ROONK

SUBDIVISION

TAN/EGA/DIM/BEN/WAN
 Mr. E / 17 y.o.
Adm on Nov, 19th 2017
Chief complaint : Mass on his left eye
• Mass on his left lower eyelid since he was born, mass begun from small size
and became larger by time , pain (-), itchy (-), redness (-), bleed (-), tearing (-),
mass in others area of body didn’t find. History of previous mass (-). Blurred
(+) on his left eye since he was child and getting worse, blurred on his right
eye since 3 years ago. History of family with the same disease (-)
• History of trauma : (-)
• History of surgery : (-)
• History of therapy : (-)
• History of wearing spectacle: (-)
• History of previous eye disease : (-)
• History of systemic disease: HT (-), DM (-)
GENERAL CONDITION

BP : 100/70 mmHg
FBG : 100 mg/dL
BG 2 hr after meal : 120 mg/dL
 Summary of Data Base

Right Eye Left Eye

5/60 cc s-250 → 5/5 VA 5/40
Spasm (-),edema (-) Eyelid Spasm (-), edema (-),
Fibrovasc. tissue (+), CI(-), PCI (-) Conj. CI (-), PCI(-), mass (+) Ø 0.6 x 0.4 cm, solid, Sharp
margin, fixed, pain (-), redness (-),
Clear Cornea Clear
Deep AC Deep
Radline Iris Radline
Round, Ø3 mm, PR (+) Pupil Round, Ø3 mm, PR (+)
Clear Lens Clear
17.3 mmHg IOP 17.3 mmHg
FR (+), detail wnl Fundus FR (+), detail wnl
 RE LE
Pain(-) EBM pain(-)

o FR : + Funduscopy FR : +
o Media : clear Media : clear
o ONH : round, sharp margin, C/D ratio 0.3, orange, ONH : shape dte, sharp margin, C/D rat dte, pale (+), SV
SV >7 7, PPA (+)
o Vasa : A/V 2/3, scle -, cross – Vasa : A/V 2/3, scle -, cross –
o Retina : exu -, haem - Retina : exu -, hem –, tigroid (+)
o Macula : fovea reflex (+) Macula : foveal reflex +
ASSESSMENT
• LE Conjunctival tumor susp limbal
dermoid
• LE Early papil atrophy
• RE Miopia

PLANNING THERAPY
• Education and information about the disease and
planning therapy
• Pro LE tumor extirpation + PA / GA
 Nov 20th, 2017
LE tumor extirpation + AMT + PA /
GA
Diff. : -
Comp. : -

Post Op Treatment

• LE Patching 24 hrs
• Mefenamic acid tab 3 x 500 mg
• Tobro ed 6x1 LE
• Protagent A ed 6x1 LE
 Wide undermine  release tumor disection tumor ekstraction Clearing tumor retain
tumor from surrounding tissue

Attach the AMT Suturing the AMT Disinfection

 Follow up day 1

Right Eye Left Eye

5/60 cc s-250 → 5/5 VA 5/40
Spasm (-),edema (-) Eyelid Spasm (-), edema (-),
Fibrovasc. tissue (+), CI(-), PCI (-) Conj. CI (-), PCI(-), SCH (+), Suture Σ2, covered by
conjunctiva
Clear Cornea AMT Absorbed
Deep AC Deep
Radline Iris Radline
Round, Ø3 mm, PR (+) Pupil Round, Ø3 mm, PR (+)
Clear Lens Clear
17.3 mmHg IOP 17.3 mmHg
FR (+), detail wnl Fundus FR (+), detail wnl
 RE LE
Pain(-) EBM pain(-)

o FR : + Funduscopy FR : +
o Media : clear Media : clear
o ONH : round, sharp margin, C/D ratio 0.3, orange, ONH : shape dte, sharp margin, C/D rat dte, pale (+), SV
SV >7 7, PPA (+)
o Vasa : A/V 2/3, scle -, cross – Vasa : A/V 2/3, scle -, cross –
o Retina : exu -, haem - Retina : exu -, hem –, tigroid (+)
o Macula : fovea reflex (+) Macula : foveal reflex +
ASSESSMENT
• LE post tumor extirpation + AMT Conjunctival
tumor susp limbal dermoid
• LE Early papil atrophy
• RE Miopia

PLANNING THERAPY
• Mefenamic acid tab 3 x 500 mg PO
• Tobro ed 6x1 LE
• Protagent A ed 6x1 LE
• Patient discharged
 BEFORE

AFTER