case report gw

8/13/2019 Case Report Gw

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Case Report

DISKA ASTARINI

I11109083


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Patient identity

Name : Mrs. S

Sex : female

Age : 84 years old Address : Kuala Secapah

Job : housewife

Religion : Moslem Patient was examined on January 21st, 2014


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Anamnesis

Main complaint :

Red eye, watery, blindness


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History of desease

History of desease :

Patient complains blurry vision is affected in right eye.Blurry vision of the right eye since a few months ago,that become worse especially during this two weeks.

Then, she told that her eye became redness until now.Not only red, but also pain and watery. Now, patienthave cloudy in her eye (right eye), so patient reallycantsee anything from right eye. She also complainingthe blurry vision at the left eye. Sometimes she had a

headache. The manifestation of clinical from thispatient : Headache (+), pain in the eyes (+), redness inthe eye (+ right eye), itch feeling in the eyes (-), andtraumatic history (-).


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Past clinical history :

Hypertension (-)

Diabetes Mellitus (denied) because patient never

did clinical check.

Glasses wearing (-)

Others eye desease (-)

Traumatic history (-)


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Family history

Hypertension (-)

Diabetes Mellitus (-) ;

Glasses wearing (-)


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General Physical assesment

General condition : Moderate

Awareness : Compos mentis

Vital sign : Blood Pressure : 130/90 mmHg

RR : 18/minute

Temperature : 36,5C


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Ophthalmological status

Visual acuity :

OD : 0

OS : 6/12


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Intra Ocular pressure (tonometry) : OD 26

mmHg,

Funduscopy :-

Visual field test: OD: cant be done

OS : normal


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Resume

A woman, 84 years old, came to ophthalmologist withthe complain of blurry vision in right eye since a fewmonths ago, and become worse during this two weeks.She told that her eye became redness until now. Not

only red, but also pain and watery. Now, patient havecloudy in her eye (right eye), so patient really cantseeanything from right eye. She also complaining theblurry vision at the left eye. Sometimes she had aheadache. The manifestation of clinical from this

patient Headache (+), pain in the eyes (+), redness inthe eye (+ right eye), watery (+), itch feeling in the eyes(-), and traumatic history (-).


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Visual acuity is 0 for OD, 6/12 for OS. Right

lense seems milky. Left lense seems cloudy.

Intraocular presure for OD 26mmHg, for OS 15

mmHg. Funduscopy cannot be done becauseof the lense opacity. Shadow test for left eye is

positive. Confrontation test just be done at

the left eye and the result is normal.


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The Diagnosis

Diagnose : OD : mature cataract with

secondary glaucoma (absolute glaucoma)

OS : immature cataract (senilis)

DDx :

OD : hipermature cataract with absolute glaucoma

OS : -


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Plan for examination:

Slit lamp

Perimetri

Whole blood test and blood glucose

Eyes USG


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Treatment

OD Pharmacological:

Timolol

Asetazolamide Surgery : Extra Capsular Cataract Extraction

OS

Non-pharmacological Using eye protection

Surgery : Pachoemulsification + IOL


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Prognosis

OD:

Ad vitam : bonam

Ad functionam : malam

Ad sanactionam : dubia ad malam

OS :

Ad vitam : bonam

Ad functionam : dubia ad bonam

Ad sanactionam : dubia ad bonam


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DISCUSSION


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A cataract is any opacity in the lens loss of

lens transparency results in blurred vision

(without pain) for both near and distance the prevalence of cataracts at 50% in

individuals aged 65-74; the prevalence

increases to about 70% for those over 75.Manifestly reduced transparency is present in

95% of all persons over the age of 65

Other factors can be involved, includingtrauma, toxins, systemic disease (such as

diabetes), smoking, and heredity


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A mature cataract is one in which all of the

lens protein is opaque; the immature cataract

has some transparent protein. Age-related

cataract is usually slowly progressive overyears


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The abnormality found in physicalexamination is the opacity of the lens. Besidethe opacity of left lense, the shadow testresults is positive.

In lens assesment found that at the righteye the lens is totally opaque, milky

appearance, funduscopy cant be done causethe light cant passes through the lens and itindicated that is mature cataract at the righteye and for the left eye the lens looks cloudyand shadow test is positive (+), show that it isan immature cataract at the left eye.


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the clinical finding from the anamnesis

and examination

Blurred vision is caused by the opacity of thelense, that can cause disrupting the refractionmedia and finally, it can hampered the light to

retinal Vision slowly burred because of the

progression of opacity in the lense (thicknessof opacity influence the degree of vision lost)

VA : 0 for OD , 6/12 for OSopacity of OD isthicker than OSso OD must be treated first


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There are some specific symptoms that can

lead to diagnose the condition of the right

eye. The IOP level for right eye is measure 26mmHg.


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Treatment

Suppression of Aqueous Production

Topical beta-adrenergic blocking agents,

Apraclonidine, Brimonidine, Dorzolamide

hydrochloride and brinzolamide, Carbonic anhydraseinhibitorsacetazolamide

Definitive therapy for both eye is surgery.


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Conclusion

The diagnosis of this patient is Mature

Cataract with Secondary right eye. And for the

right eye is immature cataract. The therapy

for OD is doing the treatment of glaucoma andsurgery for the lens extraction.


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THANK YOU

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