OPHTALMOLOGY RECORD

ACUTE GLAUCOMA

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

Observer :
Rashellya Rasyida Rahma
1261050293

DEPARTMENT OF EYE DISEASE

PERIOD OF JANUARY 23rd – FEBRUARY 25th, 2018
MEDICAL FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA
2018

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OPHTALMOLOGY RECORD

Examiner : Rashellya Rasyida Rahma

Nim : 1261050293
Tutor : Dr. dr. Gilbert W. Simanjuntak, Sp.M (K)

I. PATIENT IDENTITY
Name : Ny. T
Age : 78 years old
Sex : Female
Religion : Islam
Address : Jl. Cokro Kembang no. 12, Delanggu, Daleman, kecamatan
Tulung, kabupaten Klaten, Jawa Tengah.
Occupation : Housewife
Status : Married

II. ANAMNESIS
Anamnesis done at February 6th, 2018
Chief complaint : The vision of the right eye has been decreasing since ± 2 days ago
Additonal complaint : Headache, nausea, and red eye
Chronology of disease :
Patients come to dr. Yap's Eye Hospital with sudden decreased of right eye vision
since ± 2 days ago. Patients claim she is still able to see if both eyes open, but when the
left eye is closed, the patient's vision gets blurry. At first, the patient started to feel
diminished vision accompanied by pain in the right eye and complaints continue
constantly to become worse. She also felt glare whenever she saw bright light. 1 day ago
the patient's right eye vision suddenly disappeared and everything became dark
accompanied by worsen headache. Previously, patients had tried to relieve the symptoms
by taking panadol that they bought by themselves, but the condition is not getting any
better. In addition, the patient also complained of nausea, but did not vomit, and red eye.

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 Previous disease :
The patient never felt the same symptoms before. Patients never wore contact
lenses or eyeglasses. Patient’s denied the presence of a high blood pressure, allergy,
diabetes mellitus, and previous eye surgery.
History of family disease : No one has ever suffered like her.

III. GENERAL STATUS

General condition : Mild illness appearance
Conciousness : Compos mentis

IV. OPHTALMOLOGY STATUS

A. General examination
Parameter OD OS
Periocular Appearance Quiet Quiet
General Condition of The Severe illness appearance Quiet
eye
Eyeball position Simetric Simetric
Eyeball movement All direction All direction
Eye ball palpation Resistance (+) Normal
Pain (+)

B. Sistematic Examination
Parameter OD OS
Visual Acuity 2/60 6/6
Correction Cannot be corrected -
Visual field narrow Same as the examiner
Supersilia Growth and spread well Growth and spread well
and evenly and evenly
Silia Growth and spread well Growth and spread well
and evenly and evenly

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Palpebra Superior Color matches the color of
the skin, edema (+), tumor
(-), cicatrical (-), fallen eye
lids (-), tenderness (-)
Palpebra Inferior Color matches the color of
the skin, edema (+), tumor
(-), cicatrical (-),
tenderness (-)
Tarsal conjungtiva Hyperemic (-)
Superior/inferior Papilar (-)
Bulbi conjungtiva Conjungtiva injection (+)
Ciliar injection (+)
Cornea
 Clarity edema (+) arcus senilis (+)
 Ulcus (-)
 Cicatrix (-)
Color matches the color of
the skin, edema (-), tumor
(-), cicatrical (-), fallen eye
lids (-), tenderness (-)
Color matches the color of
the skin, edema (-), tumor
(-), cicatrical (-),
tenderness (-)
Hyperemic (-)
Papilar (-)
Normal
Clear, arcus senilis (+)
(-)
(-)

Anterior Chamber Cannot be evaluated Deep,

Hypopyon (-)
Iris Radier Radier
Brown Brown
Synechia (-) Synechia (-)
Pupil Round, diameter 6 mm, Round, diameter 3 mm,
Direct light reflex (-), Direct light reflex (+),
Indirect light reflex (-) Indirect light reflex (+)
Lens Clear Clear
Intra Ocular Pressure 47 mmHg 18 mmHg

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V. RESUME
A 78 years old female came to dr. Yap's Eye Hospital with sudden decreased of
right eye vision since ± 2 days ago. At first, the patient started to feel diminished vision
accompanied by pain in the right eye and complaints continue constantly to become
worse. She also felt glare whenever she saw bright light. 1 day ago the patient's right eye
vision suddenly disappeared and everything became dark accompanied by worsen
headache. In addition, the patient also complained of nausea, but did not vomit, and red
eye.
The patient never felt the same symptoms before. History of allergy,
hypertension, DM, and previous eye surgery was denied.
No one in her family has ever experience the same complaint as her.

PEMERIKSAAN MATA KANAN

Visual Acuity 2/60
Palpebra Superior/Inferior Color matches the color of the skin, edema
(+), tumor (-), cicatrical (-), fallen eye lids
(-), tenderness (-)

Visual field narrow

Bulbi conjungtiva Conjungtiva injection (+)

Ciliar injection (+)
Cornea
 Clarity edema (+) arcus senilis (+)
 Ulcus (-)
 Cicatrix (-)

Anterior Chamber Cannot be evaluated

Pupil Round, diameter 6 mm, Direct light reflex
(-), Indirect light reflex (-)
Intra Ocular Pressure 47 mmHg

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 VI. CLINICAL DIAGNOSE
Acute Glaucoma OD

VII. DIFFERENTIAL DIAGNOSE

Iritis OD

VIII. MEDICAL TREATMENT

Medicamentosa:
- Manitol 2 g/kg/dose in 20% in intravenous fluid over 30 minutes
- Pilokarpin 2% 1 drop/min until 5 min  1 drop/hour until 6 hour, OD
- Asetazolamid 500 mg IV  4x250mg/day
Non - Medicamentosa:
Refer to an Ophthalmologist for Iridectomy

IX. RECOMMENDED EXAMINATION

Gonioscopy
Perimetry
Ophthalmoscopy

X. PROGNOSE
OD OS
Ad Vitam Dubia Bonam
Ad Sanasionum Dubia ad malam Dubia ad bonam
Ad Fungsionum Dubia ad malam Dubia ad bonam

XI. COMPLICATION
Glaukoma Absolut OD