OPHTHALMOLOGY RECORD

Name of examine

: Nuralita Resty Pradiani

NIM

: 1161050226

Date of examination : August, 25th 2016

Tutor
I.

: dr. Gilbert W.S Simanjuntak, SpM

IDENTITY PATIENT

Name

: Mr. T

Age

: 43 years old

Status

: Married

Address

: Mungkon, Sragen, Sidoarjo.

Last Education

: Senior High School

Occupation

: Pensioner

II.

INTERVIEW (August, 10th 2016)

Main complaint

: blurred vision in the right eye

Additional complaint : photophobia, pain and redness

Course of Disease
Patient came with a blurred vision in his right eye since 3 weeks ago after his eye exposed by
glue. Blurred vision are slowly. In addition, he also felt photophobia (dazzled), pain, the eye is
red, and tearing. He had treatment to an ophthalmologist and was given an eye drops and pills
but he is forgot the name of the drugs. The complaints has improved and then he stopped the
treatment, but complaints get worse in the last 2 weeks. The patient didnt get fever, floaters (-)
and didnt have complaints in the left eye.
Previous Disease
Patient claims that there is no history of the same symptoms before. No history of diabetic,
hypertension, alergic and using long-term drugs.

III.

GENERAL STATUS

General condition

: Good

Awareness

: Compos Mentis

Blood Pressure

: 110/80 mmHg

Pulse Rate

: 80 times/min

Respiration Rate

: 22 times/min

IV.

OPTHALMOLOGIST STATUS
A. General Examination
Right Eye

Left Eye

Periocular appearance

Quiet

Quiet

General Condition of the Eye Ball

Moderate illness
appearances

Normal

Position of The Eye Ball

Symmetric

Symmetric

Eyeball movement

Normal

Normal

B. Systematic Examination
Right eye

Left eye

Visual Acuity

5/60

6/7

Pin Hole

Correction

No correction

No correction

Super cilia

Normal

Normal

Madarosis (-)

Madarosis (-)

Trichiasis (-)

Trichiasis (-)

Normal

Normal

Madarosis (-)

Madarosis (-)

Trichiasis (-)

Trichiasis (-)

Cilia

Palpebra Superior/Inferior

Quiet

Quiet

Margo Palpebra Superior/ inferior

Normal

Normal

Tarsal Conjunctiva

Hyperemis (-)

Hyperemis (-)

Scar (-)

Scar (-)

Papil (-)

Papil (-)

Konjungtiva Forniks Superior/

inferior

Hyperemis (-)

Hyperemis (-)

Bulbar Conjunctiva

Hyperemis (+),discharge (-),

ciliary injection (+),
conjuctival injection (-)

Hyperemis (-),discharge (-),

ciliary injection (-), conjuctival
injection (-)

Cornea

Opaque, keratic precipitate

(+), edema (-), arcus senilis
(-)

Infiltrate (-), edema (-), arcus

senilis (-)

Anterior Chamber

Shallow, bleeding (-) flare (+)

Deep, bleeding (-)

Iris

brown, synechiae posterior

(+)

Radier,brown

Pupil

Anisokor, irregular , 2mm,

central light reactive (-)

Isokor, round, 3mm,

central,light reactive (+)

Lens

clear

Clear

Tonometri

Same with the examiner

Same with the examiner

Field of view

Normal

Normal

V. RESUME
Mr. T, 43 years old, came with a blurr vision on his right eye since 3 weeks ago after his eye
exposed by glue. Blurry vision is slowly. In addition, he also felt photophobia, pain in the eye
lid, the eye is red, and tearing. He had treatment to an ophthalmologist and was given an eye
drops and pills but he is forgot the name of the drugs. The complaints had improved and then he
stopped the treatment, but in the last 2 weeks of complaints get worse.
From the ophthalmology examination in the right eye founded :
3

Visual Acuity

: 5/60

Bulbar Conjunctiva

: Hyperemis (+),ciliary injection (+)

Cornea

: Opaque, keratic precipitate (+)

Anterior Chamber

: Shallow, flare (+)

Iris

: brown, synechiae posterior (+)

Pupil

: Anisokor, irregular , 2 mm, central light reactive (-)

VI.

CLINICAL DIAGNOSE

Uveitis Anterior Occuli Dextra

VII.

DIFFERENTIAL DIAGNOSES

Keratitis
Conjunctivitis
VIII. MEDICAL TREATMENT
Non medicamentous : using of protective glasses
Medicamentous
: prednisolone acetate 1% 2 drops 4 times/day
Atropine sulfate 1% 2 drops 4 times/day
IX.

PLAN FOR EXAMINATION

Funduscopy
Slit lamp

VIII. PROGNOSIS

IX.

OD

OS

Ad. Vitam

Bonam

Dubia ad Bonam

Ad. Fungsionum

Bonam

Dubia ad bonam

Ad. Sanationum

Bonam

Dubia ad bonam

COMPLICATION
Secondary Glaucoma
Complicate cataract