Mr. Y/ 51 y.o.

Adm. at xxxxxxx

 Chief complaint : blurred vision on his left eye

 Pt was consulted by VR division with LE mature cataract + RRD (US) and
RE pseudophakia for cataract extraction
 Pt’s LE started to blur 4 months ago. Blurred especially in the upper part of
vision by a curtain like shadow and completely blurred in 1 month
 Pain (-), redness (-), lacrimation (-) on both eyes

• H/ of trauma: his left eye was hit when he fell in the bathroom 4 months prior to visit
• H/ of eye disease: -
• H/ of eye surgery: RE PE 1 month ago in private clinic
• H/ of using spectacle: -
• H/ of systemic disease: HT (-), DM (-)
 SUMMARY OF
DATABASE
SEPTEMBER 27,
2020
RIGHT EYE LEFT EYE
6/9 ph (-) Visual Acuity 1/300
Sp (-), ed (-) Eyelid Sp (-), ed (-)
CI (-), PCI(-) Conjunctiva CI (-), PCI(-)
Clear Cornea Clear
Deep AC Deep
Radline Iris Radline
Round, 3mm, PR (+), Pupil Not round, 3mm, PR (+), posterior synechia @ 9-3 & @5
IOL in the bag Lens Non homogenous opacity, iris pigment (+)
18 mmHg IOP soft
FR +, media clear, PNII: round, sharp margin, orange, Posterior Segment FR - , Detail: difficult to evaluate
cd rat 0,4, PPA +, Vasa: a/v 2/3 +, scle -, cross -, Retina:
exu -, haem -, tigroid +, lattice +, Makula: RF +,
hyperpigmentation +
- Retinometry difficult to evaluate
Keratometry

KR Auto KR Javal

OD: OD:
K1: 7,68/44.00 X 140 K1:
K2: 7,56/44.75 X 50 K2:

OS: OS:
K1: 7,84/43.00 X 141 K1:
K2: 7,64/44.25 X 51 K2:
Thankyou