IMMUNOLOGY
DIVISION
DIA/ CES/ EGA/ TAN/ VAT
Mr. M/ 66 y.o.
adm. On October 16th 2018
Chief complaint: Blurred vision
Blurred vision on his right eye since 3 months ago, getting worse since 3 days
before admission. Redness (-) Pain (-) Tearing (+) Glare (-) Discharge (-). His left
eye cannot see since 5 years ago.
History of previous eye disease: Glaucoma, routinely controlled at Saiful Anwar
Hospital, herpetic keratitis since 2 weeks before admission.
History of surgery:
Cataract surgery on the right eye: 5 months ago at Saiful Anwar hospital
(Phacoemulsification + IOL with difficulty: PCR and complication: vitreous
prolapse)
Cataract surgery on the left eye 16 years ago
History of therapy : Timol ed 0,5% 2x1 RLE from glaucoma division, Hervis eo 5x1
RE, Vigamox ed 6x1 RE, C. Lyteers ed 6x1 RE from Saiful Anwar Hospital.
History of trauma (-)
History of wearing spectacle (+) : RLE -11.0 since 6 years ago
History of systemic disease: hypertension (-), diabetic (-)
General Condition
BP: 130/90 mmHg
HR: 88 times/mnt, RR: 18 times/ mnt
Summary Of
Database
Oct 16th 2018
RE USG LE USG
Hct : 44,0 %
Planning
• RE intravitreal injection Vancomycin 1mg/ 0,1ml + vitreous tap + aff
corneal suture / LA
• Inf. Ciprofloxacin 2 x 400 mg IV
• Prednison 1 mg/kgBW (60 mg – 0 – 0)
• Kalk 1 x 1 tab
• Ranitidin 2 x 1 tab
• Vigamox ed 6 x 1 RE
• SA 1% ed 3 x 1 RE
• C.Lyteers ed 6 x 1 RLE
• Timol ed 0,5% 2x1 LE ~ Glaucoma subdivision
• Consult to Internal Medicine Dept.
RE intravitreal inj
vancomycin 1mg/0.1ml + Vitreous tap
+ Aff corneal suture/ LA
Conjunc SCH (+), chemosis (+), CI (-) SCH (+) , CI (+) PCI(+)
tiva PCI(-) chemosis (+) ↓ discharge (-)
Cornea white kp’s (+), brown kp’s (+), fl test (+) epithelial corneal
fl test (+) dendrite, punctat, defect size. 1,8x1mm
chemosis (+), neovascular (+), suture Σ 1 tga, white kp’s (+)
suture Σ 1 tga brown kp’s (+), neovascular (+)
AC deep, flare grade III, deep, flare grade II,
cell grade III cell grade II
Iris Posterior synechia 7-11 Posterior synechia 7-11 o’clock
o’clock
pupil midmidri ec SA 1%, PR(-) midmidri ec SA 1%, PR(-)