DUTY REPORT

Saturday, 30 Juni 2017

Ophthalmologist : Dr. dr. Trilaksana Sp.M
Senior Resident : dr. Habibi
Junior Resident : dr. Risa
Identity
• Name : Mrs. Mei Monah
• Age : 43 yo
• Address : Semarang
History
• Chief Complaint : Pain in her left eye
• Recent History : ± 1,5 hours before admission,her left eye was
punched by her husband, pain on his right eye(+), the left eye difficult
to open, watery eye (+), bleeding (+), redness in her left eye (+),
blurry vision (+), jelly like subs (+). Previously, her son take her to the
Dr. Karyadi Hospital
• Medical History : he didn’t use any medicine
• Past Medical History :
- Trauma history (+)
- Since childhood her eye already blurry, there is whiteness on her
left eye
- Alergy (-), DM (-), HT (-),spectacles (-)
• Sosioeconomic History : patient is a factory workers
 RE LE
Visual acuity 6/6 1/300
Digital IOP N -
Eyelid Edema (-), spasm (-) Spasme(+), hematom (+), edema (-), laceration (-)
Conjunctiva injection (-) Hiperemis (+), minimal chemosis (+), SKB (-), laceration (-)
Cornea Clear (+) Clear (+), lekoma(+), laceration (+) full thickness, ±6mm,
Humor Aquous(+) active, CV (+) on laceration, iris pigment
(+) on cornea endothel
Anterior chamber The depth of enough
One chamber (Iridodialisis total), clot (+), CV (+)
Iris Kripte (+)
Pupil Round, central, regular, Ø 3mm, RP (+) N Can't evaluated
Lens clear (+) impressed aphakia
Fundus Reflex Bright Dark
Funduscopy Normal limits Can't evaluated

Ocular Trauma Score: 2

- Hand Movement : 70
- Globe Rupture : -23
Raw Score Sum : 47
USG B scan:
• Lens in Cavum Vitreous, Vitreous
Haemorrhage
• Diagnosis : OS Cornea Laceration grade IV + Luxated lens, Susp.
Rupture Bulbi
• Treatment :
• Hospitalize
• examination laboratory
• EKG
• Pro: OS Cornea Hecting + Exploration Bulbi / GA
• Vigamox ED/2 hr OS
• P. Pred ED/ 2hr OS
• SA 1 % ED/8 hr OS
• IVFD RL 20 tpm
• Ceftriaxon 1gr/12 hr iv
• Methyl prednisolone 125mg/ 12 hr iv
• Consult to Anesthesia division
• Education for patient: OS Dubia ad malam
OS Cornea Hecting / GA
Dr. dr. Trilaksana Sp.M / HB, RFS
Saturday, 1 July 2017/ ok 1/ 03.00-04.00

Durante Op: Laceration on sclera

(-)
Treatment post op:
• Vigamox ED/2 hr OS
• P. Pred ED/ 2hr OS
• SA 1 % ED/8 hr OS
• Ceftriaxon 1gr/12 hr iv
• Methyl prednisolone 125mg/
12 hr iv
• Analgetic → Anesthesia
division
Follow Up Post Op I RE LE
Visual acuity 6/6 1/~ LPB
Digital IOP N N
Eyelid Edema (-), spasm (-) Spasme(+), hematom (+), edema (+) minimal
Conjunctiva injection (-) SKB (+), chemosis (+)
Cornea Clear (+) Suture is tight, lekoma(+), seidel test (-)
Anterior chamber The depth of enough Difficult to be evaluated

Iris Kripte (+) Difficult to be evaluated

Pupil Round, central, regular, Ø 3mm, RP (+) N Difficult to be evaluated

Lens clear (+) Difficult to be evaluated
Fundus Reflex Bright Dark
Funduscopy Normal limits Can't evaluated
Diagnosis: OD Post Cornea Hecting H1
Treatment:
• Vigamox ED/2 hr OS
• P. Pred ED/ 2hr OS
• SA 1 % ED/8 hr OS
• Ceftriaxon 1gr/12 hr iv
• Methyl prednisolone 125mg/ 12 hr iv
• Analgetic → Anesthesia division
Follow Up Post Op II RE LE
Visual acuity 6/6 1/~ LPB
Digital IOP N N
Eyelid Edema (-), spasm (-) Spasme(+), hematom (+), edema (+) minimal
Conjunctiva injection (-) SKB (+), chemosis (+)
Cornea Clear (+) Suture is tight, lekoma(+), seidel test (-)
Anterior chamber The depth of enough Difficult to be evaluated

Iris Kripte (+) Difficult to be evaluated

Pupil Round, central, regular, Ø 3mm, RP (+) N Difficult to be evaluated

Lens clear (+) Difficult to be evaluated
Fundus Reflex Bright Dark
Funduscopy Normal limits Can't evaluated
Diagnosis: OD Post Cornea Hecting H 2
Treatment:
• Vigamox ED/2 hr OS
• P. Pred ED/ 2hr OS
• SA 1 % ED/8 hr OS
• Ceftriaxon 1gr/12 hr iv
• Methyl prednisolone 125mg/ 12 hr iv
• Analgetic → Anesthesia division
• USG B scan → Suprahoroidal Haemorrhage