OPHTHALMIC RECORD

Name of Examiner : Wulan Puspita

NIM : 1161050214
Examiner : DR. dr. Gilbert W. S. Simanjuntak, Sp.M (K)

I. PATIENT IDENTITY
Name : RS (Pediatric)
Sex : Male
Age : 9 years old
Education : Primary school
Job : Student
Religion : Moslem
Address : Cawang III RT 03/ RW 011, Cawang, Jakarta Timur.
Status : Single

II. ANAMNESIS ( Autoanamnesis, September 9th, 2016 )

Main complaint : Redness on the left eye

Additional complaint : Pain, blurry vision, Photophobia, Itchy, sandy-gritty

sensation, and watery on the left eye

History of Disease
The Patient with his mom came to UKI Hospital, Jakarta with main
complaint redness on his left eye since 2 weeks ago. This complaint is felt
continuous and increasingly day by day. At first, about 2 weeks ago, His left eye
was contaminated sand when playing with sand, and then day by day became
redness on left eye, it happens continuously that is also becoming more redness
everyday. He also complained about his pain coinside redness on left eye, day by
day became more severe and it happens continuously along with the pain in the
left eye that is also becoming more painful everyday. He also complained another
symptoms such the blurry vision that happened a week ago, it happened
progressively along with the photophobia, sandy-gritty sensation, itchy and
watery on his left eye. Pasient often rubed his eyes. To reduce the complaints,
Patients using insto, routinetly used but the complaints weren’t improved and
then got worsen. The Patient have never been treated by any doctor.
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 Discharge(+), Swelling(+), Glare(+), headache(-). A history of trauma to the eye
and a history of long-term drug use are denied. Patient’s not using glasses or
contact lenses. There are no complaints about his right eye.

Previous Disease History

Patient never had complaints like this before. A history of trauma to the eye
and a history of long-term drug use are denied. A history of food allergies and
medications allergies are denied. History of hypertension, diabetes mellitus,
cholesterol are denied.

Family Disease History

There is nobody in his family who experience the complaints like this before.

Personal Habit
The patient denied of using contact lenses or glasses, smoking, and alcohol
consuming.

III. GENERAL STATUS

General condition : Mild appearance of illness
Consciousness : Composmentis

IV. OPHTHALMIC STATUS

1. General Examination

General Examination Right Eye Left Eye

(Inspection and Palpation)

Periocular appearance Quiet Edema palpebra,

Redness konjungtival
bulbar, watery
General condition of the eye Normal Hiperemic, watery
Eyeball position Symmetric Symmetric
Eyeball movement Normal to all direction Normal to all direction
Visual field Wide Wide

2. Systematic Examination

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 Systematic Examination Right Eye Left Eye

Visual acuity
§ Before correction
§ Correction
§ After correction
Supercilia
Cilia Superior / Inferior
1.0 0,7 ph 0,8
- -
- -
Normal, homogenous Normal, homogenous
madarosis (-) madarosis (-).
Normal, madarosis (-), Normal, madarosis(-),
trichiasis (-). Trichiasis (-).

Palpebrae superior / inferior Edema (-), tumor(-), Edema (+), tumor(-),

hordeolum (-), hordeolum (-),
chalazion (-), chalazion (-),
ptosis(-), ptosis(-),
pseudoptosis (-) pseudoptosis (-)
tenderness (-). tenderness (-).
Margo palpebrae Tumor (-), Tumor (-),
superior/inferior ptosis(-), ptosis(-),
ectropion (-), ectropion(-),
entropion(-). entropion(-).
Tarsal conjunctiva superior / Smooth surface, Smooth surface,
inferior bleeding (-), bleeding (-),
hyperemic (-), hyperemic (-),
cicatrical (-), cicatrical (-),
secretion (-). secretion (-).
Bulbar conjunctiva Bleeding (-), Bleeding (-),
conjungtival injection (-), conjungtival injection (+),
cicatrical (-), cicatrical (-),
secretion (-), secretion (-),
pinguecula (-), pinguecula (-),
pterygium (-). pterygium (-)
Fornix conjunctiva Hyperemic (-) Hyperemic (-)

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 Cornea Pericorneal injection (-) Pericorneal injection (+)
Clear infiltrate (-), ulcus (-), Clear infiltrate (+)
cicatrical (-), arch senile (-). like a cloudy,
ulcus (-), cicatrical (-)
arch senile (-).
Sclera Colour: white, Colour: white,
bleeding (-), bleeding (-),
cicatrical (-). cicatrical (-).
Anterior chamber Deep, clear, hypopion (-), Deep, clear, hypopion (-),
hyphema (-). hyphema (-).
Iris Radier,Colour: black, Radier,Colour: black,
atrophy (-),sinekia (-), crypt atrophy (-), sinekia (-),
(+). crypt(+)
Pupil Round, isochor, 3mm, Round, isochor, 3 mm,
direct light reflex (+), non Direct light reflex (+),
direct light reflex (+). non direct light reflex
(+).
Lens Clear,shadow test (-). Clear,shadow test (-).

V. RESUME
A 9 years old boy with his mom came to UKI Hospital, Jakarta with main
complaint redness on his left eye since 2 weeks ago. This complaint is felt
continuous and increasingly day by day. It happens continuously that is also
becoming more redness everyday. He also complained about his pain coinside
redness on left eye, day by day became more severe and it happens
continuously along with the pain in the left eye that is also becoming more
painful everyday. He also complained another symptoms such the blurry
vision that happened a week ago, it happened progressively along with the
photophobia, sandy-gritty sensation, itchy and watery on his left eye. Pasient
often rubed his eyes. To reduce the complaints, Patients using insto, routinetly
used but the complaints weren’t improved and then got worsen. The Patient
have never been treated by any doctor. Discharge(+). Swelling(+). Glare(+).
Patient never had complaints like this before. Patient’s not using glasses or
contact lenses. A history of trauma to the eye and a history of long-term drug
use are denied. A history of food allergies and medications allergies are
denied. History of hypertension, diabetes mellitus, cholesterol are denied.

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 GENERAL STATUS
General condition : Mild appearance of illness
Consciousness : Compos mentis

OPHTHALMOLOGY STATUS
From the ophthalmological examination on the right and left eyes, obtained:

General Examination Right Eye Left Eye

(Inspection and Palpation)

Periocular appearance Quiet Edema palpebra,

Redness konjungtival
bulbar, watery
General condition of the eye Normal Hiperemic, watery

Systemic examination Right Eye Left Eye

Visual acuity
§ Before correction 1.0 0,7 ph 0,8
Palpebrae superior / Normal Edema (+)
inferior

Bulbar conjunctiva Normal conjungtival injection (+),

hiperemic
Cornea Normal Pericorneal injection (+),
Clear infiltrate (+)
like a cloudy

VI. CLINICAL DIAGNOSE

Keratitis Oculus sisnistra

VII. DIFFERENTIAL DIAGNOSE

§ Uveitis anterior Oculus sinistra
§ Keratoconjungtivitis Oculus sinistra
§ Acute glaucoma Oculus sinistra
VIII. TREATMENT
§ Non-Medical Treatment :
o Don’t rub both eyes
o Wash hand before and after touching secret or discharge of eyes.
o Avoid exposure of the direct sun ray, wind, and dust from the eyes.

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 o Use a cap and/or sunglasses to avoid the direct exposure of
ultraviolet rays into the eye.
o Control to the doctor.
§ Medication Treatment:
o Local antibiotic  Levofloxacin 0,3%
LFX (5mg/mL) every 3 hour a day (in 3 days)
Continue  every 4 hour a day

IX. RECOMMENDED EXAMINATION

§ Slit-lamp biomicroscopy
§ Fluorescent test
§ Microbiology culture examination and antimicrobial susceptibility testing

X. COMPLICATION
§ Corneal Ulcus
§ Corneal perforation
§ Visual Disorders (Astigmatism)
§ Corneal Scar

XI. PROGNOSIS

Right Eye Left Eye

Ad Vitam Bonam Bonam
Ad Sanationum Bonam Dubia ad Bonam
Ad Functionum Bonam Dubia ad Bonam

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