Case Report

Ophthalmology Department
Kardinah Stage Hospiral
Medical Faculty of Universitas Trisakti
18 February - 23 March 2019
 Case Report
Ophthalmology Department

Patient Identification
• Full Name: Mrs. Siti Chodijah
• Age: 62 year-old
• Occupation: Housewive
• Religion: Moslem
• Education: Elementary
• MR Number: 802543
• Admission: 28 February 2019
 Case Report
Ophthalmology Department

Current Medical History

• 62-year old woman admitted to ophthalmology clinic with a
chief complaint of soreness in both eyes and headache for
a week
 Case Report
Ophthalmology Department

Past Medical History

• Past ocular history includes soreness, blurred vision,
redness, watery right eye with headache and burning
sensation two years before current admission
• Patient was then admitted for hospitalization, had 3-
months monitoring period before surgery was conducted
• Vision improved post-surgery, but then a new complain of
a blurred vision was submitted and was diagnosed
immature cataract
 Case Report
Ophthalmology Department

Past Medical History

• After the glaucoma surgery on the right eye, the left eye
begun to possess the same symptoms of redness, watery,
and blurred vision
• For over a year, the vision deteriorates with the
examination of intraocular pressure stagnant in high
pressure
• Surgery was performed to ease the high intraocular
pressure
 Case Report
Ophthalmology Department

Past Medical History

• The patient got hospitalized for vertigo 1 year prior
• The patient have no history of hypertension or type II
diabetes
• The patient have no family history of the same symptoms
 Case Report
Ophthalmology Department

Medication History
• Regular eyedrops
• Isotic (Timolol) 3 times a day
• Catarlent (Potassium Iodide) 2 times a day
 Case Report
Ophthalmology Department

Physical Examination
• Normal vital signs
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Ophthalmology Department

Ophthalmic Examination
• Vision
• Right Eye: 5/60
• Left Eye: 0
• Intraocular Pressure
• Schiotz Tonometry
• Right Eye: 23,8 mmHg
• Left Eye: 17,3 mmHg
 Case Report
Ophthalmology Department

Ophthalmic Examination
• Anterior Segment
• Palpebra
• No abnormalities
• Cilia
• No abnormalities
• Conjunctiva
• Right Eye: No conjunctival injection
• Left Eye: Conjunctival injection
• Cornea
• Right Eye: White-colored fibrous scarring due to trabeculectomy
• Left Eye: White-colored fibrous scarring due to trabeculectomy
• Pupil
• Regular
• Direct Light Reflex: -/-
• Indirect Light Reflex -/-
 Case Report
Ophthalmology Department

Ophthalmic Examination
• Camera Oculi Anterior
• Right eye: Acute-angled
• Left eye: Acute-angled
• Iris
• Brown-colored
• Lens
• OD: Positive shadow test
• OS: Positive shadow test
 Case Report
Ophthalmology Department

Ophthalmic Examination
• Posterior Segment
• Red Reflex
• Right eye: Negative
• Left eye: Negative
• Visual Field Testing
• Right Eye: Visual field loss in the upper right quadrant
• Left Eye: Untestable
 Case Report
Ophthalmology Department

Summary
• 62-year-old woman admitted to ophthalmology clinic due
to complaints of soreness in both eyes and headaches
• Glaucoma surgery performed 2 years prior to admission
on the right eye and 1 year earlier on the left eye
• Immature cataract occurred in both eyes
• Ophthalmic examination shows a vision of 5/60 on the
right eye and 0 on the left eye
• Patient received a daily eye drops of timolol and
potassium iodide
 Case Report
Ophthalmology Department

Diagnosis
• Chronic Acute-Angle Glaucoma on right and left eye
• Immature cataract on right and left eye
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Ophthalmology Department

Treatment and Education

• Treatment
• Timolol eye drops 3 times a day
• Potassium Iodide eye drops 3 times a day
• Education
• Regular checkups and maintaining treatment
compliance
• Caffeine avoidance
• Systemic disease prevention
• Trauma prevention
Terima kasih.