Pemicu 8

Winsen Haryono
405120122
Kelompok 10
LO 1
Kelainan pada mata
Laceration of the lids
• Any lid defect should be repaired by direct closure whenever possible, even
under tension, since this affords the best functional and cosmetic results
• Superficial lacerations  parallel to the lid margin without gaping  sutured
with 6-0 black silk  removed after 5 days
• Laceration with mild tissue loss just sufficient to prevent direct primary closure
 usually be managed by performing a lateral cantholysis  to increase lateral
eyelid mobility
• Laceration with extensive tissue loss  require major reconstructive
procedures such as are use following lid resection for malignant tumours
• Lid margin lacerations invariably gape and must therefore be very carefully
sutured with perfect alignment
Bowling B. Kanski’s Clinical Ophthalmology. 8th ed. New South Wales: Elsevier; 2015.
• Canalicular laceration should be repaired withinn 24 hours.
• The laceration is bridging by silicone tubing (Crawford), which is threaded down
the lacrimal system and tied in the nose, following which the laceration is sutured.
• Alternatively, repair of a single canaliculus is performed by using a
monocanalicular stent and, if necessary, securing its footplate to the lid using 8-0
suture material.
• The tubing is left in situ for 3-6 months
• it is very important to ensure that the patient's immunization status is satisfactory after
any injury
• Without any prior immunization  250 units of human tetanus immunoglobulin IM 
if previously immunized but a booster has not been administered within the last 10
years  IM or subcutaneous tetanus toxoid
Lenticular dislocation
• Due to 360˚ rupture of the zonular fibres is rare and may be into
the vitreous, or less commonly, into the anterior chamber
• An underlying predisposing condition should be suspected
Hyphaema
Signs
• Is a common complication
• The source of the bleeding is the
iris or ciliary body
• Characteristically, the red blood
cells sediment inferiorly with a
resultant ‘fluid level’, except
when the hyphaema is total
Treatment
• Aimed at prevention of
secondary haemorrhage and
control of any elevation of
intraocular pressure that may
result in corneal blood staining
Hifema

Bowling B. Kanski’s Clinical Ophthalmology. 8th ed. New South Wales: Elsevier; 2015.
Vitreous haemorrhage
• Often in association with posterior vitreous detachment
• Pigment cells (‘tobacco dust’)  floating in the anterior
vitreous, and though not necessarily associated with a retinal
break, should always prompt a careful retinal assessment
Iridodialysis
• Dehiscence of the iris from the ciliary body at its root
• Pupil  D-shaped and the dialysis is seen as a dark biconvex area near the
limbus
• Asymptomatic if  covered by upper lid; exposed in the palpebral
aperture, uniocular diplopia and glare sometimes ensue, and may
necessitate surgical repair of the dehiscence
• Pseudophakic eye  the detached iris may be ejected through a cataract
surgical incision
Iridodialisis

Bowling B. Kanski’s Clinical

Ophthalmology. 8th ed. New South
Wales: Elsevier; 2015.
 Edem Kornea
S Gangguan penglihatan
Nyeri
Melihat seperti ada lingkaran
Terasa ada benda asing
Silau
O Visus : menurun
PF mata : edem, fotofobia, halo
A Edem kornea
P Alpha 2 Adrenergic agonist : Brimonidine
Beta Adrenergic antagonist : Timolol
Kortikosteroid topikal : Prednisolone
Benda asing di kornea
• Extremely common & cause considerable irritation
• Leukocytic infiltration  around any foreign body of some duration
• If allowed to remain, there is a significant risk of secondary infection
& corneal ulceration
• Ferrous foreign bodies of even a few hours’ duration  result in rust
staining of the bed of the abration
• Metallic foreign bodies  sterile, perhaps due to acute rise in
temperature during transit through the air
• Organic and stone foreign bodies carry a higher risk of infection
• Management :
• Careful slit-lamp examination  locate the exact position and depth
of the foreign body
• Removed under slit-lamp visualization using a sterile 26-gauge needle
• Magnetic removal  may be useful for a deeply embedded metallic
foreign body
• A residual ‘rust ring’  easiest to remove with a sterile ‘burr’
• Antibiotic ointment  instilled together with a cycloplegic and/or
typical NSAIDs to promote comfort
Intraocular foreign bodies
• May traumatize the eye mechanically, introduce infection or exert other
toxic effects on the intraocular structures
• It may be located anywhere from the anterior chamber to the retina and
choroid
• Stone & organic foreign bodies are associated with a higher rate of
infection, and this is particularly high with soil-contaminated or vegetables
matter, when prophylaxis with intravitreal antibiotics is required
• Iron & copper may undergo dissociation and result in siderosis and
chalcosis respectively
Bowling B. Kanski’s Clinical
Ophthalmology. 8th ed. New South
Wales: Elsevier; 2015.
• Initial management :
• Accurate history  determine the origin of the foreign body
• Examination :
• Topical fluorescein  identify an entry wound
• Alignment & projection of identified wounds may allow logical deduction of
the probable location of a foreign body
• Gonioscopy & fundoscopy must be performed
• Associated signs such as lid laceration & damage to anterior segment
structures must be noted
• CT  axial & coronal cuts  detect and localize a metallic intraocular foreign
body, providing cross-sectional images
• MR  contraindicated  metallic (specifically ferrous) intraocular foreign body
 • Technique of removal :
• Magentic removal of ferrous foreign bodies involves the creation of a sclerotomy
adjacent to the foreign body, with application of a magnet followed by cryotherapy to
the retinal break  scleral buckling may be performed to reduce the risk of retinal
detachment if this is judged to be high
• Forceps removal  non-magnetic foreign bodies and magnetic foreign bodies that
cannot be safely removed with a magnet  involves pars plana vitrectomy & removal
of the foreign body with forceps either through the pars plana or limbus depending on
its size
• Prophylaxis against infection

Bowling B. Kanski’s Clinical Ophthalmology. 8th ed. New South Wales: Elsevier; 2015.
Siderosis :
• Steel  most common  projected into the eye by hammering or power tool use
• Ferrous IOFB undergoes dissociation  deposition of iron in the intraocular epithelial
structures, notably the lens epithelium, iris & ciliary body epithelium and the sensory
retina  exerts a toxic effect on cellular enzyme systems, with resultant cell death
• Signs  anterior capsular cataract, consisting of radial iron deposits on the anterior lens
capsule & reddish brown staining of the iris  give rise to heterochromia iridis
• Complication  secondary glaucoma due to trabecular damage, and pigmentary
retinopathy followed by atrophy of the retina and RPE  can have a profound effect of
vision
• Electroretinography  progressive attenuation of the b-wave over time
Chalcosis :
• Ocular reaction to an intraocular foreign body with a high copper content
involves a violent endopthalmitis-like picture, often with progression to phthisis
bulbi
• An alloy such as brass or bronze, with a relatively low copper content 
chalcosis
• Electrolytically-dissociated copper  deposited intraocularly  picture similar
to that seen in Wilson disease
• Thus a Kayser-Fleischer ring develops, as does an anterior 'sunflower' cataract
• Retinal deposition  golden plaques visible opthalmoscopically
• Copper is less retinotoxic than iron  degenrative retinopathy does not develop
& visual function may be preserved
Chemical injuries
• Majority are accidental & a few due to assault
• Alkali burns are twice as common as acid burns
• The severity is related to the properties of the chemical, the area of
affected ocular surface, duration of exposure and related effects such as
thermal damage
• Alkalis tend to penetrate more deeply than acids, as the latter coagulate
surface proteins, forming a protective barrier
• Most common involved alkalis  ammonia, sodium hydroxide and lime
• Commonest acids implicated  sulphuric, sulphurous, hydrofluoric,
acetic, chromic and hydrochloric
Bowling B. Kanski’s
Clinical
Ophthalmology. 8th
ed. New South
Wales: Elsevier; 2015.
Pathophysiology
Healing of the corneal epithelium & stroma takes
Damage by severe chemical injuries place
• Necrosis of the conjunctival & corneal epithelium • The epithelium heals by migration of
with disruption and occlusion of the limbal
vasculature epithelial cells which originate from limbal
stem cells
• Deeper penetration  breakdown & precipitation
of glycosaminoglycans & stromal corneal • Damage stromal collagen is phagocytosed
opacification
by keratocytes and new collagen is
• Anterior chamber penetration results in iris & lens synthesized
damage
• Ciliary epithelial damage impairs secretion of
ascorbate  required for collagen production and
corneal repair
• Hypotony & phthisis bulbi may ensue in severe
cases
Management
Emergency treatment :
• Copious irrigation  crucial to minimize duration of contact with the chemical and normalize
the pH in the conjunctival sac as soon as possible
– A sterile balanced buffered solution  normal saline or Ringer lactate  irrigate the eye
for 15-30 minutes or until pH is neutral
– A topical anasthetic should be instilled prior to irrigation  improves comfort and
facilitates cooperation
– A lid speculum may be helpful
• Double-eversion of the upper eyelid  so that any retained particulate matter trapped in the
fornices is identified and removed
• Debridement of necrotic areas of corneal epithelium  promote re-epithelialization & remove
associated chemical residue
• Admission to hospital  required for severe injuries  to ensure adequate eye drop instillation
in the early stages
• Grading of severity :
• Grade 1  clear cornea (epithelial damage only) & no limbal ischaemia
(excellent prognosis)
• Grade 2  hazy cornea but with visible iris details & less than one-third of
the limbus being ischaemic (good prognosis)
• Grade 3  total loss of corneal epithelium, stromal haze obscuring iris
details & between one-third & half limbal ischaemia (guarded prognosis)
• Grade 4  opaque cornea & more than half limbal ischaemia (very poor
prognosis)
• Other features to note at initial assessment  the extent of corneal and
conjunctival epithelial loss, iris changes, status of the lens and intraocular
pressure
Medical treatment
• Mild (grade 1-2) injuries  topical antibiotic ointment for about a week  topica steroids &
cycloplegics if necessary
• The main aims  more severe burns  to reduce inflammation, promote epithelial regeneration &
prevent corneal ulceration
• Moderate-severe injuries  preservative-free drops
• Steroids
• Cycloplegia
• Topical antibiotic drops
• Ascorbic acid
• Citric acid
• Tetracyclines
• Symblepharon formation should be prevented as necessary by lysis of developing adhesions with a
strile glass rod or damp cotton bud
• Monitor IOP  treat if necessary
Surgery
Early surgery
• Promote revascularization of the limbus,
restore the limbal cell population & re-
establish the fornices
• Advancement of Tenon’s
capsule & suturing to the
limbus
• Limbal stem cell
transplantation from the
patient's other eye or from a
donor
• Amniotic membrane grafting
• Gluing or keratoplasty
Late surgery
• Division of conjunctival bands & treating
symblepharon
• Conjunctival or mucous membrane grafts
• Correction of eyelid deformities
• Keratoplasty should be delayed for at least
6 months & preferably longer to allow
maximal resolution of inflammation
• Keratoprosthesis my be required in very
severely damaged eyes because the
results of conventional grafting are poor
Dislokasi lensa

Bowling B. Kanski’s Clinical

Ophthalmology. 8th ed. New South
Wales: Elsevier; 2015.
Periokular hematoma

Bowling B. Kanski’s Clinical Ophthalmology. 8th ed. New South Wales: Elsevier; 2015.
LO 2
Kelainan pada telinga
Hematoma aurikular
S Tanpa rasa sakit
Inflamasi minimal
O Riwayat trauma tumpul
Cauliflower ear
A Hematoma aurikular
P Observasi  thick bore needle
Insisi  drainase
Bolster
Needle aspiration

Snow, Wackym. Ballenger’s otorhinolaryngology head and neck surgery. 17th Ed. USA: PMPH-USA; 2009; 14:193.
Gleeson W, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS, Lund VJ, Luxon LM, Watkinson JC. Scott-brown’s otorhinolaryngology, head and neck surgery. 7th
ed. Great Britain: Hodder Arnold; 2008; 236m: 3373-4.
Gleeson W, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS, Lund VJ, Luxon LM, Watkinson JC. Scott-brown’s otorhinolaryngology, head and neck surgery. 7th
ed. Great Britain: Hodder Arnold; 2008; 236m: 3373-4.
Laserasi aurikular
S Otalgia
O Riwayat trauma
A Laserasi aurikular
P Operasi
Kosmetik
Antibiotik  mencegah
perikondritis

Snow, Wackym. Ballenger’s otorhinolaryngology head and neck surgery. 17th Ed. USA: PMPH-USA; 2009; 14:193.
http://emedicine.medscape.com/article/83294-overview#a6
 Trauma tulang temporal
S Tuli konduktif
Otorea
O CT-scan (gold standard)  fraktur tulang temporal
MRI  kerusakan N. facialis dan hematoma koklear
Timpanomimetri  periksa middle ear fluid
Periksa nistagmus  Romberg atau Unterberger test
Electronystagmography + caloric test
Facial nerve function
Cerebrospinal fluid leak
A Trauma tulang temporal
P Pasien isolated otic-capsule sparing fracture di tulang temporal  tidak perlu pengobatan 
observasi

Gleeson W, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS, Lund VJ, Luxon LM, Watkinson JC. Scott-brown’s otorhinolaryngology, head
and neck surgery. 7th ed. Great Britain: Hodder Arnold; 2008; 237g: 3494-6.
Gleeson W, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS, Lund VJ, Luxon LM, Watkinson JC. Scott-brown’s otorhinolaryngology, head
and neck surgery. 7th ed. Great Britain: Hodder Arnold; 2008; 237g: 3494-6.
 Ossicular chain trauma
S Gangguan pendengaran
O Audiometri  tuli kondutif
Timpanomimetri  type A graph + very high peak
A Ossicular chain trauma
P Operasi:
• Dislokasi inkus  osikuloplasti atau reposisi inkus
• Fraktur stapes  strut atau piston antara inkus dan stapes
• Luksasio stapes  stapedektomi
• Fraktur maleus  small bone grafts

Snow, Wackym. Ballenger’s otorhinolaryngology head and neck surgery. 17th Ed. USA: PMPH-USA; 2009; 21:254-5.
 Whiplash injury
S Sakit di leher (7 hari setelah cedera) 88-100%
Jarang:
• Parastesi
• Pusing
• Gangguan pendengaran
• Tinitus
• Konsentrasi jelek
O Riwayat trauma kepala atau leher
PF: penurunan gerakan leher
Pemeriksaan neurologis: hipoaesthesia dan gangguan pendengaran
A Whiplash injury
P Istirahat  cervical collar
Pasien vertigo:
• kontrol pergerakan kepala dan badan
• kontrol pola nafas
• rehabilitasi vestibular

Gleeson W, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS, Lund VJ, Luxon LM, Watkinson JC. Scott-brown’s otorhinolaryngology, head
and neck surgery. 7th ed. Great Britain: Hodder Arnold; 2008; 237g: 3498-9
 Barotrauma
S Otalgia
Pusing
Tinitus
Hemoragi
Gangguan pendengaran
O CT-scan  hemoragi dan pneumosefalus dalam ruang epidural
Otoskopi  normal
A Barotrauma
P Operasi

Snow, Wackym. Ballenger’s otorhinolaryngology head and neck surgery. 17th Ed. USA: PMPH-USA; 2009; 21:254-5.
Gleeson W, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS, Lund VJ, Luxon LM, Watkinson JC. Scott-brown’s
otorhinolaryngology, head and neck surgery. 7th ed. Great Britain: Hodder Arnold; 2008; 237g: 3499-512.
Gleeson W, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS, Lund VJ, Luxon LM, Watkinson JC. Scott-brown’s
otorhinolaryngology, head and neck surgery. 7th ed. Great Britain: Hodder Arnold; 2008; 237g: 3499-512.