Saturday, November 10th 2016

Rara/Angel/Aryawan/Nindya/Yoga/Cynthia/Ayu
Trisna
Consultant : dr. Wayan Eka Sutyawan, SpM

1 PATIENT

IG Kt Adi Wirawan/Male/25y.o/(09/11/16)
S
Patient
was
refferred
from
Mendoyo Primary health Care
Jembr-ana.
Patient feel pain
in his left eye
after hit by iron
plate since 8
hours ago while
working
breaks
down the iron.
Patient feel
blurry , redness ,
and watery in left
eye.
History
of
wearing
glasses (-)
History
of
Diabetic
(-),
Hypertension (-),
medication (-)
Drug allergy (-)

O
6/6
Normal
Normal

VA
Palpebral
Conjuncti
va

Clear, FL (-)
Cornea

Deep
AC
Round,
regular
Reflex (+),
RAPD(-)
Clear

Iris
Pupil
Lens

Clear
FR(+)

Vitreous
Fundus

13

IOP

A
1/60 PH NI
Spasm
CVI(+), PCVI (+),
SCB (+) at temporal
side
fullthickness
Laceration 8mm and
form like _l , from
paracentral at
5oclock to
peripheral 7oclock.
Iris pigment (+),
Seidel test (+)
Hyphema (+) inferior
at 4-5oclock
Oval, Middilatation
Refleks(-)
Hazy , Iris Pigment
(+)

LE Sharp injury
c/
--SCB
- Fullthickness
Corneal
laceration
--Hyphema
- Iridoplegia
-- Susp
Traumatic
cataract
BETTS Criteria
Type A
Grade D
Zone 1

P
- Hospitalized
- IVFD RL 12 dpm
- Cefoperazone
Sulbactam
2x1 gr IV
- Ketorolac 3x30
mg IV
- Tetagam 1 amp
IM
- Levofloxacin ED
@ hour LE
- LE Pro repair
corneal
laceration with
GA
- Lab examination
- Rontgen Thorax
PA,
Skull AP/Lat
- Consult to
Anesthesia Dept.

Refleks(+) minimal,
Detail difficult to be
examined
Eye
3
Moveme
nt
2

PICT AT EMERGENCY ROOM

3

Thorax Foto

Interpretation:
Within normal limit

Skull AP/Lat
5

No fracture at calvaria and

maxillofacial, foreign bodies (-)

Laboratory Result
WBC

11.31

RBC

5.00

HB

14.35

PLT

174.70

SGOT

21.1

SGPT

12.60

BUN

9.0

SC

0.83

RBS

85

Na

141

3.4

WITHIN NORMAL
LIMIT

SURGERY REPORT
7

1.

Patient lie down with GA-OTT

2.

Desinfection with RL : betadine = 9:1

3.

Narrow the sterile operating field with sterile doek

4.

Taegel superior and inferior Palpebra with soft silk 5.0

5.

Hecting cornea With Nylon 10.0

6.

Make side port at 10o clock

7.

Injection Viscoelastic in the COA

8.

Heacting Cornea with nylon 10.0

9.

Irigation Aspiration

10.

Injection air in the COA

11.

Gentamycin EO

12.

Wound Dressing

13.

Operation finished

POST SURGERY
8

A: LE sharp injury post repair corneal

laceration rupture day 0
P:
IVFD RL 12 dpm
Cefoperazone Sulbactam 2x1gram IV
Ketorolac 3x30mg IV
Levofloxacin ED 6x1 LE
P-Pred ED 6x1 LE
Methilprednisolone 3x16mg PO
Atropin ED 3x1 LE

FOLLOW UP DAY 1 (11/11/2016)

S
Post op (+)
pain minimal

O
6/6
Normal
Normal

VA
Palpebral
Conjunctiva

1/300
Spasm
CVI(+), PCVI (+)

Clear
deep
Round, regular
Reflex (+),
Clear
Clear
reflex (+)

Cornea
AC
Iris
Pupil
Lens
Vitreous
Fundus

Edema(+), Suture (+)

Deep,Bubble (+)
Oval, Middilation on
atropin
Reflex(-)
Hazy

n/p

IOP

Reflex (-)
n/p
Eye
Movement

LE Sharp injury
post repair
corneal
laceration day 1
c/
-Susp Traumatic
cataract

- IVFD RL 12 dpm
- Cefoperazone
sulbactam 2x1
gr IV
- Ketoroloac
3x30mg IV
- Levofloxacin ED
6x1 LE
- P.Pred ed 6x1 LE
- Atropin ed 3x1
LE
- Metilprednisolon
3x 16mg tab
- Consult to
Cornea Lens
division and
take over

10

Cornea Lens Division

12

A : LE Sharp injury post repair cornea day

1 with complication traumatic cataract
susp
-

P.
- Cefoperazone

sulbactam 2x1 gr IV
- Ketoroloac 3x30mg IV
- Levofloxacin ED 6x1 LE
- P.Pred ed 6x1 LE
- Atropin ed 3x1 LE
- Metilprednisolon 3x 16mg tab

FOLLOW UP DAY 1 (12/11/2016)

S
Post op (+)
pain minimal

O
6/6
Normal
Normal

VA
Palpebral
Conjunctiva

Clear
deep
Round, regular
Reflex (+),
Clear
Clear
reflex (+)

Cornea
AC
Iris
Pupil
Lens
Vitreous
Fundus

n/p

IOP

1/300
Spasm
CVI(+), PCVI (+), SCB at
inferior side
Edema(+), Suture (+)
Deep,Bubble (+)
Oval, Middilation on
atropin
Reflex(-)
Hazy

LE Sharp injury
post
repair
corneal
laceration day 2
c/
-susp traumatic
cataract

- Cefadroxil
tab
2x500mg
- Levofloxacin ED
6x1 drop LE
- P.Pred ed 6x1
drop LE
- Atropin ed 3x1
drop LE
- Metilprednisolon
3x 16mg
- Mefenamic acid

Reflex( -)
n/p
Eye
Movement

3x500mg
Control to
policlinic
on
Monday, 14/11/
2016

13

(14/11/2016)
S
Pain (-)

O
6/6
Normal
Normal
Clear
deep
Round, regular
Reflex (+),
Clear
ONH N II round, well
dermacated, CDR 0,3,
aa/vv 2/3,
retina :
good, macula : reflex
(+)

VA
Palpebral
Conjunctiva
Cornea
AC
Iris
Pupil
Lens
Vitreous
Fundus

IOP

5/60 ph NI
Normal
CVI(+), PCVI (+)
Suture (+),
oedema(+)min
Deep,cell (+), flare (+)
Oval, Middilation on
atropin
Reflex(-)
Hazy
clear
ONH N II round, well
dermacated, aa/vv
2/3,retina :pale,
Macula : reflex (+)

LE Sharp injury
post
repair
corneal
laceration day 2
c/
-susp traumatic
cataract
- Retina
bleeding
and
berlins oedema

- Levofloxacin ED
6x1 drop LE
- P.Pred ed 6x1
drop LE
- Atropin ed 3x1
drop LE
- Metilprednisolon
3x 16mg
Consult to
vitreoretina
division

11,3
13
Eye
Movement

14

VitreoRetina Division
17

A : LE Susp Traumatic Optic Neuropathy

P. LE OCT Macula

PICTURE: LAST CONDITION

18