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    Ophthalmic Record

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    andrirombe
    The document is an ophthalmic record for a 55-year-old male patient. Upon examination, the doctor found a pterygium in the patient's left eye that extends from the nasal conjunctiva onto the cornea. The patient's main complaint was a growing membrane in his left eye for the past 2 weeks. His right eye and vision were normal. The doctor diagnosed the patient with a Grade II pterygium in the left eye and recommended medical treatment with eye drops and protecting the eye from sunlight. The prognosis for the right eye was good but doubtful for the left eye in terms of healing and vision.

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    Ophthalmic Record

    Uploaded by

    andrirombe
    68 views7 pages
    The document is an ophthalmic record for a 55-year-old male patient. Upon examination, the doctor found a pterygium in the patient's left eye that extends from the nasal conjunctiva onto the cornea. The patient's main complaint was a growing membrane in his left eye for the past 2 weeks. His right eye and vision were normal. The doctor diagnosed the patient with a Grade II pterygium in the left eye and recommended medical treatment with eye drops and protecting the eye from sunlight. The prognosis for the right eye was good but doubtful for the left eye in terms of healing and vision.

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    mata

    Original Title

    Ophthalmic Record (1)

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    The document is an ophthalmic record for a 55-year-old male patient. Upon examination, the doctor found a pterygium in the patient's left eye that extends from the nasal conjunctiva onto the cornea. The patient's main complaint was a growing membrane in his left eye for the past 2 weeks. His right eye and vision were normal. The doctor diagnosed the patient with a Grade II pterygium in the left eye and recommended medical treatment with eye drops and protecting the eye from sunlight. The prognosis for the right eye was good but doubtful for the left eye in terms of healing and vision.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    68 views7 pages

    Ophthalmic Record

    Uploaded by

    andrirombe
    The document is an ophthalmic record for a 55-year-old male patient. Upon examination, the doctor found a pterygium in the patient's left eye that extends from the nasal conjunctiva onto the cornea. The patient's main complaint was a growing membrane in his left eye for the past 2 weeks. His right eye and vision were normal. The doctor diagnosed the patient with a Grade II pterygium in the left eye and recommended medical treatment with eye drops and protecting the eye from sunlight. The prognosis for the right eye was good but doubtful for the left eye in terms of healing and vision.

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    OPHTHALMIC RECORD

    Name of Examiner

    : Andry Ganesha Rombe

    NIM

    : 1161050253

    Examiner

    : DR. dr. Gilbert W. S. Simanjuntak, Sp.M (K)

    I.

    II.

    PATIENT IDENTITY
    Name

    : Mr. A

    Sex

    : Male

    Age

    : 55 years old

    Education

    : Bachelor

    Occupation

    : Off-shore Oil Miner

    Religion

    : Moslem

    Address

    : Wates RT 002/ RW 003, Yogyakarta.

    Status

    : Marriage

    ANAMNESIS ( Autoanamnesis, June 2nd, 2016 )


    Main complaint

    : Appear as membranes on the left eye

    Additional complaint

    : Wedge feeling at the left eye

    History of Disease
    The Patient came to the Hospital with main complaint, appear as
    membranes on the left eye since 2 weeks ago, and since 2 years ago, at the inner
    corner of the eye near the patients nose, patient feels that there is something
    increasingly growing, first it was not too big, then getting bigger and became a
    meat-like-fiber, towards the center of the left eye. The eyes do not feel pain. The
    Patient also complained wedge feeling at the left eye. The Patient admitted his
    sight was still good and there is no vision problems at all. The Patient have never
    been treated by any doctor or even have used any medications. Swelling of the
    eye region is denied. Discharge of the eyes is denied. Glare of the eye is denied.

    OPHTHALMIC RECORD UKI HOSPITAL 2016


    1

    Itchy feeling of the left eye is denied. More frequent watering of the eye is
    denied. Patients not using glasses or contact lenses.
    Previous Disease History
    Patient never had complaints like this before. A history of food allergies
    and medications allergies are denied. History of hypertension, diabetes mellitus,
    cholesterol are denied. A history of trauma to the eye and a history of long-term
    drug use are denied. And there is nobody around the patient that encountered the
    same complaints as the patient did.
    Family Disease History
    There is nobody in his family who experience the complaints like him.
    Personal Habit
    The patient denied the using of contact lenses, smoking, and alcohol
    consuming. The patient never use sunglasses at work.
    III.

    IV.

    GENERAL STATUS
    General condition

    : Mild appearance of illness

    Consciousness

    : Compos mentis

    OPHTHALMIC STATUS
    1. General Examination
    General Examination
    (Inspection and Palpation)
    Periocular appearance
    General condition of the eye
    Eyeball position
    Eyeball movement
    Visual field

    Right Eye

    Quiet
    Normal
    Symmetric
    Normal
    Wide

    2. Systematic Examination
    OPHTHALMIC RECORD UKI HOSPITAL 2016
    2

    Left Eye

    Quiet
    Unwell
    Symmetric
    Normal
    Wide

    Right Eye

    Left Eye

    Visual acuity

    Before correction

    6/9 PH (+) 6/6

    6/6

    Correction

    Normal, homogenous

    Normal, homogenous

    madarosis (-)
    Normal, madarosis (-),

    madarosis (-).
    Normal, madarosis(-),

    trichiasis (-).

    Trichiasis (-).

    Palpebrae superior /

    Edema (-), tumor(-),

    Edema (-), tumor(-),

    inferior

    hordeolum (-), chalazion hordeolum (-),

    After correction
    Supercilia
    Cilia Superior / Inferior

    (-),

    chalazion (-),

    ptosis(-),

    ptosis(-),

    Margo palpebrae

    tenderness (-).
    Tumor (-),

    tenderness (-).
    Tumor (-),

    superior/inferior

    ptosis(-),

    ptosis(-),

    ectropion (-),

    ectropion(-),

    Tarsal conjunctiva

    entropion(-).
    Smooth surface,

    entropion(-).
    Smooth surface,

    superior / inferior

    bleeding (-),

    bleeding (-),

    hyperemic (-),

    hyperemic (-),

    cicatrical (-),

    cicatrical (-),

    secretion (-).
    Bleeding (-),

    secretion (-).
    Bleeding (-),

    conjungtival injection

    conjungtival injection

    (-),

    (-),

    cicatrical (-),

    cicatrical (-),

    secretion (-),

    secretion (-),

    pinguecula (-),

    pinguecula (-),

    pterygium (-).

    pterygium extends

    Bulbar conjunctiva

    from the nasal


    conjungtiva to the
    Fornix conjunctiva

    Hyperemic (-)

    OPHTHALMIC RECORD UKI HOSPITAL 2016


    3

    nasal corneal limbic.


    Hyperemic (-)

    Cornea

    Clear infiltrate (-), ulcus Clear infiltrate (-),


    (-), cicatrical (-), arch

    ulcus (-), cicatrical (-)

    senile (+).

    arch senile (+).


    The pterigyum cross
    the limbus cornea
    about 2 mm to the

    Sclera

    Anterior chamber

    Colour: white,

    center of the kornea.


    Colour: white,

    bleeding (-),

    bleeding (-),

    cicatrical (-).
    Deep, clear, hypopion

    cicatrical (-).
    Deep, clear, hypopion

    (-), hyphema (-).


    Iris

    Pupil

    Radier,Colour: brown,

    Radier,Colour: brown,

    atrophy (-),sinekia (-),

    atrophy (-), sinekia (-),

    crypt (+).
    Round, isochor, 3mm,

    crypt(+)
    Round, isochor, 3 mm,

    direct light reflex (+),

    Direct light reflex (+),

    non direct light


    reflex (+).
    Clear,shadow test (-).

    Lens
    V.

    (-), hyphema (-).

    non direct light reflex


    (+).
    Clear,shadow test (-).

    RESUME
    The Patient came to the Hospital with main complaint, appear as
    membranes on the left eye since 2 weeks ago, and since 2 years ago, at the
    inner corner of the eye near the patients nose, patient feels that there is
    something increasingly growing, first it was not too big, then getting bigger
    and became a meat-like-fiber, towards the center of the left eye. The eyes do
    not feel pain. The Patient also complained wedge feeling at the left eye. The
    Patient admitted his sight was still good and there is no vision problems at all.
    The Patient have never been treated by any doctor or even have used any
    medications. Swelling (-), Discharge (-), Glare (-), Alergies (-), Itchy (-), no
    previous disease history, and the patient never use sunglasses at work.

    OPHTHALMIC RECORD UKI HOSPITAL 2016


    4

    GENERAL STATUS
    General condition

    : Mild appearance of illness

    Consciousness

    : Compos mentis

    From the ophthalmological examination on the right and left eyes, obtained:
    Right Eye

    Left Eye

    Visual acuity

    Before correction

    6/9 PH (+) 6/6

    6/6

    Correction

    Normal

    Normal

    inferior
    Margo palpebrae superior Normal

    Normal

    / inferior
    Tarsal conjunctiva

    Normal

    Normal

    superior / inferior
    Bulbar conjunctiva

    Quiet

    Conjungtival

    After correction
    Palpebrae superior/

    injection (-), there is


    pterygium extends
    from the nasal
    conjungtiva to the
    Fornix conjunctiva

    Normal

    nasal corneal limbic.


    Normal

    Clear

    The pterigyum cross

    superior / inferior
    the cornea limbic

    Cornea

    Sclera
    Anterior chamber
    Iris

    about 2 mm to the
    Colour: white
    Deep & clear
    Radier, colour: brown

    center.
    Colour: white
    Deep & clear
    Radier, colour:
    brown

    Pupil

    Round, isochor,

    Round, isochor,

    4 mm, direct light reflex

    4 mm, direct light

    OPHTHALMIC RECORD UKI HOSPITAL 2016


    5

    (+), non direct light

    reflex (+), non direct

    reflex (+).

    light reflex (+).

    Lens

    VI.

    VII.

    VIII.

    Clear,

    Clear,

    shadow test (-).

    shadow test (-).

    CLINICAL DIAGNOSE
    Pterygium Grade II OS
    DIFFERENTIAL DIAGNOSE
    Pseudopterygium OS
    Pinguecula OS

    TREATMENT

    Medical Treatment :
    o Atrificial Tears (Topical Lubricating Drops) : Cendo Lyteers 3-4
    drops x 1 a day.

    Non-Medical Treatment :
    o Avoid exposure of the direct sun ray, wind, and dust from the eyes.
    o Use a cap and/or sunglasses to avoid the direct exposure of
    ultraviolet rays into the eye.
    o Control to the doctor.

    IX.

    X.

    RECOMMENDED EXAMINATION

    Corneal Topography

    Test Sonde

    PROGNOSIS

    Ad Vitam
    Ad Sanationum
    Ad Functionum
    XI.

    Right Eye

    Left Eye

    Bonam
    Bonam
    Bonam

    Bonam
    Dubia ad Malam
    Dubia ad Bonam

    COMPLICATION

    Visual Disorders (Astigmatism)

    Eyes movement disorders

    OPHTHALMIC RECORD UKI HOSPITAL 2016


    6

    Conjunctival and Corneal Scar

    OPHTHALMIC RECORD UKI HOSPITAL 2016


    7

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