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    Case Report

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    Jehan Fauzi R
    This case report describes a patient who presented with pain and blurred vision in the right eye after being stuck by a twig while working in his yard. On examination, he was found to have a full thickness corneal laceration in the left eye with prolapsed iris. He underwent emergency corneal laceration repair surgery on the left eye. Post-operatively, his vision in the left eye remained poor and he developed a traumatic cataract. His prognosis for vision, health and cosmesis in the left eye was guarded.

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    Case Report

    Uploaded by

    Jehan Fauzi R
    61 views21 pages
    This case report describes a patient who presented with pain and blurred vision in the right eye after being stuck by a twig while working in his yard. On examination, he was found to have a full thickness corneal laceration in the left eye with prolapsed iris. He underwent emergency corneal laceration repair surgery on the left eye. Post-operatively, his vision in the left eye remained poor and he developed a traumatic cataract. His prognosis for vision, health and cosmesis in the left eye was guarded.

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    This case report describes a patient who presented with pain and blurred vision in the right eye after being stuck by a twig while working in his yard. On examination, he was found to have a full thickness corneal laceration in the left eye with prolapsed iris. He underwent emergency corneal laceration repair surgery on the left eye. Post-operatively, his vision in the left eye remained poor and he developed a traumatic cataract. His prognosis for vision, health and cosmesis in the left eye was guarded.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    61 views21 pages

    Case Report

    Uploaded by

    Jehan Fauzi R
    This case report describes a patient who presented with pain and blurred vision in the right eye after being stuck by a twig while working in his yard. On examination, he was found to have a full thickness corneal laceration in the left eye with prolapsed iris. He underwent emergency corneal laceration repair surgery on the left eye. Post-operatively, his vision in the left eye remained poor and he developed a traumatic cataract. His prognosis for vision, health and cosmesis in the left eye was guarded.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 21

    CASE REPORT

    CORNEA AND REFRACTIVE SURGERY SUBDIVISION

    JEHAN FAUZI Rr
    CHIEF COMPLAINT
    Pain on the right eye
    HISTORY OF PRESENT ILLNESS
     ±3H BDOV
     Patient cleaned up his yard, suddenly his right eye stucked
    by twig. Felt pain and blurred vision.
     ±2H BDOV
     Went to District Hospital, referred to SGH
     DOV
     Corneal laceration on the left eye, blurred vision, pain +
    HISTORY OF PAST ILLNESS
     History of Eye Diseases : (-)
     History of Diabetes Mellitus: (-)
     History of Hypertension : (-)
     History of Surgery : (-)
     History of Wearing Spectacles : (-)
     History of Eye and Head Trauma: (-)
    PHYSICAL EXAMINATION
     General condition : Good, alert

     Vital Sign
     BP : 118/71 mmHg

     HR : 72 x/minute

     RR : 20 x/minute

     T : 36◦C

     VAS : 5
    RE EXAMINATION
    VISUAL ACUITY 6/6
    EYE LID Within normal limit
    CONJUNCTIVA Within normal limit
    CORNEA clear
    ANTERIOR CHAMBER Deep and clear

    IRIS / PUPIL Round, Central, 3 mm, light reflex +/+

    LENS Clear
    VITREUS BODY Clear
    PAPIL Distinct margin, CD 0.3
    MACULA Reflex (+)
    RETINA a/v 2/3
    IOP N
    LE EXAMINATION
    1/60 VISUAL ACUITY
    Spasm gr I EYE LID
    Hyperemis gr II, CI (+) CONJUNCTIVA
    Full thickness laceration + 4x1 mm with prolapsed iris CORNEA
    Deep ANTERIOR CHAMBER
    Not round, central, 3 mm, light reflex +/+ IRIS / PUPIL
    Dense opacity, phacodenesis (-) LENS
    VITREUS BODY
    PAPIL
    Couldn’t be assesed
    MACULA
    RETINA
    N- IOP
    Free OM
    LE EXAMINATION
    DIAGNOSIS
    LECorneal Laceration Full
    Thickness with Prolapsed Iris
    MANAGEMENT AND PLAN
     RE Pro Emergency Corneal Laceration Repair under General
    Anesthesia
     ATS 1500 IU im
     Ceftriaxone 1 gram/12 hours iv
     Ketorolac 30mg/8 hours iv
     Levofloxacin ED/1 hours LE
     Ceftazidim ED/1 hour LE
    RE EXAMINATION D+1
    HM G/G VISUAL ACUITY
    Spasm gr II EYE LID
    Hyperemis gr II, CI (+) CONJUNCTIVA
    Mild edema in the central to infero temporal, graft + CORNEA
    Deep and clear ANTERIOR CHAMBER
    Not round, central, posterior synechia IRIS / PUPIL
    Dense opacity LENS
    VITREUS BODY
    PAPIL
    Macular reflex (+)
    MACULA
    RETINA
    N IOP
    Free OM
    LE EXAMINATION D+1
    ULTRASONOGRAPHY
    MANAGEMENT AND PLAN
     Ciprofloxacin 500 mg/12 hours
     Mefenamic acid 500 mg/8 hours
     Levofloxacin ED/2 hours LE
     C.eftazidim ED/2 hours LE
     Betamophtal ED/2 hours LE
     Methylprednisolone 16mg 1-1-0
    LE EXAMINATION D+6
    HM G/G VISUAL ACUITY
    Spasm gr I EYE LID
    Hyperemis gr I, CI (+) CONJUNCTIVA
    corneal graft + CORNEA
    Deep and clear ANTERIOR CHAMBER
    Not round, central, , Ø 7mm ,posterior synechiae IRIS / PUPIL
    Dense opacity LENS
    VITREUS BODY
    PAPIL
    Coudn’t beasessed
    MACULA
    RETINA
    N IOP
    Free OM
    LE EXAMINATION D+6
    DIAGNOSIS
    LE Post Repair Corneal
    Laceration D+6 + Traumatic
    Cataract
    MANAGEMENT AND PLAN
     Ciprofloxacin 500 mg/12 hours
     Mefenamic acid 500 mg/8 hours
     Levofloxacin ED/2 hours LE
     C.eftazidim ED/2 hours LE
     Betamophtal ED/2 hours LE
     Methylprednisolone 16mg 1-1-0
    PROGNOSIS
     RIGHT EYE
     Ad Visam : Dubia ad Bonam
     Ad Sanam : Dubia ad Bonam
     Ad Vitam : Bonam
     Ad Cosmeticam : Dubia ad Bonam
    THANK YOU
    ADVICES AND SUGGESTIONS ARE VERY WELCOME

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