Duty Report

Friday, March 30, 2018

Ophthalmologist: dr. Maharani, Sp.M(K)
Senior: dr. Intan S
Junior: dr. Rhema
 Identity
• Name: ny. NK
• Age: 36 yo
• MR: B280770
• Chief Complain: pain in the right eye
• Recent history:
Patients come with right eye complaints of pain
since waking up. complaints accompanied by
nerocos (+), red eye (+), eye props (+), dizziness
(+), nausea (-). then the patient soaked the right
eye with warm water. Complaints are not
reduced, patients come to RSDK
• history of insect bites (-)
• history of trauma (-)
• history of the same complaint and the patient
was diagnosed with herpes (+)
 OD OS
Visual acuity 1.0 f1 1.0 f1
IOP T dig N T dig N
Eyelid Edema (-), spasme (-), Edema (-), spasme (-),
hiperemis (-) hiperemis (-)
Konjungtiva Mix injeksi (+) Injeksi (-)
Kornea Edema (+), flourecen test Edema (-)
(+), defect (+) central
paracentral, size 6 x8 mm,
infiltrat (-), necrotic tissue
(-)
COA Depth Depth
Iris Crypte (+) Crypte (+)
Pupil Round, central, regular, Ø 4 Round, central, regular, Ø 3
mm, RP (+) N, RAPD (-) mm, RP (+) N, RAPD (-)

RF (+) bright (+) bright

Sensitibitas cornea test (+) normal
 OD. Corneal Erotion
Therapy:
• Oxytetracycline eye oint. 3x1 OD
• Na. Diclofenac 2x50 mg p.o
• buckle press right eye for 24 hours
• Education: control eye clinic
 Identity
• Name: an. KR
• Age: 3 yo
• MR: C687117
• Chief Complain: bleeding in the left eye
• Recent history:
The patient came with a bloody left eye
complaint since 9am in the morning after
bumping the key. complaints accompanied by
pain (+), swelling (+), blood out of the nose (+).
then the patient went to the local hospital and
was referred to Kariadi Hospital.
History of trauma (+)
 OD OS
Visual acuity C,S,M C,S,M
IOP T dig N T dig N
Eyelid Edema (-), spasme (-), Edema (+) minimal, spasme
hiperemis (-) (-), hiperemis (+), punctum
(+) intak
Konjungtiva Injeksi (-) Konjungtiva palpebra
inferior: wound (+) in nasal
size 1x1 mm, bleeding (-)
Kornea Edema (-) Edema (-)
COA Depth Depth
Iris Crypte (+) Crypte (+)
Pupil Round, central, regular, Ø 3 Round, central, regular, Ø 3
mm, RP (+) N, RAPD (-) mm, RP (+) N, RAPD (-)

RF (+) bright (+) bright

 OS. Konjunctiva Palpebra Inferior
Laceration
• Therapy:
• Gentamicin ED/ 4 hour OD
• Education: control eye clinic
 Identity
• Name: Tn. S
• Age: 52 yo
• MR: C687118
• Chief Complain: right eye exposed plastic
cable
• Recent history:
the patient came with a right eye complaint
exposed to a plastic cable while tying a tree
limb. complaint accompanied by red eye (+),
blurred vision (+). no medication administered
by the patient.
Historys of using spectacles (-)
 OD OS
Visual acuity 0.50 0.25 f2
IOP T dig N T dig N
Eyelid Edema (-), spasme (-), Edema (-), spasme (-),
hiperemis (-) hiperemis (-)
Konjungtiva Mix Injeksi (+) Injeksi (-)
Kornea Edema (+), flourescen test Edema (-)
(+), defect (+) oval,
multiple, paracentral, size
6x3 mm, 1x1 mm
COA Depth Depth
Iris Crypte (+) Crypte (+)
Pupil Round, central, regular, Ø 3 Round, central, regular, Ø 3
mm, RP (+) N, RAPD (-) mm, RP (+) N, RAPD (-)

RF (+) bright (+) bright

 OD. Corneal Erotion
• Therapy:
• Oxytetracycline eye oint. / 6 hours OD
• Vitamin C 1x500 mg po
• buckle press right eye for 24 hours
• Education: control eye clinic
•
 Identity
• Name: Sdr. R
• Age: 18 yo
• MR: C662899
• Chief Complain: left eye vision blurred
• Recent history:
the patient came with a blurred vision left eye
complaint since 2 weeks ago. complaints
accompanied by red eye (+), pain (+), glare (+).
patients use Insto for 3 days drip 1 times at
night. complaints are not reduced, watery eyes
(+), more pain (+), swollen eyes (+), vision like
there is mist (+), see the black dot (+). then the
patient came to the hospital
• Historys of using spectacles (-)
• history of trauma (-)
• history of cavities (-)
• history of having pets (-)
• history of eating raw food (-)
 OD OS

Visual acuity 1.0 0.25

IOP T dig N T dig N

Eyelid Edema (-), spasme (-), Edema (-), spasme (-),

hiperemis (-) hiperemis (-)
Konjungtiva Injeksi (-) Mix Injeksi (+)

Kornea Edema (-) Edema (+), Kp’s (+)

COA Depth Depth, cell grade II

Iris Crypte (+) Crypte (+)

Pupil Round, central, regular, Ø 3 Round, central, regular, Ø 5

mm, RP (+) N, RAPD (-) mm, RP (+) decreases,
RAPD (-)

Lens Clear, pigmen iris in Pigmen iris /cell (+) in

anterior capsul lens (+) anterior lens
CV Cell (-) Cell grade I, filamen (+)
OS. Panuveitis
• Therapy:
• P-pred ED/ 6 hour
OS
• SA1% ED/ 12 hour
OS
• Education: control
to eye clinic
 Identity
• Name: tn. S
• Age: 45 yo
• MR: C662899
• Chief Complain: left eye feels blocked
• Recent history:
patients come with a complaint of the left eye
feels blocked. complaint accompanied by red
eye (+), watery eye (+). a complaint arose after
meta was hit by an iron bounce 3 days ago.
because of the weighty complaints, the patient
came to the hospital
 OD OS

Visual acuity 1.0 f2 0.8

IOP T dig N T dig N

Eyelid Edema (-), spasme (-), Edema (-), spasme (-),

hiperemis (-) hiperemis (-)
Konjungtiva Injeksi (-) Injeksi (-)

Kornea Edema (-), lekoma (+) Edema (+) minimal, gram

(+) paracentral
COA Depth Depth, cell grade II

Iris Crypte (+) Crypte (+)

Pupil Round, central, regular, Ø 3 Round, central, regular, Ø 4

mm, RP (+) N, RAPD (-) mm, RP (+), RAPD (-)

Lens cloudy lens uneven cloudy lens uneven

OS. Corpus aleinum
• Therapy:
• Extraction corpal
• LFX ED/ 4 hour OS
• Education: control
eye clinic
 Identity
• Name: tn. DA
• Age: 25 yo
• MR: C687128
• Chief Complain: pain in the left eye
• Recent history:
patients present with left eye complaints of pain.
complaint appeared 3 days ago as it was hit by a
futsal ball. (+), red eyes (+), occurrences, blurred
vision of the left eye (+), feels blocked (+), pain (+).
the patient does not seek treatment anywhere until
the day. since this morning, the vision of the left eye
blurred back so that patients went to the hospital.
history using glasses (-)
double vision history (-)
 OD OS

Visual acuity 1.0 1.0

IOP 18.0 mmHg 19.6 mmHg

Eyelid Edema (-), spasme (-), Edema (-), spasme (-),

hiperemis (-) hiperemis (-)
Konjungtiva Injeksi (-) Mix Injeksi (+), Chemosis
(-)
Kornea Edema (-), lekoma (+) Edema (-)

COA Depth Depth, cell (-). Flare (-),

hypema (-)
Iris Crypte (+) Crypte (+), iridodialisis (-),
iridophexis (-)
Pupil Round, central, regular, Ø 3 Round, central, regular, Ø 4
mm, RP (+) N, RAPD (-) mm, RP (+) N, RAPD (-)

Lens clear Clear, subluxation of lens

(-)
• free eye movement
in all directions
• orbita bone
crepitation (-)
 OS. hyperemis conjunctiva
Therapy:
• Flumetholon 3x1 OS
• Education: control eye clinic
 Identity
• Name: an. DA
• Age: 7 yo
• MR: C687136
• Chief Complain: both eyes are exposed to
alteco glue
• Recent history:
the patient came with a right eye complaint
exposed to alteco glue while playing with his
brother. both eyes can not be opened. patients
are taken to the hospital
 OD OS

Visual acuity difficult to evaluate difficult to evaluate

IOP difficult to evaluate difficult to evaluate

Eyelid the superior and inferior the superior and inferior

palpebra are tightly sealed, palpebra are tightly sealed,
there is the remaining there is the remaining
hardened alteco glue (+) hardened alteco glue (+)
Konjungtiva difficult to evaluate difficult to evaluate

Kornea difficult to evaluate difficult to evaluate

COA difficult to evaluate difficult to evaluate

Iris Crypte (+) Crypte (+), iridodialisis (-),

iridophexis (-)
Pupil difficult to evaluate difficult to evaluate

Lens difficult to evaluate difficult to evaluate

left and right eye
irrigation was
performed with RL
1500 cc
 OD OS

Visual acuity C,S,M C,S,M

IOP T dig N T dig N

Eyelid Edema (-), spasme (-), Edema (-), spasme (-),

hiperemis (-), eyelash cut hiperemis (-), eyelash cut
(+), alteko (-) (+), alteko (-)
Konjungtiva Injeksi (-) Injeksi (-)

Kornea Edema (-) Edema (-)

COA Depth Depth

Iris Crypte (+) Crypte (+)

Pupil Round, central, regular, Ø 3 Round, central, regular, Ø 3

mm, RP (+) N, RAPD (-) mm, RP (+) N, RAPD (-)

Lens clear Clear

 ODS. Chemical Trauma
Therapy:
• left and right eye irrigation was performed
with RL 1500 cc
• Oxytetracycline eye oint 3x1 ODS
• Education: control eye clinic
 Identity
• Name: tn. IP
• Age: 16 yo
• MR: C687137
• Chief Complain: the left inner eyelid appears a
bump
• Recent history:
the patient came with a complaint of the left
eyelid part of the emerged bump. complaints
have been felt since 2 weeks ago. yellow lumps,
pus (-), pain (-), feels blocked in the eyes, red
eyes (-). the patient went to the hospital
 OD OS
Visual acuity 0.8 1.0
IOP T dig N T dig N
Eyelid Edema (-), spasme (-), Edema (-), spasme (-),
hiperemis (-) hiperemis (-), palpebra
inferior: bump (+), yellow,
2x2 size rounded, tender
(-), pus (-)
Konjungtiva Injeksi (-) Injeksi (+),
Kornea Edema (-), lekoma (+) Edema (-)
COA Depth Depth
Iris Crypte (+) Crypte (+)
Pupil Round, central, regular, Ø 3 Round, central, regular, Ø
mm, RP (+) N, RAPD (-) 3 mm, RP (+) N, RAPD (-)

Lens clear Clear

 OS. Hordeolum Internum
Therapy:
• Fucidic Acid eye oint/ 8 hour OS
• Compress with warm water
• Education: control eye clinic  pro OS. Incisi
hordeolum
Thank You