CHAPTER IV

DISCUSSION

The patient comes with total blindness in the right eye with the history of
gradually vision loss since 2013 and dim vision in the left one since a month ago.
No redness in both eyes. In the case of normal eye with gradually vision loss we
have to suspect cataract, glaucoma, and retinopathy. The diagnosis can be made
by history taking and physical examination.
The patient is a 72-years old woman with no history of hypertension, diabetes,
or any other disease just like leukemia or anemia. This information has leading the
diagnosis to cataract or glaucoma rather than retinopathy. We can ensure this
firstly by doing the some physical examination such as external examination of
the eye using loop and pen light to see the lens for cataract diagnosis. The result is
there is the opacity in both of lens with positive shadow test that strongly indicate
the immature cataract. But, immature cataract is not suitable with the visual
acquity of the right eye. Immature cataract without any others problem can not
cause the total blindness. So, we have to think that theres another problem in the
right eye and we still have two others diagnosis that havent exclude before,
glaucoma and retinopathy. From the physical examination we also get the
information about anisochor pupil with mid-dilate pupil in the right eye that have
diminish pupil reflex. Mid-dilate pupil is a pathognomonic sign for glaucoma, it is
a very important information that should be confirm by internal examination using
funduscopy. The funduscopy result is very specific for glaucoma, the cupping disc
(cup and disc ratio about 0,9) with no hemorrhagic, exudates, micro aneurism, or
vascular proliferation that specific for retinopathy.
After conclude the diagnosis with glaucoma, we have to classified the type of
glaucoma, especially for therapy purpose. In this patient, the glaucoma can be due
to primary or secondary process. The secondary process is due to the immature
cataract that can cause phacomorphic glaucoma (secondary cataract et causa
intumescence of the lens). Intumescence of the lens will cause the closed-angle
glaucoma characterized by hyperemi and the patient report ocular pain, headache,
nausea, and vomiting. No one of the symptom reported by this patient so the
glaucoma must be the primary. It feasibly primary open-angle glaucoma
glaucoma that should be ensure by using gonioscopy examination and tonometry.
The treatment purpose is to control intraocular preasure.
Funduscopy examination of the left eye show the normal result so the visual
problem may due to immature senile cataract. The surgery will make the visual
acuity better.
Glaucoma screening is important to performed in the left to detect the
asymptomatic glaucoma. The examination such as funduscopy and tonometry that
routinely performed every year.