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OPHTALMOLOGY RECORD

MATURE SENILE CATARACT

Examiner:
Dr. Gilbert WS SimajuntakSp.M (K)
Observer:
Victor Umbu Awang
1061050155

DEPARTMENT OF EYE DISEASE


PERIOD OF OCTOBER 3rd November 5th , 2016
MEDICAL FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA

STATUS OPHTALMOLOGY
The Examine
Student number
Examiner

I.

PATIENT IDENTITY
Name
Age
Address
Occupation
Gender
Religion
Status

II.

: Victor Umbu Awang


: 1061050155
: dr. Gilbert WS SimajuntakSp.M (K)

: Mrs. M
: 61 years old
: Kampung Melayu, East jakarta
: Housewife
: Female
: Moeslim
: Married

HISTORY
Anamnesis done at October 26th, 2016
Main complaint
: Blurred Vision
Additional complaint : tearing eyes
History of present illness

Patients came to the General Hospital UKI with complaint blurred vision like a foggy
since 3 months. Patients feel her vision blurred continuously throughout the day both look
near and far. Complaints perceived gradually becoming more and more blurred. Blurred
vision starts from reading difficulties, so that the eyes felt tired after reading. Patients do
complain of glare if they see the light, red eye (-), pain (-), throbbing pain in head (-), watery
eyes (-), itching (-), out dirt tear (-), seeing double (-) , saw a rainbow around the light source
(-).
sight of both eyes are blurred to interfere with the activity. Patients do not treat both
eyes. Complaints felt increasingly become heavy until the patient feels bothered to move.
Therefore, the patient went to the UKI Hospital.

History of past illness:


Patients using the glasses, the patient had never had a complaint like this before.
Hypertension history denied, denied a history of diabetes mellitus, cholesterol denied.
A history of trauma to the eye and a history of longterm drug use is denied.

History of family illness:


Denied
History of social life:
Patient not consumed alcohol and cigarrets..

III.

GENERALIST STATUS
General state : mild
Awareness
: composmentis
A Disease/ clinical symptom that has to do with complaints: denied

IV.

OPHTHALMOLOGY STATUS
A. General examination
General examination
The circumstances
surrounding the eye
General state of the eye
The position of the
eyeball
Eyeball movement
Eyeball pressure
Visual field

OD

OS

Normal

Normal

Mild

Mild

Symmetric

Symmetric

Normal
14 mmhg
Wide

Normal
14 mmhg
Wide

B. Systemic examination
Systemic examination
Aciesvisus
Correction
After correction
Near correction
Super cilia
Cilia

OD
6/30
6/12
-

OS
5/12
6/9
-

Grow evenly
Grow evenly, good

Grow evenly
Grow evenly, good

Palpebral superior

position
edema (-), pseudoptosis (-)

position
edema (-), pseudoptosis (-)

Palpebral inferior

, hyperemic (-)
Normal, edema (-), ptosis

, hyperemic (-)
Normal, edema (-), ptosis

(-), hyperemic (-)


Hyperemic, follicle (-)

(-), hyperemic (-)


Hyperemic, follicle (-)

Conjunctivatarsalis
superior et inferior

Conjunctiva bulbi
Sclera
Cornea
a. Clarity
b. Infiltrate
c. Ulcers
d.Sikatriks
e. Neovascularization
f. Fluorescein test
g. Sensibility
h. Others
Anterior chamber
a. Depth
b. Hyphema
c. Hypopyon
Iris
Pupil

Hyperemic
Clear, sclera hyperemic

Hyperemic
Clear, sclera hyperemic (-),

(-), silier injection (-)

silier injection (-)

Clear
(-)
(-)
(-)
(-)
Not evaluated
Not evaluated
-

Clear
(-)
(-)
(-)
(-)
Not evaluated
Not evaluated
-

Deep
(-)
(-)
Radier, brown, sinekia (-)
Round, diameter 3 mm, R.

Deep
(-)
(-)
Radier, brown, sinekia (-)
Round, diameter 3 mm, R.

direct light (+), R. indirect

direct light (+), R. indirect

light (+), isokor


Unclear
Shadow Test (-)

light (+), isokor


Unclear
Shadow Test (-)

Lens

V.

RESUME
Patients come to the General Hospital UKI with complaint blurred vision like a foggy

since 3 months. Patients feel her vision blurred continuously throughout the day both look
near and far. Complaints perceived gradually becoming more and more blurred. Blurred
vision starts from reading difficulties, so that the eyes felt tired after reading. Patients do
complain of glare if they see the light, red eye (-), pain (-), throbbing pain in head (-), watery
eyes (-), itching (-), out dirt tear (-), seeing double (-) , saw a rainbow around the light source
(-).
sight of both eyes are blurred to interfere with the activity. Patients do not treat both
eyes. Complaints felt increasingly become heavy until the patient feels bothered to move.
Therefore, the patient went to the UKI Hospital.
Patients using the glasses, the patient had never had a complaint like this before.
Hypertension history denied, denied a history of diabetes mellitus, cholesterol denied. A
history of trauma to the eye and a history of longterm drug use is denied.
GENERALIST STATUS
General state : Mild

Awareness

: Composmentis

Systemic examination
Aciesvisus
Correction
After correction
Near correction
Super cilia
Cilia

OD
6/30
6/12
Grow evenly
Grow evenly, good

Grow evenly
Grow evenly, good

Palpebral superior

position
edema (-), pseudoptosis

position
edema (-), pseudoptosis

Palpebral inferior

(-), hyperemic (-)


edema (-), ptosis (-),

(-), hyperemic (-)


edema (-), ptosis (-),

hyperemic (-)
Hyperemic, follicle (-)

hyperemic (-)
Hyperemic, follicle (-)

Hyperemic
Clear, sclera hyperemic

Hyperemic
Clear, sclera hyperemic (-),

(-), silier injection (-)

silier injection (-)

Clear
(-)
(-)
(-)
(-)
Not evaluated
Not evaluated
-

Clear
(-)
(-)
(-)
(-)
Not evaluated
Not evaluated
-

Deep
(-)
(-)
Radier, brown, sinekia (-)
Round, diameter 3 mm, R.

Deep
(-)
(-)
Radier, brown, sinekia (-)
Round, diameter 3 mm, R.

direct light (+), R. indirect

direct light (+), R. indirect

light (+), isokor


Unclear

light (+), isokor


Unclear
Shadow Test (-)

Conjunctiva

tarsalis

superior et inferior
Conjunctiva bulbi
Sclera
Cornea
a. Clarity
b. Infiltrate
c. Ulcers
d. Sikatriks
e. Neovascularization
f. Fluorescein test
g. Sensibility
h. Others
Anterior chamber
a. Depth
b. Hyphema
c. Hypopyon
Iris
Pupil

Lens

Shadow Test (-)

VI.

OS
5/12
6/9
-

WORKING DIAGNOSIS

ODS Mature Senile Cataract

VII.

DIFFRENTIAL DIAGNOSIS
ODS Mature Senile Cataract
ODS Hipermature Senile Cataract

VIII.

WORKUP
Pre-operation inspection
a. Eye examination: keratometri, tonometry, ultrasound biometry.
b. Systemic examination: vital signs

IX. MANAGEMENT
Consul to the ophthalmologist for ODS plan extra capsular cataract extraction and
installation of Intra Ocular Lens (IOL).
Patient education:
1. Explain to patients that the views of both eyes were blurred due to cataracts in both
eyes lens.
2. Explain to patients that cataract can not be treated with medication, but can be
cured with surgery and administration of planting the lens of the eye.
3. Describe the complications that will occur if no surgery, the possibility of the lens
will melt, the content of the lens will come out, cause inflammatory reactions and
increased eye pressure.
4. Describe the possible complications during surgery and postoperatively.

X.

COMPLICATION
Glaucoma

XI.

PROGNOSIS
Ad. Vitam
Ad. Fungsionum
Ad. Sanationum

OD
Dubia ad Bonam
Dubia ad Bonam
Dubia ad Bonam

OS
Dubia ad Bonam
Dubia ad Bonam
Dubia ad Bonam

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