NEURO-OPHTHALMOLOGY

WEEKLY REPORT
DIA/ EGA/TAN/ TTA/ ASA
 MR. H/35 Y.O
ADMISSION: NOVEMBER 9TH, 2018
Chief complain: Blurred on his left eye
Patient complained of blurry vision that slowly worsen since a month
ago. He also felt slightly pain on his left eyes.
Redness (-), diplopia (-), glare (-), headache (+), scalp tenderness (+)
nausea (-), vomiting (-). fever (+) a day before.
History of trauma (-)
History of treatment (-)
History of previous eye diseases (-)
History of wearing spectacles (-)
Prior medical history: hospitalized because of cardiac and
gastrointestinal problems, but he didn’t know the diagnosis.
History of systemic disease : DM(?) never got laboratory check, HT (-)
History of alcoholic (-)
GENERAL CONDITION
BP: 120/70 mmHg
 SUMMARY OF DATA BASE
NOVEMBER 9 TH, 2018
Right Eye Left Eye
Subjective: blurry on left eyes
6/6 Visual Aquity 6/12 ph(-)
spasm -, edema - Eyelid spasm -, edema -
CI - , PCI - Conjungtiva CI - , PCI -
clear Cornea clear
deep Anterior Chamber deep
radline Iris radline
round, Ø 3 mm, RP + , Pupil round, Ø 4 mm, RP + ,
RAPD - RAPD +
clear Lens clear
20.6 mmHg IOP 20.6 mmHg
FDT EBM FDT
pain(-) pain(-)
Right Eye Left Eye
12 FPV 12
4/8 MRD 4/8
10 MLD 10
13 LA 13
 Right Eye Left Eye
Diplopia
- - - - - -
- - -
- - - - - -
- - -
- - - - - -
- - -
RGD(+), only can read Ishihara RGD(+), only can read
control plate control plate
wnl Amsler Grid wnl
1.65 Contrast Sensitivity 1.65
1.50
RF: +, Media: clear Funduscopy RF: +, Media: clear
ONH: shape dte, blurry ONH: shape dte, blurry
margin @ sup-inf, orange, Hertel margin @ all quadran,
SV >7, elevation 1D hyperemia, elevation 3D,
Vascular: a/v 2/3 ,scle -, hemorhage +, turtuosity +
cross - 16 16 Vascular: a/v 2/3 ,scle -,
Retina: hemorrhage -, cross -
103
exudate - Retina: hemorrhage -,
Macula: FR +, exu - exudate -
Macula: FR +, exu +
 Assessment
RLE edema papil ec. Susp. AAION dd. Optic neuritis
dd. papiledema

Treatment :
• Hospitalization
• Education and information about the diasease,
planning therapy, risk and prognosis
• Laboratory examination
• Methyl prednisolone i.v. inj. 4x250 mg in 100cc NS
• Ranitidin 2x50 mg i.v
• Neurobion drip 1x1 amp i.v.
• Kalk 1x1 tab orally
• Consult to Internal Medicine dept. for metilprednisolon
administration
 LAB RESULT
Hb : 13,6 g/dL
Eri : 4,58 x 106
Leu : 3,50 x 103
Hct : 39,3 %
PLT : 204.000
FBG/ 2hPPBG : 74 mg/dl / 66 mg/dl
Ureum / Creatinine : 32,5 / 0,82
SGOT/ SGPT: 35/ 41
LED: 38 mm/ jam
CRP: 0,80 mg/dL
Total cholesterol/ HDL/ LDL/ trigliserida: 186/ 144/ 26/134
INTERNAL MEDICINE DEPT.

There’s no contraindication for

methylprednisolon administration in this
patient
 Subjective: his vision still same
Visual Aquity 20/25 ph(-) 20/20f 20/20
Eyelid spasm -, edema - spasm -, edema - spasm -, edema -
Conjungtiva CI - , PCI - CI - , PCI - CI - , PCI -
Cornea clear white kp’s clear
Anterior Chamber deep deep deep
Iris radline radline radline
Pupil round, Ø 3 mm, RP +, round, Ø 3 mm, RP + round, Ø 3 mm, RP+
RAPD - , RAPD dte
Lens clear clear clear
IOP 20,6 mmHg 20.6 mmHg n/p
EBM FDT FDT FDT
pain(-) pain(-) pain(-)
 Diplopia
- - - - - - - - -
- - - - - - - - -
- - - - - - - - -

Ishihara RGD (+), control plate (+) RGD (+) control plate (+) RGD (+) control plate (+)
83 1517 6x Cannot read: 2, 6, 97, 45 83 6x 7321
3536 Can read: 42, 35, 29, 96 5727 9710 424
2910 16x 97x 1519 45x 3515
9626 7421 5x 262
57x 7x 45x 2x 1615 969
5x 7421 5x
3x 2x
Amsler Grid Wnl
Wnl Wnl
Funduscopy RF: +, Media: clear RF: +, Media: clear RF: +, Media: clear
ONH: shape seems round, ONH: shape seems round, ONH: shape seems round,
blurry margin @ nas-sup- blurry margin @ nas-sup- blurry margin @ nas-sup-inf,
inf, cd ratio dte, orange, inf, cd ratio dte, orange, SV cd ratio dte, orange, SV dte,
SV dte, elevation 2D, dte, elevation 2D, elevation 2D, hemorhage -,
hemorhage -, turtuosity - hemorhage -, turtuosity - turtuosity -
Vascular: a/v 2/3 ,scle -, Vascular: a/v 2/3 ,scle -, Vascular: a/v 2/3 ,scle -, cross
cross - cross - -
Retina: hemorrhage -, Retina: hemorrhage -, Retina: hemorrhage -,
exudate - exudate - exudate -
Macula: FR +, exu - Macula: FR +, exu - Macula: FR +, exu -
Visual Aquity 20/30 ph(-) 20/30 ph(-) 20/50
Eyelid spasm -, edema - spasm -, edema - spasm -, edema -
Conjungtiva CI - , PCI - CI - , PCI - CI - , PCI -
Cornea Clear, white kp’s -, Clear, white kp’s -, Clear, white kp’s +,
fine kp’s +, brown kp’s + fine kp’s +, brown kp’s + fine kp’s +, brown kp’s +
Anterior Deep, flare grade II-III Deep, flare grade II-III Deep, flare grade II,
Chamber cell grade II-III cell grade II-III cell grade II
Iris radline radline radline
Pupil round, Ø 3 mm, RP + , round, Ø 3 mm, RP + , round, midmidri
RAPD dte RAPD dte ec.homatro, RP- , RAPD
dte
Lens clear clear clear
IOP 17.3 mmHg 17.3 mmHg n/p
EBM FDT FDT FDT
pain(-) pain(-) pain(-)
Vitreous cell Grade II Grade II Grade II
 Left Eye
Diplopia - - - - - -
- - -
- - - - - - - - -
- - - - - - - - -

Ishihara RGD (+), control plate(+) RGD (+), control plate(+) RGD (+), control plate(+)

Amsler Grid Wnl Wnl Wnl

Funduscopy RF: +, Media: clear RF: +, Media: clear RF: +, Media: clear
ONH: shape dte, blurry ONH: shape dte, blurry @ ONH: shape dte, blurry
@ all margin, cd ratio all margin, cd ratio dte, @ all margin, cd ratio dte,
dte, hyperemia, SV dte, hyperemia, SV dte, hyperemia, SV dte,
elevation 2-3, peripapil elevation 2D, hemorhage elevation 2-3D, peripapil
hemorhage +, turtuosity +, turtuosity - hemorhage +, turtuosity -
- Vascular: a/v 2/3 ,scle -, Vascular: a/v 2/3 ,scle -,
Vascular: a/v 1/3 ,scle -, cross - cross -, sheating +
cross -, sheating + Retina: hemorrhage -, Retina: hemorrhage +,
Retina: hemorrhage +, exudate - exudate +, flameshape +
exudate +, flameshape + Macula: FR +, exu - Macula: FR -, exu +
Macula: FR -, exu +
Assesment RLE Edem papil ec RE Edem papil ec susp.
susp. AAION dd optic AAION dd optic neuritis
neuritis with with improvement
improvement LE edem papil
susp.AAION dd optic
neuritis + panuveitis ec
susp. CMV
Planning • Methyl prednisolone • Methyl prednisolone
i.v. inj. 4x250 mg in i.v.  postponed
100cc NS (II,III,IV,V) • Laboratory
• Ranitidin 2x50 mg i.v examination: CD4, IgM
• Neurobion drip 1x1 and IgG anti CMV and
amp i.v. Rubella
• Kalk 1x1 tab orally • Thorax photo PA
• Cito consult to Infection
and Immunologi
division
• Consult to
Pulmonology and
Internal Medicine dept.
• Pro fundus photo 
Monday, Nov 12th
2018
RE Edem papil ec
susp. AAION dd optic
neuritis with
improvement
LE edem papil
susp.AAION dd optic
neuritis dd panuveitis
ec susp. CMV
•Valgancyclovir tab 2x
900 mg PO
•Homatro ed 3x1 LE
•Vosama ed 3x1 LE
•Methylprednisolone →
Stop until 3rd day of
valgancycolvir
consumption
•Cetirizin tab 3x 10 mg
 RE USG LE USG

 Posterior capsule : intact Posterior capsule : intact

Vitreous anterior – media - Vitreous anterior – posterior :
posterior : echodense (-) echodense (+), low spike, after
Retina : on place movement (+)
 Choroid : wnl Retina : on place
 ONH : on place Choroid : wnl
PNII : on place
LABORATORY EXAMINATION
Hb: 12.5 g/dL
RBC: 4.24 x 106 / µL
WBC: 12, 79 x 103/ µL
Ht: 36.30%
Plt: 235 x 103 /µL
LED: 23 mm/hour
Anti Rubella IgM/ IgG: 0,321/ 201,0
Anti CMV IgM/ IgG: 0,356/ 284,4
CD 4: 6 Cell/ µL
INFECTION AND IMMUNOLOGI DIVISION

A) LE CMV Retinitis
P)
Valgancyclovir 2x900 mg
Homatropin 2% 3 x 1 drop LE
Vosama ed 3 x 1 drop LE
If there’s strong indication for steroid
administration, adjusted to 0,5mg/kgBW with
sistemic antiviral
 PULMONOLOGY DEPT.
A)
Susp. Lung Tuberculosis
Immunocompromised state dt. HIV Infection
P)
Laboratory examination: sputum  inducted with NS
3% nebulization
HIV determinant tests
Category 1 Antituberculosis drug if TB (+)
INTERNAL MEDICINE DEPT.
A)
Immunocompromised state dt. HIV infection
Generalized papule + crusta (PPE related to HIV
infection)
P)
IVFD NS 20 drop/min
Cetirizine 1x10 mg orally
Antituberculosis drug from Pulmonology dept.
Antiretroviral  wait HIV determinant tests result
FUNDUS PHOTO RE
FUNDUS PHOTO LE
 FOLLOW UP DAY 3
NOVEMBER 12 H, 2018
Right Eye Left Eye
Subjective: his vision still same
Visual Aquity 20/50
Eyelid spasm -, edema -
Conjungtiva CI - , PCI -
Cornea Clear, white kp’s +,
fine kp’s +, brown kp’s +
Anterior Chamber Deep, flare grade II,
cell grade II
Iris radline
Pupil round, midmidri ec.homatro,
RP- , RAPD dte
Lens clear
IOP n/p
EBM FDT
pain(-)
- Vitreous cell Grade II
 Right Eye Left Eye
- - - Diplopia - - -
- - - - - -
- - -
- - - - - -
- - -
RGD (+) control plate (+) - - - RGD (+) only can read control
83 6x 7321 plate
5727 9710 424 Ishihara
1519 45x 3515
7421 5x 262
2x 1615 969
wnl AG wnl
RF: +, Media: clear Fundus RF: +, Media: clear
ONH: shape round, sharp margin, copy ONH: shape dte, blurry @ all
cd ratio 0,3, orange, SV >7, margin, cd ratio dte, hyperemia,
elevation 1D, turtuosity - SV dte, elevation 2-3D, peripapil
Vascular: a/v 2/3 ,scle -, cross -, hemorhage +, turtuosity -
sheating - Vascular: a/v 2/3 ,scle -, cross -,
Retina: hemorrhage -, exudate -, sheating +
flameshape - Retina: hemorrhage +, exudate +,
Macula: FR +, exu - flameshape +
Macula: FR -, exu +
 RE USG LE USG

 Posterior capsule : intact Posterior capsule : intact

Vitreous anterior – media - Vitreous anterior – posterior :
posterior : echodense (-) echodense (+), low spike, after
Retina : on place movement (+)
 Choroid : wnl Retina : on place
 ONH : on place Choroid : wnl
PNII : on place
 Assessment
RE Edem papil ec susp. AAION dd optic neuritis with
improvement
LE edem papil susp.AAION dd optic neuritis dd panuveitis ec
susp. CMV

Treatment :
 Metilprednisolon 3 x 8 mg orally  postponed until got 3
days of Valgancyclovir
 Inj. Ranitidine 2 x 50 mg i.v  Ranitidine 2x150 mg orally
 Drip Neurobion 1 x 1 amp i.v  Neurodex 1 x 1 tab orally
 Kalk 1 x 1 tab orally  STOP
 Homatropin 2% ed 3 x 1 drop LE
 Vosama ed 3 x 1 drop LE
 Valgancyclovir 2 x 900 mg orally
 Controlled to outpatient clinic
BEFORE

AFTER