: Tampak sakit : Compos Mentis : 110/70 mmHg : 80 x/menit : 18 x/menit : 36,8C

Status Oftalmologikus
VOD TIOD : 1/~ PSB : P : N+0 VOS : 6/12 ph 6/6 TIOS : 18,5 mmHg

KBM:

simetris, proptosis

GBM

Palpebra Konjungtiva Kornea

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

Retraksi (+) Sklera Show (+) Jernih

BMD Iris Pupil Lensa

sedang Gambaran baik B,S,RC (+) , 3 mm jernih

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

Pemeriksaan Scrapping kornea

Gram (+) kokus KOH : hifa (-)

Corneal drawing

Follow Up

21-6-2013

22-6-2013

VOS TIOS KBM GBM Palpebra Konjungtiva Kornea

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

BMD Iris Pupil Lensa RFOD

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)

Vitreus : echo free Retina : Intak Choroid : Tidak menebal

Follow Up

23-6-2013

24-6-2013

VOS TIOS KBM GBM Palpebra Konjungtiva Kornea

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

BMD Iris Pupil Lensa RFOD

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

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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

Danofloxacin Difloxacin Enrofloxacin Ibafloxacin Marbofloxacin Orbifloxacin Pradofloxacin Sarafloxacin

Bakteri Faktor predisposisi Adhesin+Sekresi eksopolisakarida Invasi Eksotoksin Nekrosis sel PMN Pelepasan enzim lisosim (Kolagenase+Hidrolase) Kerusakan kolagen & proteoglikan

ULKUS KORNEA Peradangan: infiltratif supuratif Kerusakan epitel Penggaungan

TINJAUAN PUSTAKA

Etiologi Ulkus Kornea Bakterialis.


COCCUS GRAM (+)
Staphylococcus aureus Staphylococcus coagulase negative Streptococcus pneumoniae Streptococcus alpha haemolyticus Streptococcus pyogen Streptococcus beta haemolyticus Enterococcus Peptostreptoccus

BASIL GRAM (+)


Corynebacterium diphteriae Corynebacterium xerosis Lysteria monositogen Basil antrax, Basil cereus, Basil subtilis Propionebacterium acne Clostridium sp Actinomyces sp Nocardia sp Mycobacteria

COCCUS GRAM (-)


Neisseria gonorrhoe Branhamella cataralis

BASIL GRAM (-)


Pseudomonas spesies Proteus spesies Moraxella spesies Acinobacter calcaceticus Haemophilus sp Brucella sp E.Colli Klebsiella pneumoniae Shigella sp Enterobacter sp Bacteroides sp

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.

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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.

The Cornea (second edition,p161)

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

Danofloxacin Difloxacin Enrofloxacin Ibafloxacin Marbofloxacin Orbifloxacin Pradofloxacin Sarafloxacin

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

Virulensi Bakteri Menempel Menghindar Invasi Replikasi inokulasi

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

Derajat ulkus kornea bakteri


Gambaran Ringan Sedang Berat

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

Evaluasi klinis pengobatan ulkus kornea bakteri


Tanda
Ukuran defek epitel Infiltrat stroma: Densitas Batas Dalam Ukuran Reaksi sel darah putih: Pada stroma Reaksi pada bilik mata depan

Perbaikan
Tidak berubah/mengecil

Perburukan
Meluas

Menurun Lebih jelas Tidak berubah/lebih dangkal Tidakberubah/mengecil


Menurun (terlokalisasi) Menurun

Meningkat Kurang jelas Lebih dalam Lebih luas


Meningkat Meningkat

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.

THE CAUSES AND CLINICAL PICTURES OF KERATITIS INFECTIONS

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.

THE CAUSES AND CLINICAL PICTURES OF KERATITIS INFECTIONS


2. VIRUS Herpes simplex virus, Adenovirus 3. PARASITES Acanthamoeba sp. 4. FUNGI Aspergillus sp, Candida sp. Fusarium

THE CAUSES AND CLINICAL PICTURES OF KERATITIS INFECTIONS

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

Bacillus species B. cereus


Soil contaminated trauma progress Severe pain infiltrate quite small 24 hours of the injury Lid edema Conjunctival chemosis Circumferential corneal edema ring ulcer

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

THE CAUSES AND CLINICAL PICTURES OF KERATITIS INFECTIONS

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

Often not promptly diagnosed Mixed infections cytology examination cultured

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