Case Reports

Astigmat Miop Simplex ODS + Amblyopia + seborrheic blepharitis

By:

Liana Herdita Santoso

11.2013.099

Supervisor:

Dr. Michael I L, Sp.M

Faculty of Medicine, University Christian Activities of Discourse

Registrar of Clinical Sciences Ophthalmology

Hospital Family Medical Center (FMC), Sentul

The period of 20 July s / d August 22, 2015

Clinical work

STATUS SCIENCE EYE DISEASE

FACULTY OF MEDICINE UKRIDA

SMF SCIENCE EYE DISEASE

Hospital Family Medical Center-Sentul

Case Presentation

Signature

Name: Liana Herdita Santoso

NIM: 11 2013 099

Dr. Supervisor: Dr. Michael IL, Sp.M -------------------

STATUS OF PATIENTS

I. IDENTITY

Name: MA

Age: 16 years

Male gender

Islam

Occupation: Student

Address: Curug

Inspection Date: 23 July 2015

II. History

Autoanamnesis conducted on 23 July 2015

Main Complaint:

Shaded vision

Additional complaints:

Itchy eyes, dizziness

History Disease Now:

Patients come to the FMC Poly Eye Hospital with complaints of view ghosting or blurring. Complaints felt one day ago. One day the patient had lost her glasses. complaint is felt when the patient does not wear glasses to see objects far or near. The patient had been wearing glasses since three years ago, with five cylindrical lenses on the right and left eyes. Patients had never examined the eye back since 3 years ago. Patients want to make a glass eye.

Patients also feel dizzy when you see the shaded object. Patients often feel itchy in both eyes, especially at the upper and lower eyelids, therefore patients often do kucek- dub eye, it has lasted less than three years. Red eye patient denied. At kesaharian also patients often take off glasses, especially used when reading and playing games. Patients from childhood often watch TV with close range. A history of drug allergies and denied food.

Formerly Disease history

a. General

- Asthma: none

- Hypertension: no

- Diabetes Mellitus: none

- Stroke: none

- Allergies: none

b. Eye

- History previous sore eyes: no

- History of the use of glasses: no

- History of eye surgery: no

- History of previous eye trauma: no

Illness Family history:

Similar eye disease: no

Other eye diseases: no

Asthma: none

Diabetes: no

Glaucoma: none

Allergies: none

Hypertension: no

History Habits:

Patients often mengkucek- dub eye every day and drive a motorcycle by not covering the eyes.

III. PHYSICAL EXAMINATION

A. STATUS generalist

General state: Good

Awareness: Compos mentis

Vital Signs: Blood Pressure: 120 / 70mmHg

Nadi: 90 x / min

Respiration: 18 x / min

Temperature: afebrile

Head / neck: Enlargement KGB does not exist

Thorax, Heart: within normal limits

Pulmonary: within normal limits

Abdomen: within normal limits

Extremities: within normal limits

B. STATUS OPTHALMOLOGIS

DESCRIPTION OD OS

1. The vision

0.25 vision ph ph 0.5 0.5 0.6

Correction C -5.50 -2.00 x 180 0.6 C 0.5 X180

Addisi - -

Distansi pupil - -

Old glasses - c 5:00 - 5:00 c

2. EYE BALL POSITION

Exophthalmos None None

Enoftalmos None None

Deviation None None

Free eye ball movement in all directions Free to all directions

Strabismus None None

Nystagmus None None

3. SUPERSILIA

Color Black Black

Symmetrical Symmetrical Symmetrical

4. eyelid superior and inferior

Edema None None

Tenderness No No

Ectropion None None

Entropion None None

Blepharospasm None None

Trichiasis None None

Cicatricial None None

Ptosis None None

Dendraf eyelashes (+) Dendraf (+)

Meibomian gland sebum (+) sebum (+)

5. The superior and inferior conjunctiva

Hematoma None None

Crepitations None None

Follicles None None

Papil None None

Cicatricial None None

Anemis None None

Lithiasis None None

The corpus alienum None None

6. conjunctiva bulbi

Secretions None None

The conjunctiva injection None None

Ciliary injection None None

Subconjunctival hemorrhage None None

Pterygium None None

Pinguekula None None

Nevus Pigmentosus None None

Dermoid Cysts No No

7. sclera

Colour White White

Jaundice None None

8. CORNEAL

Clarity Clear Clear

Surface Average score

Sensibility Good Good

Infiltrates None None

Keratik Precipitate None None

Cicatricial None None

Ulcers None None

Perforation None None

Senile arch None None

Edema None None

9. BILIK EYES FRONT

In the depths In

Clarity Clear Clear

Hyphema None None

Hypopyon None None

Intraocular lense None None

10. IRIS

Color Brown

Kripte - -

Sinekia None None

Coloboma None None

11. PUPIL

Amid Amid layout

Round shapes Round

RAPD - -

Direct light reflex + +

Reflex Light Indirect + +

12. LENS

Clarity Clear Clear

Amid Amid layout

Shadow Negative test negative

13. palpation

Pain Press None None

Tumor mass None None

TIO Normal Normal

IV. SUPPORTING INVESTIGATION

Is not done.

V. RESUME

History

A man came to the hospital eye poly FMC with complaints eyes shaded from 1 day ago. Pasein also feel dizzy. The views are shaded when the patient does not wear glasses. Pasein lost his glasses since 1 day ago. Patients wearing glasses since 3 years ago with the cylinder 5 on the right and left eyes. Patients often took off his glasses, patients wear glasses, especially when reading and playing games. Patients also often feel itchy in the eye, especially the upper and lower eyelids so that patients often mengkucek- gup eyes.

Of ophthalmological status is obtained:

Vision OD OS

0.25 vision ph ph 0.5 0.5 0.6

Correction C -5.50 -2.00 x 180 0.6 C 0.5 X180

Eyelid superior and inferior

Dendraf eyelashes (+) Dendraf (+)

Meibomian gland sebum (+) sebum (+)

VI. DIAGNOSIS OF WORK

Astigmat Miop Simplex

Amblyopia

seborrheic blepharitis

VII. EXAMINATION RECOMMENDED

-

IX. TREATMENT

Non medika mentosa

o Glass eye lenses refractive cylinder fit

o Warm compresses on the eyes for 5-10 minutes

o Cleaned with baby shampoo

Medika mentosa

o Local Antibiotics

ceftriason ed fl 1

S 3 GTT 2 ODS

o Systemic antibiotics:

amoxicillin 500 mg tab No.XV

S 3 dd tab 1

PROGNOSIS

OCCULI Dextra (OD) OCCULI Sinistra (OS)

Ad Vitam: Bonam Bonam

Ad Fungsionam: Dubia Dubia

Ad Sanationam: Bonam Bonam