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    Cataract AND Refractive Surgery Subdivision: Ika/Tev/Fas/Dha/Yac

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    Friska Hutahaean
    1. The document summarizes cataract surgery reports for 3 patients. Patient 1 was a 63-year-old male who underwent phacoemulsification and intraocular lens implantation in his right eye, with postoperative vision of 20/70 and 20/40. Patient 2 was a 23-year-old female who underwent the same procedure in her left eye, with postoperative vision of 20/150 and 20/70. Patient 3 was a 55-year-old female who underwent small-incision cataract surgery and intraocular lens implantation in her left eye. 2. The second part of the document provides medical history and examination findings for a 76-year-old male admitted for blurred vision in

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    Cataract AND Refractive Surgery Subdivision: Ika/Tev/Fas/Dha/Yac

    Uploaded by

    Friska Hutahaean
    30 views15 pages
    1. The document summarizes cataract surgery reports for 3 patients. Patient 1 was a 63-year-old male who underwent phacoemulsification and intraocular lens implantation in his right eye, with postoperative vision of 20/70 and 20/40. Patient 2 was a 23-year-old female who underwent the same procedure in her left eye, with postoperative vision of 20/150 and 20/70. Patient 3 was a 55-year-old female who underwent small-incision cataract surgery and intraocular lens implantation in her left eye. 2. The second part of the document provides medical history and examination findings for a 76-year-old male admitted for blurred vision in

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    1. The document summarizes cataract surgery reports for 3 patients. Patient 1 was a 63-year-old male who underwent phacoemulsification and intraocular lens implantation in his right eye, with postoperative vision of 20/70 and 20/40. Patient 2 was a 23-year-old female who underwent the same procedure in her left eye, with postoperative vision of 20/150 and 20/70. Patient 3 was a 55-year-old female who underwent small-incision cataract surgery and intraocular lens implantation in her left eye. 2. The second part of the document provides medical history and examination findings for a 76-year-old male admitted for blurred vision in

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    30 views15 pages

    Cataract AND Refractive Surgery Subdivision: Ika/Tev/Fas/Dha/Yac

    Uploaded by

    Friska Hutahaean
    1. The document summarizes cataract surgery reports for 3 patients. Patient 1 was a 63-year-old male who underwent phacoemulsification and intraocular lens implantation in his right eye, with postoperative vision of 20/70 and 20/40. Patient 2 was a 23-year-old female who underwent the same procedure in her left eye, with postoperative vision of 20/150 and 20/70. Patient 3 was a 55-year-old female who underwent small-incision cataract surgery and intraocular lens implantation in her left eye. 2. The second part of the document provides medical history and examination findings for a 76-year-old male admitted for blurred vision in

    Copyright:

    © All Rights Reserved
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    Download as pptx, pdf, or txt
    of 15

    CATARACT

    AND
    REFRACTIVE SURGERY
    SUBDIVISION

    IKA/TEV/FAS/DHA/YAC
    CATARACT SURGERY REPORT

    NO NAME/AGE RE/ VA PRE OP VA POST SURGERY


    LE OP
    1. Mr. k/63 y.o RE 0.5/60 ph 5/40 20/70 PH OD Phaco +
    20/40 IOL/LA
    2. Mrs. S. A/23 LE 1/300 20/150 ph OD Phaco +
    yo 20/70 IOL/LA
    3. Mrs. Y/55 yo RE 1/300 cor(-) ph(-) 20/150 ph (-) OS SICS +
    IOL/LA
    MR. M / 76 Y.O
    ADM. JAN, 29 TH 2018
    Chief complain : Blurred vision on her right eye
    Blurred on her right eye since 7 month ago, gradually and
    getting worse. Pain (-), redness (-), tearing (-), glare (-)
    History of wearing spectacle :-
    History of surgery : Cataract surgery on December 2017,
    Tumorectomy mammae in 2015
    History of disease : DM(+) on therapy, HT (-), breast cancer
    in 2015, CVA thrombosis, dyslipidemia
    History of therapy : ASA, Simvastatin, Gabapentin, MST,
    and she has finished chemotherapy on October 2017
    History of trauma :-
    GENERAL CONDITION
    BP: 130/80 mmHg
    FBS : 182 mg/dL
    Cholesterol : 211 mg/dl
    Trigliserida : 219 mg/dl
    LDL : 158 mg/dl
    SUMMARY OF
    DATA BASE
    Right Eye Left Eye
    LP (+) BP Visual 5/12f cc C-2.25 x 100  5/5f ph (-)
    Acuity
    spasm (-), edema (-) Eyelid spasm (-), edema (-)
    CI (-) , PCI (-)Conjungtiva CI (-), PCI (-)
    Clear Cornea Clear
    Deep AC Deep
    Radline Iris Radline
    Round, midri d.t midriatyl, PR (- Pupil Round, midri d.t midriatyl, PR (-)
    )
    Not homogen opacity, opacity @ Lens IOL on place
    subcapsular posterior
    14,6 mmHg IOP 17,3 mmHg
    FR (+) dim, detail dte Funduscopy FR (+) dim, detail wnl
    Dte ec visus Retinometri 0.8

    KR 1: 8.00/42.50x100 Keratometry KR 1: 7.90/42.50x1450


    KR 2: 7.80/43.00X1000 KR 2: 7.80/43.00X600

    AXL : 23.63 mm Biometri AXL : 23.46 mm


    ACD : 3.02 mm ACD : 2.44 mm
    Lens : 3.84 mm Lens : 3.81 mm
    Ext IOL : +21.00 D IOL : +21.00 D
    USG
    RE USG LE USG

    Posterior capsule : intact Posterior capsule : intact


     Vitreous:  Vitreous:
    anterior , media, posterior: echo anterior , media, posterior: echo
    dense (-) dense (-)
     Retina : on place  Retina : on place
     Choroid : wnl  Choroid : wnl
     PNII : on place  PNII : on place
    INTERNAL MEDICINE DEPARTMENT

    Assesment DM type 2

    Glimepiride 4mg-0-0
    Planning
    therapy
    NUEROLOGY DEPARTMENT

    Assesment CVA Thrombosis

    Planning ASA 1 x 80 mg
    therapy
    Simvastatin 0-0-20mg
    Gabapentin 0-0-30mg
    Diagnosis

    • RE Cataract Br Gr III + PSC


    • LE Pseudophakia

    Treatment

    • Hospitalized
    • Education and information about the
    disease and risk
    • Education and information about the
    planning therapy
    • Pro RE SICS + IOL / LA
    TREATMENT

    Performed Feb, 12nd 2018


     Diff :

     Compl : -
    IOL inserted: +21.00 D

    Post Op Ciprofloxacin tab 2 x 500 mg


    Treatment
    Mefenamic acid tab 3x500mg (if needed)

    Levocin e.d 1 drop/hour RE

    Fluorometholone e.d 1 drop/hour RE


    FOLLOW UP
    DAY 1
    Right Eye Left Eye
    20/150 ph (-) Visual Acuity 5/12f cc C-2.25 x 100  5/5f ph (-)
    spasm (+), edema (-) Eyelid spasm (-), edema (-)
    Chemosis (+), SCH (+), CI (-) , PCI (-) Conjungtiva CI (-), PCI (-)
    Suture 5 tight good app, edema (+), Cornea Clear
    striae(+)
    Fl cell gr IV, shallow, retained nucleus AC Deep
    (+) @ 5 o’clock, coagulum <1/3 AC,
    hyphema (+)
    Iridodialysis @ 1 o’clock, radline Iris Radline
    not round, PR (-) Pupil Round, 3 mm, PR (+)
    IOL on place Lens IOL on place
    5 mmHg IOP 14,6 mmHg
    FR (+) detail dte Funduscopy FR (+) detail wnl
    KR 1: 8.20/41.00x150 Keratometry
    KR 2: 7.30/46.00X1000
    ASSESSMENTF:OLLOW UP DAY 1
    • RE Pseudophakia post SICS/LA day – 1
    • LE Pseudophakia

    TREATMENT :
    • Ciprofloxacin tab 2x500 mg
    • Methylprednisolone tab 3x8 mg
    • Mefenamic acid tab 3x500mg (if needed)
    • Levocin e.d 1 drop/hour RE
    • Fluorometholon e.d 1 drop/hour LE
    • Peribulbar injection Dexamethasone : Gentamycin = 1:1
    • RE Patching
    BEFORE

    AFTER
    THANK YOU

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