CHAPTER III

CASE REVIEW

1. Patients identitiy
Name : Mrs. L
Gender : Female
Age : 72 y/o
Address : Jln. Tanjung Raya II Gg. H. Ghani, Parit Mayor
Race : Bugis
Occupation :-

Religion : Islam

Anamnesis and physical examination was performed on September 11th 2014.

2. Patients History
a. Chief Complaint

Vision lost

b. Current Medical History

The patient report vision lost of the right eye since 2013. The vision is
gradually loss. Firstly, the patient see the black spot in her vision that becomes
bigger in size so that she can not see as wide as usual. But she still can see the
lights and can read the big size of number one by one. Now, the patient report
that the right eye is totally blind, can not see even just a light. Red eye, pain of
the eye, vomiting, and headache is not reported.
The patient use the left for her vision. But, she also complaint that the left eye
is going under the vision problem since one month ago. The vision becomes
dim and makes the patient can not see well. Red eye, pain of the eye,
vomiting, and headache is also not reported. With the function left, the patient
still can do some activity by herself, for example walking, bathing, cooking,
washing clothes,and take the medicine.
 c. Past Medical History
The patient never feel this problem before, the ophthalmic problem that the patient
have previously just like conjunctivitis with the purulent discharge. The patient was
diagnosed with immature cataract on both of eye, she was under the
ophthalmologist observation to get some operation therapy for the left eye.
The ophthalmologist told her that operating the right one will not result in
good vision again. The ophthalmologic medicine that the patient consume ar
Lyters, Floxa, and Timol.
The systemic problem that the patient have is asthma and arthritis. She
routinely consume the medicine to heal her asthma and gastritis, such as using
salbutamol and antalgin. The patient deny any history of diabetes mellitus,
hypertension, and/or trauma to either eye.

d. Family Medical History

There is no other family member with similar symptom with the patient.
There is no glaucoma, cataract, and hypertension history in her family. Her
daughter was died due to diabetes mellitus.

3. Physical Examination
General condition : Good
Awareness : Compos mentis
Vital signs :
a. Blood pressure : 130/90 mmHg
b. Heart rate : 88 times/menit
c. Respiratory rate : 20 times/menit
d. Temperature : 37,2oC
4. Ophthalmological Status
a. Visual acuicity:
OD :0
OS : 6/60 +ph no improvement
b. External Examination
 OD
Ortho
Movement (+), Ptosis (-),
Lagoftalmos (-), Edema (-)
No triangle shape
fibrovascular growth,
hyperemis (-), anemis (-),
discharge (-), injection(+),
foreign body (-)
Clear, edema (-) , infiltrat (-),
ulkus (-)
Deep
Iris colour: Brownish,
Synechia (-)
Pupil: Round, 4mm, mid-
dilated, anisochor, direct light
reflex (diminished), indirect
light reflex (diminished),
shadow test (+)
Hazy
OS
Eyeball Position Ortho
Palpebra Movement (+), Ptosis (-),
Lagoftalmos (-), Edema (-)
Conjunctiva No triangle shape
fibrovascular growth,
hyperemis (-), discharge
(-), injection (-), foreign
body (-)
Cornea Clear, edema (-) , infiltrat
(-), ulkus (-)
Anterior Chamber Deep
Iris/pupil Iris colour: Brownish,
Synechia (-)
Pupil:Round, 2mm,
anisochor, direct light
reflex (+), indirect light
reflex (+), shadow test (+)
Lens Hazy
 Clear Vitreous Clear

Fundus reflex (+), cup and Fundus Fundus reflex (+), normal
disc ratio about 0,9, normal papil, normal blood vessel,
arteries-veins ratio, normal normal arteries-veins ratio,
macula normal macula

c. Eyeball Movement
+ + + + + +

+ + + +

+ + + + + +

d. Palpation of Intraocular Preasure: No significance difference

e. Visual field test
OD : Can not be performed
OS : Normal

5. Resume
A 72 years old woman complain total blindness of OD with gradually vision lost
history since 2013. She also complain dim vision of OS since one month ago.
Red eye (-), pain (-), vomiting (-), headache (-). History of the same complain (-),
asthma (+), arthritis (+), hypertension (-), diabetes (-), trauma (-). No glaucoma,
cataract, and hypertension history in her family, diabetes history (+).
Visual acquity of OD=0, OS=6/60, anisochor pupil (4 mm/2 mm), direct light
reflex (-/+), indirect light reflex (-/+), shadow test (+/+).

6. Diagnosis
 a. Working diagnosis
OD : Primary glaucoma with immature senile cataract
OS : Immature senile cataract
b. Differential diagnosis
OD : Secondary glaucoma et causa senile cataract
OS :-

7. Plan of Examination
a. Indirect funduscopy
b. Perimetry examination
c. Gonioscopy examination
d. Tonometry examination

8. Treatment
OD :
Timolol ophthalmic 0,5% 2x1

OS :
Surgical treatment for cataract by using ECCE technique

9. Prognosis
OD :
a. Ad vitam : dubia ad malam
b. Ad functionam : dubia ad malam
c. Ad sanationam : dubia ad malam
OS :
a. Ad vitam : dubia ad bonam
b. Ad functionam : dubia ad bonam
c. Ad sanationam : dubia ad bonam