Case Report

1. Patient Identity a. Name b. Sex c. Age d. Address e. E !nic ". Job g. Religion : Mr. J : Male : 39 years old : Dusun Nalaya Landak Region : Dayak : S#as a : $a olik

Anamnesis and %!ysical examina ion doing on "ebruary &' ! ()&( in !e emergency room a ().3) %.m.

2.

Anamnesis Main Complain Sudden los o" *ision in bo ! eyes

History of disease &+ !ours be"ore en er !e !os%i al %a ien com%lained suddenly *ision los o" bo ! !is eyes, no red eyes, no %ain. S!or ly be"ore !e %a ien com%lained o" ex%eriencing *ision loss, !e sa# a "las!es o" brig! lig! in !is eyes. -!ere is no !is ory o" blurred *ision be"ore !is com%lain occured. .a ien com%lain !a !e sa# a black do s in !is *isual "ields.

.a ien s also com%lained o" !eadac!e and "e*er u% o no#. -!ere is no !is ory "or using eyeglasses

Past Clinical History .a ien claims !a !ere is no !is ory o" !e same sym% oms be"ore.

.a ien !a*e !y%er ension !is ory /uncon rolled0, DM !is ory denied. -!ere is a rauma !is ory /s one !ro#n0 bu i !a%%ens long ime ago, %a ien and !is "amily canno remember !e es ima ed imes . Family History -!ere are no one o" !is "amily !a*e !e same com%lain

3.

Physical Examination 1eneral 2ondi ion A#areness 3i al Signs a. 4lood %ressure b. 7ear Ra e c. Res%ira ory 8re9 d. -em%era ure : &5)6&() mm7g : 55 x6minu e : ()x6minu e : 35,&o2 : Seem modera e %ain : 2om%os men is

!ftalmolo"y Examination

3isus: a. :D b. :S !# :r !o Eye 4all .osi ion Eye 4all Mo*emen :) :) !$ :r !o

. osis /;0, lago" almos /;0, edema /;0

.al%ebra

. osis /;0, lago" almos /;0, edema/;0

Redness /;0, #a ery /;0, disc!arge /;0 2lear, edema /;0 2lear, dee%

2on<unc i*a

Redness /;0, #a ery /;0, disc!arge /;0

2ornea 2amera :kuli An erior

2lear, edema /;0 2lear, dee%

=ris colour : bro#n .u%il: circular, 3mm, isokor, reac i*e o lig! 2lear

=ris6%u%il

=ris colour : bro#n .u%il: circular, 3mm, isokor, reac i*e o lig!

Lens

2lear

4lurred > .oor 8undus Re"lex Demarca ed %a%il > cdr ),3 , re ina #as %ale, #i ! gray colour es%ecially around !e macula.

3i reous

4lurred > .oor 8undus Re"lex

8undus

Demarca ed %a%il > cdr ),3 , re ina #as %ale, #i ! gray colour es%ecially around !e macula.

-onome ri digi al

Normal im%ression > c!e#y like <elly 2anno be examined

3isual 8ield -es

%.

Res&me .a ien com%lains sudden los o" *ision in bo ! o" !is eyes since &+ !ours ago. 4o ! eyes doesn? red, %ain, i c!y and #a ery. 7e com%lains sa# a "las!es o" brig! lig! be"ore !is *ision is los , and sa# a black do s oo. .a ien s also com%lained o" !eadac!e and "e*er u% o no#. 3i al signs o" !is %a ien are in normal range, exce% !e blood %ressure, !a #as grade ( !y%er ension. 3isual acui y o" :DS is )6). 3i reous :DS is blurred c!arac eri@ed by %oor "undus re"lex. =n "undusko%i examina ion, #e "ind demarca ed %a%il > cdr ),3 , re ina #as %ale, #i ! gray colour es%ecially around !e macula.

'.

#ia"nosis Aorking diagnosis :

:D : Ablasio Re ina Regma ogenosa :S : Ablasio Re ina Regma ogenosa

Di""eren ial diagnosis : :D : Ablasio Re ina Non;Regma ogenosa > 2en ral 3enous Re ina :clusion > :S : Ablasio Re ina Non;Regma ogenosa > 2en ral 3enous Re ina :clusion >

(.

Plan for Ad)anced examination Sli Lam% Examina ion Labora ory assesmen /es%ecially blood glucose le*el0 BS1 Re ina 2-;S2AN

*.

+reatment Non;medikamen osa : 4ed Res > res ric ed ac i*i y Educa ion /ex%lain abou %lanning "or rea men 0 4andaged bo ! o" !is eyes Medikamen osa -o%ical :D :S :; :; !e disease and

Sys emic

=38D RL () -.M An i;%yre ic An i;!y%er ension An rain =3 2a% o%ril &x ')) mg 3x& () mg %er oral

Surgery

: Scleral bucke or *i rek omi

,.

Pro"nosis :D : a. Ad *i am : ad bonam

b. Ad "unc ionam : ad malam c. Ad sana ionam : ad malam

:S : a. Ad *i am : ad bonam

b. Ad "unc ionam : ad malam c. Ad sana ionam : ad malam