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    Chapter III

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    PspduntanDuaribusebelas
    The document describes a case review of a 72-year-old female patient who presented with total blindness in her right eye and dim vision in her left eye. Her right eye was diagnosed with primary glaucoma and immature senile cataract, while her left eye was diagnosed with immature senile cataract. Her treatment plan included topical eye drops for her right eye and surgical cataract removal for her left eye.

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    Chapter III

    Uploaded by

    PspduntanDuaribusebelas
    25 views6 pages
    The document describes a case review of a 72-year-old female patient who presented with total blindness in her right eye and dim vision in her left eye. Her right eye was diagnosed with primary glaucoma and immature senile cataract, while her left eye was diagnosed with immature senile cataract. Her treatment plan included topical eye drops for her right eye and surgical cataract removal for her left eye.

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    The document describes a case review of a 72-year-old female patient who presented with total blindness in her right eye and dim vision in her left eye. Her right eye was diagnosed with primary glaucoma and immature senile cataract, while her left eye was diagnosed with immature senile cataract. Her treatment plan included topical eye drops for her right eye and surgical cataract removal for her left eye.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    25 views6 pages

    Chapter III

    Uploaded by

    PspduntanDuaribusebelas
    The document describes a case review of a 72-year-old female patient who presented with total blindness in her right eye and dim vision in her left eye. Her right eye was diagnosed with primary glaucoma and immature senile cataract, while her left eye was diagnosed with immature senile cataract. Her treatment plan included topical eye drops for her right eye and surgical cataract removal for her left eye.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 6

    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 OS
    Ortho Eyeball Position Ortho

    Movement (+), Ptosis (-), Palpebra Movement (+), Ptosis (-),


    Lagoftalmos (-), Edema (-) Lagoftalmos (-), Edema (-)
    No triangle shape Conjunctiva No triangle shape
    fibrovascular growth, fibrovascular growth,
    hyperemis (-), anemis (-), hyperemis (-), discharge
    discharge (-), injection(+), (-), injection (-), foreign
    foreign body (-) body (-)
    Clear, edema (-) , infiltrat (-), Cornea Clear, edema (-) , infiltrat
    ulkus (-) (-), ulkus (-)
    Deep Anterior Chamber Deep

    Iris colour: Brownish, Iris/pupil Iris colour: Brownish,


    Synechia (-) Synechia (-)
    Pupil: Round, 4mm, mid- Pupil:Round, 2mm,
    dilated, anisochor, direct light anisochor, direct light
    reflex (diminished), indirect reflex (+), indirect light
    light reflex (diminished), reflex (+), shadow test (+)
    shadow test (+)
    Hazy 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

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