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• Sosioeconomic History :
He is a mechanic. Expenses by BPJS
Opthtalmological Status
Right Eye Description Left Eye
0.16 F2 Ph (-) Visual acuity 6/6 E
17.3 mmHg TIO 12.2 mmHg
Swollen (+), spasm (+), excoriation Palpebra Swollen(-), spasm (-)
10x2mm, bleeding (+)
Hyperemis (+), laceration (-), SCB Conjungtiva injectie (-)
(-)
Intact Sclera Intact
Macula (+) Φ 1mm paracentral Cornea Swollen (-)
(+) 5 o’clock, defect (-), gram (-)
Fluoresence (-)
OD OD OS
CV (+), Cell grade 3, hyphema (-) Anterior VH grade 3
chamber
Crypt (+), iridodialisis (-), Iris Crypt (+)
iridorexis (-)
Oval, central, reguler, ø 4 mm, Pupil Round, central, reguler, ø 3mm,
RP (+) ↓ RP (+) N
Clear, phacodonesis (-) Lens clear
Less Bright Fundus Reflex Bright
Defect (-)
USG B Scan
• Probe : axial vertical
• Gain 80dB
• Lens : echo spike (+),
subluxation (+)
• CV : turbidity (+), point like
lesion (+) spike 20-30%, mass
like lesion (-), membrane like
lesion (-)
Vitreous opacity, mostly like
vitreous haemorrhage
Diagnose :
• RE vitreous hemorrhage caused by blunt
trauma
• Suspect lens subluxation
Therapy :
• Inpatient pending
• Semivoler
• P pred ED/3 hours RE
• SA 1%/12 hours RE
• Glaucon-KCl 1x250 mg po
• MP 8 mg 2-0-1 po
• Ranitidin/12 hours
• Control Tuesdaydidn’t come3 days
Education :
- Risk IOP, cataract, inflamation
THANK YOU