Vitreo-Retina Subdivision

Mrs. P/ 53 y.o
Admission on Dec, 27th 2017
Chief complain : Blurred on her right eyes
• Blurred on her right eye since 1,5 months ago and gradually getting worsed. She also saw
like threads that follow everytime she glance. Pain(-), redness(-), glare (+).
• She also complained blurred on her left eye since 2 years ago. Pain(-), redness(-), glare (-).
• History of trauma : -
• History of treatment : She got cataract surgery on her right eye since 3 years ago, and
she got cataract surgery + use of silicon oil on her left eye since 4 year ago
• History of previous eye diseases : cataract
• History of allergic : (-)
• History of heavy lifting : (-)
• History of wearing spectacle : (+)
• History of family : (-)
• History of systemic disease : DM(-), HT(+) Not Controlled, Cholesterol (-)
General Condition

BP : 160/90 mmHg, HR 86x/m

 Summary of Data Base
Dec, 27th 2017
Right Eye Left Eye
5/12 F Visual Acuity LP (-)
spasm (-) edema (-) Eyelid spasm (-) edema (-)
CI (-) PCI (-) Conjunctiva CI (-) PCI (-)
Fl test (+) punctat Cornea Fl test (+) punctat, lekoma (+)
Deep Anterior Chamber Deep
Radline Iris Radline
Round, Pupil Round, Ø3mm, PR (-)
IOL on Place, PCO- Lens IOL on Place, PCO +
8,5mmHg IOP 10,2 mmHg
 Funduscopy
Dec 27th 2017

Funduscopy :
• RF : +/+dim
• Media : Vitreous opacity gr I ec tobacco dust /opacity gr III ec PCO
Detail OS : DTE
Detail OD:
• ONH : round+, sharp margin+, c/d ratio 0,4, orange+, SV >7
• Vascular : a/v 2/3+ ,scle-, cross-
• Retina : hemorrhage -, exudate -, detach +, tear + (horse shoe),
scar post laser +,wrinkling +
• Macula : FR + / macula on +
RLE USG (27/12/2017)

• Posterior Capsule: intact

•Posterior Capsule: dte
• Vitreous
•Vitreus :
Anterior :Echodense (+) low spike
Anterior : echo dense (+) med spike
Media : Ecodense (+) low -med
Media : echo dense (+) med spike
spike
Posterior : echo dense (+) med spike
Posterior: Echodense (+) low spike
•Retina : dte
Retina: Continous line (?)
•Choroid : dte
• Choroid : within normal limit
•ONH : dte
• ONH : on place
Detachment Chart
27/12/2017
 Diagnosis
RE RRD with macula on + PVR gr B + post demarcation laser
LE Silicon filled eye post Vitrectomy ec Susp RRD + PCO + corneal leucoma
RLE pseudophakia + PEE
•
Laboratory
Hb 14,80 g/dl
• Rbc 5,15 106/ɥL Result
• Wbc 6,92 103/ɥL
• Hct 43,50 % 29/12/2017
• Trombocyte 265 103/ɥL
• Diff Count
• Eosinophile 5,3 %
• Basophile 0,6 %
• Neutrophile 60,5 %
• Lymphocyte 26,2 %
• Monocyte 7,4 %
• LED 4 mm/hour
• Hb-A1c 4,40 %
• FBG 85 mg/dl
• 2HPP 120 mg/dl
• SGOT 14 U/L
• SGPT 11 U/L
• Ureum 32,2 mg/dL
• Creatinin 0,61 mg/dL
• Total Cholesterole 145 mg/dl
• TG 143 mg/dl
• HDL Cholesterole 35 mg/dl
• LDL Cholesterole 103 mg/dl
Cardiolog Dept
 Follow Up Day 2
Dec, 28th 2017
Right Eye Left Eye
2/50 ph 20/30 Visual Acuity LP (-)
spasm (-) edema (-) Eyelid spasm (-) edema (-)
CI (-), PCI (-) Conjunctiva CI (-) PCI (-)
Fl test (+) punctat Cornea Fl test (+) punctat,lekoma (+)
Deep Anterior Chamber Deep
Radline Iris Radline
Round, Midmidri Pupil Round, 3mm, PR -
IOL on Place Lens IOL on Place, PCO +,silicon filled
eye
7,1mmHg IOP 17,3 mmHg
 Funduscopy
Dec 28th 2017

Funduscopy :
• RF : +/+dim
• Media : Vitreous opacity gr I ec tobacco dust /opacity gr III ec PCO
Detail OS : DTE
Detail OD:
• ONH : round+, sharp margin+, c/d ratio 0,4, orange+, SV >7
• Vascular : a/v 2/3+ ,scle-, cross-
• Retina : hemorrhage -, exudate -, detach +, tear +,
scar post laser +,wrinkling +,horseshoe tear +
• Macula : FR +,macula on +
 Diagnosis
RE RRD with macula on + PVR gr B + post demarcation laser
LE Silicon filled eye post Vitrectomy ec Susp RRD +PCO + corneal leucoma
RLE pseudophakia + PEE
 RE Pars Plana Vitrectomy
+endodrainase+endolaser+silicon oil /GA
Dec, 29th 2017
Diff : -
Comp : -

Post OP Treatment :
•Ciprofloxacin tab 2 x 500 mg (po)
•Mefenamic acid tab 3 x 500 mg (po)
•Vigamox ed 6 x 1 drop RE
•Vosama ed 6 x 1 drop RE
•SA 1% ed 3 x 1 drop RE
•Bedrest with pronation position
 Follow Up Day 3
Dec, 30th 2017
Right Eye Left Eye
Visual Acuity LP (-)
3/60 ph 20/50
Spasm -, Edema + Eyelid spasm (-) edema (-)
CI + , PCI + min , SCH (+), Conjunctiva CI (-) PCI (-)
chemosis + , secret (-)
Striae(+) min,Edema(+) min, Cornea Fl test (+) punctat,lekoma (+)
fl test + punctat
Fl cell -,Deep Anterior Chamber Deep
Radline Iris Radline
Round, Midri dt SA 1% Pupil Round, Ø 3mm, PR -
Iol on place Lens IOL on Place, PCO +
7,1 mmHg IOP 17,3 mmHg
 Funduscopy
Dec,30 th 2017

Funduscopy :
• RF : +/+dim
• Media : Clear /opacity gr III ec PCO
Detail OS : DTE
Detail OD:
• ONH : round+, sharp margin+, c/d ratio 0,4, orange+, SV >7
• Vascular : a/v 2/3+ ,scle-, cross-
• Retina : hemorrhage +, exudate - , detach -, tear +,
scar post laser +,wrinkling +, retina flat +, silicon oil +
• Macula : FR +, macula on +
Detachment Chart
30/12/2017
 USG (30/12/2017)

•Posterior Capsule: dte •Posterior Capsule: dte

•Vitreus : •Vitreus :
Anterior : echo dense (+) med spike Anterior : echo dense (+) med spike
Media : echo dense (+) med spike Media : echo dense (+) med spike
Posterior : echo dense (+) med spike Posterior : echo dense (+) med spike
•Retina : dte •Retina : dte
•Choroid : dte •Choroid : dte
•ONH : dte •ONH : dte
FOLLOW UP
DAY 3
Dec, 30 th 2017
 Detachment Chart
Before After
Before

After