LAPORAN KASUS

PTERYGIUM
Supervisor:

Dr. Jaya Negara. , Sp.M (K)

By:
Ni Putu Arysta Dewi ( 1002005020 )
Bagus Agung Surya Dipta Nugraha ( 1002005041 )
IGN Ariwangsa Asbita ( 1002005050 )

OUTLINE

Introduction

Case Report
Patients Identity
Patients Name

: Olvilesa A Tarunni

Age

: 38 tahun

Gender

: Perempuan

Address

: Jalan Batas Dukuh Sari gang Merak No. 36 Denpasar

Profesion

: Ibu Rumah Tangga

Religion

: Kristen Protestan

State/Country

: Bali/Indonesia

Patients photo took with her

permission

ANAMNESIS
Chief Complaint: The felling of foreign body presents on
left eye.
Current illness :
Patient felling of foreign body present on left eye since 1 week
BATH. The patient complaints settled along days to disrupt
the activity of the patient. Patient also complains suffering
from watery of her left eye since 1 week BATH. Patient
complaint redness on left eye since 1 month BATH. History
of infection, sekret on the eye, trauma disangkal pasien

 Medication History:
The patient said using eye drop given by midwife, but patient forget name of the
medication.

Past illness history:

The patient said never feel the same complaint before. Symptoms such as
hipertensi, diabetes mieltus, and asma are all denied to be suffering by the
patient herself.

Social History:
The patient is a housewife who everyday just doing house chores. The patient claims
of frequently being exposed to sun rays, dust and surrounding pollutions.

Past Family Ilness:

None of her family members are suffering from what she is suffering from. Systemic
illness such as asthma and medicational allergy as well as food area all denied by
the patient.

Physical Examination
Present Status
General condition :
Conciounce
:
Blood pressure
:
Pulse
:
Axilla temperature :

Good
Compos mentis
120/80 mmHg
80 kali / menit
36 C

General status
a. Eye

explained in the opthalmagic status

b. ENT
-

Ears

: normal shape, inflammation signs (-/-), wound scar (-)

Nose

: normal shape, inflammation signs (-), excoriation (-), congestion(-)

Throat : tonsil (T1/T1), pharynx hyperemis (-),

c. Mouth : cyanosis (-), tongue atrophy (-)

d. Nexk

e. Thorax :

gland enlargement (-)

symmetrical (+)

Heart : Single S1S2, regular, murmur (-)

Pulmo :
f.

vesicular (+/+), rhonki (-/-), wheezing (-/-)

Abdomen :

g. Extremities

distension (-), intestional sounds (+) normal

:

warm +/+

edema - / -

 Local Eye Examination

OD

Examination

OS

6/6

Vision

6/6

Edema (-)

Palpebra

Edema (-)

Calm

Conjunctiva

Fibrovascular (+)

Clear

Cornea

Clear

Normal

BMD

Normal

Round, regular

Iris

Round, regular

Central,round, isokor,
RP (+)

Pupil

Central, Round, isokor,

RP (+)

Clear

Lense

clear

Positive

Fundal Reflex

Positive

20,7

TIO

21,0

DIFFERENTIAL DIAGNOSIS
OS Pterygium stadium II
OS Pseudopterygium
OS Pinguekula
DIAGNOSIS
OS Pterygium stadium II

Proposed Examination
Slit lamp
THERAPY
Eyefresh ed 6 x1 OS
Protection both eyes with glasses

PROGNOSIS
Ad vitam
: dubia ad bonam
Ad fungsionam : dubia ad bonam
Ad sanasionam : dubia ad bonam

Discussion
Theory

Case

From the anamnesis we can see that there is

increased in pain in either one or both the eyes,
accompanied with feeling of itchiness, watery eyes,
redness and or swelling. This condition may have
been there for years without any pressing symptoms
till in the end causes loss of eyesight, uneasiness due
to inflammation and irritation to the eys. Foreign
object sensation can be felt.

The result from the patients anamnesis fits

the subjective diagnostic criteria which
covers eye symptoms such as foreign
object sensation and watery eyes.

On closer inspection of the pterygium it is seen as

fibrovascular tissue growth on the conjunctival
surface. Pterygium gives the impression which is
vascular and thick but there are also cases of
pteryigum that are avascular and flat. Pterygium is
commonly found near the nasal conjunctival and
extended till the nasal cornea, but pterygium can also

The objective diagnostic criteria that can

be seen on the patient such as presence of
fibrovascular tissue that enters from the
conjunctival into the corneal region in a
triangular shape with numerous blood
vessels is noted on the patients right eye.

THEORY

CASE

The causes of a pterygium is widely unknown

for sure and is suspected to be a type of
neoplasm, inflammation and a kind of
degeneration. Pterygium is also suspected to
be caused by chronic irritation due to dust,
sun rays and hot air.

in the case, patient is a housewife who daily

homework. She said when traveling by bike,
the patient did not use a helmet because
proximity to the destination. Patients also
stay in outside which is near the coastal area
that has a high sunlight intensity

The following are the classification of

In this patient she is suffering from
pteryigum stadiums such as :
pterygium stadium II.
Stadium I : Pterygium limited to the corneal
limbus
Stadium II : Pterygium breaches the limbus
but not more than 2mm
Stadium III : Pterygium already breach as in
stadium 2 but not more than the pupils wall.
Derajat IV : Pterygium has breached the
pupil till its affecting the eyesight.

THEORY

CASE

The management for pterygium cases is

based on the stadium and severity of the
pterygium. When the pterygium is stll in its
early stages such as in stadium I and II
conservative therapy is given.

The management that was recommended in

this case is eye fresh eye drop 6 time a days
because the patient's discomfort over the
eye complaints such as forein body
sensation, watery eyes and also with
cosmetic reasons. Additionally, extirpation
pterygium first performed is because that
pterygium does not interfere with the field of
view of the current operator cataract surgery
when the operation take place.

The prognosis of this pterygium solely based

on the severity of the pterygium itself.

The prognosis of this patient in particular is

ad vitam: dubius ad bonam, ad fungsionam:
dubius ad bonam, ad sanationam: dubius ad
bonam.

CONCLUSION
Have been reported cases, female patients aged 37 years, complained of left
eye has foreign body sensation since 1 weeks ago.
The patient also complained of frequent watery. History of the use of glasses
uses, history of infection and trauma denied by the patient.
There is a medical history using eye drops, but patients say forget the name
of the medicine.
History of systemic diseases denied. The patient worked as a housewife who
daily homework.
From the results of a careful history and examination has been conducted, it
was found working diagnosis OS pterygium grade II.
Patients will be given eyefrsh eye drop 6 times a day.
This patient prognosis ad vitam: bonam dubious ad, ad fungsionam: bonam
dubious ad, ad sanationam: dubious ad bonam.

SUKSMA
TERIMA KASIH
THANK YOU