ODS DRY EYE + BLEFARITIS

KLINIK MATA ORBITA

Patient’s Identity

1
Name : Mrs.D

Age : 46 yo

Medical Record : 008213

Addres : Danau Mahalara

Occupation : Housewife

Date of Examination : 30 july 2019

HISTORY TAKING
Main Complaint : Foreign body feeling

A 46-year-old woman comes to the orbital eye clinic with complaints that
there is a foreign things in both eyes, a complaint that has been felt since 1
week ago and often recurs. Complaints are accompanied by sore eyes,
itching, red eyes (-), glare (-), blurred vision (-). Patients have often treated
with the same complaint. Previously 2 years ago was also diagnosed with
Bleararitis.
HISTORY TAKING
History of disease Medical history

She denies any history of She had never been treated

trauma, history of using before.
glasses, DM, Hypertension
and allergy. There is no family
with the same complaints, and
there is no history of the other
eye’s problem before.
PHYSICAL EXAMINATION
VISUS

OD Visus OS
20/30 Uncorrected Visual Acuity 20/25

- Correction -
- Best correct visual acuity -

- Near visua acuity -

- Correction -
- Best corrected near visual -
acuity
 PHYSICAL EXAMINATION
OD OS
Palpebra Margo Oedema (-) Hyperemia (-) Oedema (-) Hyperemia (-)
Crust (-) Lump (-) Crust (-) Lump (-)
Cilia Squama (+) Inward Squama (+) Inward
Eyelashes (-) Eyelashes (-)
Lacrimal Apparatus Lacrimation (-) Lacrimation (-)

Conjunctiva Hyperemia (-) Hyperemia (-)

Cornea Clear Clear

Anterior Chamber Normal, depth Normal, depth

Iris Brown Brown

Pupil Round, central Round, central

Direct/Indirect Light Reflex OD+ OS+

RAPD - -

Lens Clear Clear

 PHYSICAL EXAMINATION
PALPATION
OD OS

Ocular Pressure Tn Tn

Tumor / Mass (-) (-)

Pre Auricular Gland Not palpable Not palpable

PHYSICAL EXAMINATION

Ocular Dextra
Ocular Dextra Ocular Sinistra
Ocular Sinistra
 DIAGNOSIS
ODS DRY EYE + BLEFARITIS

DIFFERENTIAL DIAGNOSIS
Maibom gland
Conjungtivits
TREATMENT
Cendo lyters (Sodium chloride & pottasium chloride)
4 dd 1 gtt ODS
Doksisiklin 100 mg 1 dd1
PROGNOSIS

Quo ad Vitam
Bonam

Quo ad Sanasionam
Bonam

Quo ad Visum
Malam

Quo ad Cosmeticum
Bonam
Thank you