OPTHALMIC RECORD

Monalisa Silaen 0361050154

OPHTHALMIC RECORD
PATIENT IDENTITY Name : Mr. A Age : 66 years old Address : Martuha, Lampung Occupation : Self-employed dan Farmer ANAMNESIS (9th July 2013) Main complain Blurred vision about 2 months ago Additional complain When walking patients often bump into things around

History of disease

Approximately 6 months before entering the hospital the patient complained of blurred vision in the right eye, the patient is slowly getting blurred vision, no headaches, no nausea, no vomiting, no pain, a view like seeing rainbows around light denied, the diminishing the patient's perspective or blurred until about 2 months before entering the hospital the patient's right eye can not see anymore. The patient went to the hospital, the patient was given medication and advised drops but the patient refused surgery. Approximately 1 month before entering the hospital the patient complained of blurred vision in the left eye, the same complaint with the complaints as in the right eye. Slowly become blurred view of the patient, is increasingly severe. Patient complained of a narrow view that patients often bump into things around him. Such a view see no smoke, sight seeing flying objects do not exist, no headaches, no pain, no nausea, no vomiting, no red eyes, no watery eyes, no eye dirt, patients treated at the hospital Lampung and was given

Previous disease
Patients had a history of diabetes of approximately 7 years ago, the patient was not taking medication regularly, the patient also had a history of hypertension is approximately 10 years ago. History of denying the use of glasses, a history of traumatic denied, denied family history, surgical history

General status
General condition : Patients seemed to limp Symptom or illness related to the complain BP: 160/100 GDS: 400 OPHTHALMIC STATUS General Examination

Ophthalmic status
Right Eye
Periocular appearance No edema

Left Eye
No edema Normal Symetric Normal

General condition of the eye normal Eyeball position Eyeball movement Symetric Normal

Systematic Examination Right Eye Visual acuity Correction Supercilia Cilia 0 Normal, Madarosis (-) Black color, Oedema(-), Ulcer (-), Sinofris (-), Growth and Spread evenly, Trikhiasis (-) Oedema (-), Hematoma (-), Ptosis (-), Lagoftlamus (-), Blepharospasm (-) Left Eye 6/36 Normal, Madarosis (-) Black color, Oedema (-), Ulcer (-), Sinofris (-), Growth and Spread evenly, Trikhiasis (-) Oedema (-), Hematoma (-), Ptosis (-), Lagoftlamus (-), Blepharospasm (-)

Margo Palpebra sup/inf

Right Eye
Tarsal conjunctiva sub/inf Pink color, Hyperemia (-), Sikatrik (-), Hordeolum (-), Kalazion (-) Normal, Hyperemia (-), Oedema (-), Secret (-) Normal,Conjunctiva injection (-), Siliaris injection (-),Sub Conjunctival Hemorrhage (-), Peterigium (-), Pinguekula (-)

Left Eye
Pink color, Hyperemia (-), Sikatrik (-), Hordeolum (-), Kalazion (-) Normal, Hyperemia (-), Oedema (-), Secret (-) Normal, Conjunctiva injection (-), Siliaris injection (-), Sub Conjunctival Hemorrhage (-), Peterigium (-), Pinguekula (-)

Fornixes conjunctiva sup/inf Bulbar conjunctiva

Right Eye

Right Eye

Cornea

Clear Infiltrat (-), Ulcer (-), Slugs (-), Sikatrik (), Neovascularization (-), Fluorescent tests, Plasidoskop, Sensibility not performed Deep Iridoplegi Mid dilatation 6 mm Light Reflexs : (-) Turbid

Anterior chamber Iris Pupil

Clear Infiltrat (-), Ulcer (-), Slugs (-), Sikatrik (-), Neovascularization (-), Fluorescent tests, Plasidoskop, Sensibility not performed Deep Reguler Color : Brown Round, isochors 2 mm Light Reflexs : (+) Turbid

Lens

C. Special Examination
Tonometri

OD: 54 mmHg

OS: 28

mmHg

RESUME
Male patients aged 66 years came with complaints of blurred vision in the left eye since one month before entering the hospital. Perceived grievances continuously and slowly but increasingly heavy. Patients feel more narrow view so often hit stuff around it, like a rainbow no shadow, no headaches, no nausea, vomiting, see a view like no smoke. About 2 months ago the patient's right eye was not able to see. Initially less than 6 months before entering the hospital the patient blurred vision, severe and increasingly slowly getting blurred vision, no pain, no headache, no vomiting nausea, rainbows around light view does not exist, no watery eyes there. Patients had a history of diabetes of approximately 7 years ago, did not take

Ophthalmic Examination
Right Eye
Visual acuity Anterior Chamber Iris Pupil 0 Deep Iridoplegi Mid Dilatation 6mm Light Reflexs: (-) Turbid

Left Eye
6/36 Deep Reguler Color: Brown Round, isochor 2mm Light Reflexs: (+) Turbid

Lens

Tonometri

54 mmHg

28 mmHg

CLINICAL DIAGNOSE
Right Eye Left Eye

Absolute Glaucoma

Primary Open Angle Glaucoma

Differential Diagnose Normal Pressure Glaucoma Ocular Hypertension Primary Angle Closure Glaucoma

MEDICAL TREATMENT Beta-blocker (Timolol Maleat 0,5% 2 drops/day, in the morning and afternoon) Pilokarpin

SPECIFIC EXAMINATION
Slip Lamp Opthalmoskop

PROGNOSES
Right Eye
Ad vitam Ad sanationum Ad functionum Malam Malam Malam

Left Eye
Dubia Malam Dubia

COMPLICATIONS Blindness