Refleksi Kasus Myopia: Ilmu Kesehatan Mata

Download as pptx, pdf, or txt
Download as pptx, pdf, or txt
You are on page 1of 12

ILMU KESEHATAN MATA

REFLEKSI KASUS
MYOPIA
DEPARTEMENT OF OPHTHALMOLOGY
MIOPIA

4A
Patient Identity
Name : Ny. I
Gender : Female
Age : 33 years old
Address : JL. Poros maros
Religion : Islam
Ethnic/Nationality : Bugis / Indonesia
Employment : PNS
Medical Record : 001263
ANAMNESIS

Main Complaint: Blurred vission in the both eyes

A 33-year-old woman came to the eye clinic of Salewangang Hospital in Maros with blurred
vision since two years ago. Difficultly reading and seeing distant object clearly . Blurred vision
occurs slowly, the patient also complained of having to squint to see the focus on an object.
Complaints of red eye (-), pain (-), glare (-), eye discharge (-), history in front of the computer
for a long time in a day (+).

Disease History:
history of wearing glasses (+). History of diabetes (-). History of trauma to the eye area (-).
History of taking drugs for a long time (-).

Family Disease History:


 -
OD Vision OS
Distant vision without
20/50 20/50
correction
-2,25 D correction -2,25 D
PEMERIKSAAN
VISUS Distant vision with
20/20 20/20
best correction
- Close vision -
- correction -
Close vision with
- -
correction
OD OS

Palpebral Edema (-) Edema (-)

Cilia normal Normal

Lacrimal Lacrimasi (-) Lacrimasi (-)


Apparatus
PEMERIKSAAN SEGMENT Conjunctiva Hyperemia (-) Injectio (-) Hyperemia (-), Injectio (-)
ANTERIOR Chemosis(-) Chemosis (-)
Cornea clear Clear

Anterior Normal Depth Normal Depth


Chamber
Iris Brown, Crypt (+) Brown, Crypt (+)
Pupil Round, Central Round, Central
Direct / Inderct +/+ +/+
Light Reflex
RAPD - -
Lens Clear Clear
EXAMINATION
OD OS
METHODS

PALPASI Tenderness (-) (-)

Tumor/Mass (-) (-)

Pre Auriculer gland Tidak teraba Tidak teraba


EXAMINATION
OD OS
METHODS

TEKANAN Palpation Tn Tn
INTRAOCULAR
Non Contact
- -
Tonometry/ schiotz
• DIAGNOSIS
DIAGNOSIS ODS Miopia Simpleks

• DIFFERENTIAL DIAGNOSIS
Astigmatisma
Hipermetropia
◂ Monofokal eyegalsses

TERAPI
OD OS
S C Axis S C Axis
-2.50 - EDUCATION
- : -2.50 - -
Add: -
Dist. Pup. 62/60 mm
Quad Ad Vitam : Bonam
Quad Ad Functionam : Bonam
PROGNOSIS Quad Ad Cosmetican : Bonam
Quad Ad Sanationam : Bonam
Terima kasih

You might also like