OPHTALMOLOGY RECORD

FUNGAL KERATITIS

Examiner:
dr. Gilbert W S Simajuntak Sp.M (K)

Observer:
Fransiska Sinurat, S. Ked
1161050043

DEPARTMENT OF OPHTHALMOLOGIC
PERIOD DECEMBER 14th JANUARY 23rd 2016
MEDICAL FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA
STATUS OPHTALMOLOGY
Observer

: Fransiska Sinurat, S. Ked

Student number

: 1161050043

Examiner

: dr. Gilbert W S Simajuntak Sp.M (K)

I.

II.

PATIENT IDENTITY
Name
: Tn. S
Age
: 33 years old
Address
: Jalan Batikan No. 27, Yogyakarta
Occupation : Carpenter
Gender
: Man
Religion
: Moslem
Status
: Married
HISTORY
Anamnesis was on January 13rd, 2016 in dr. Yap Eyes Hospital, Yogyakarta.
Main complaint
: right eye redness since one day ago.
Additional complaint : right eye blurred vision, pain, and dazzled.
History of present illness:
A patient came to dr. Yap Eyes Hospital, Yogyakarta with complaint of right
eye redness since one day ago. He said the redness location is at the white part of the
right eyeball. The redness formed by a lot of red lines. Patient felt the redness of his
right eye along the day. Patient said, when he was working two weeks ago, he got
sawdust piles in his right eye. He felt itchy then rubbed his eye with his hand. Patient
used insto eye drops but the symtomps did not decrease. Patient also feels his right
eye vision is blurred, pain, and dazzled decrease slowly.
Patient has never experienced a complaint like this before. history of allergy,
eye surgery, hypertension, and Diabetes Mellitus denied. Patient never used glasses or
soft lens before.

History of past illness:

Patient has never experienced a complaint like this before. History of allergy,
eye surgery, hypertension, and Diabetes Mellitus denied. Patient never used glasses or
soft lens before.
2

History of family illness:

Denied.
History of social life:
Denied.
III.

GENERALIST STATUS
General state : mild illness
Awareness
: compos mentis
Blood pressure: 120/80 mmHg
A disease clinical symptom that has to do with complaints: denied

IV.

OPHTHALMOLOGY STATUS
A. General examination
General examination
The circumstances
surrounding the eye
General state of the eye
The position of the
eyeball
Eyeball movement
Eyeball pressure
Visual field

OD

OS

Normal

Normal

Mild

Normal

Symmetric

Symmetric

Normal
Wide

Normal
Wide

B. Systemic examination
Systemic examination
Acies visus
Correction
After correction
Near correction
Super cilia
Cilia

Grow evenly
Grow evenly, good

Grow evenly
Grow evenly, good

Palpebral superior

position
Normal, edema (-),

position
Normal, edema (-),

Palpebral inferior

ptosis(-), hyperemic (-)

Normal, edema (-),

ptosis(-), hyperemic (-)

Normal, edema (-),

ptosis(-), hyperemic (-)

Hyperemic (+), follicle (-)

ptosis(-), hyperemic (-)

Hyperemic(-), follicle (-)

Hyperemic (+), follicle (-)

ciliary injection (+)
Normal

Hyperemic (-), follicle (-)

ciliary injection (-)
Normal

Conjunctiva tarsalis
superior et inferior
Conjunctiva bulbi
Sclera
Cornea

OD
1/60 pin hole (-)
-

OS
6/6
-

a. Clarity
b. Infiltrate
c. Ulcers
d. Sikatriks
e. Neovascularization
f. Fluorescein test
g. Sensibility
h. Others
Anterior chamber
a. Depth
b. Hyphema
c. Hypopyon
Iris
Pupil

Lens
a. Clarity
b. Turbidity
V.

Turbid
(+) grey
(-)
(+)
(-)
Not evaluated
Not evaluated
Satellite lesions
Deep
(-)
(-)
Radier, brown, sinekia (-)
Round, diameter 3 mm,

Clear
(-)
(-)
(-)
(-)
Not evaluated
Not evaluated
(-)
Deep
(-)
(-)
Radier, brown, sinekia (-)
Round, diameter 3 mm,

direct light reflex (+),

direct light reflex (+),

indirect light reflex (+),

indirect light reflex (+),

isokor

isokor

(-)
(-)

(-)
(-)

RESUME
A patient came to dr. Yap Eyes Hospital, Yogyakarta with complaint of right
eye redness since one day ago. He said the redness location is at the white part of the
right eyeball. The redness formed by a lot of red lines. Patient felt the redness of his
right eye along the day. Patient said, when he was working two weeks ago, he got
sawdust piles in his right eye. He felt itchy then rubbed his eye with his hand. Patient
used insto eye drops but the symtomps did not decrease. Patient also feels his right
eye vision is blurred, pain, and dazzled decrease slowly.
Patient has never experienced a complaint like this before. history of allergy,
eye surgery, hypertension, and Diabetes Mellitus denied. Patient never used glasses or
soft lens before.
GENERALIST STATUS
General state : mild ilness
Awareness
: compos mentis
Systemic examination
Acies visus
Correction
After correction

OD
1/60 pin hole (-)
-

OS
6/6
4

Near correction
Super cilia
Cilia

Grow evenly
Grow evenly, good

Grow evenly
Grow evenly, good

Palpebral superior

position
Normal, edema (-),

position
Normal, edema (-),

Palpebral inferior

ptosis(-), hyperemic (+)

Normal, edema (-),

ptosis(-), hyperemic (-)

Normal, edema (-),

ptosis(-), hyperemic (+)

Hyperemic(+), follicle (-)

ptosis(-), hyperemic (-)

Hyperemic(-), follicle (+)

Hyperemic(+),
ciliary injection (+)
Normal

Hyperemic (-)
ciliary injection (-)
Normal

Turbid
(+) grey
(-)
(-)
(+)
(-)
Not evaluated
Not evaluated

Clear
(-)
(-)
(-)
(-)
(-)
Not evaluated
Not evaluated

Satellite lesions

(-)

Conjunctiva tarsalis
superior et inferior
Conjunctiva bulbi
Sclera
Cornea
a. Clarity
b. Infiltrate
c. Ulcers
d. Edema
d. Sikatriks
e. Neovascularization
f. Fluorescein test
g. Sensibility
h. Others
Anterior chamber
a. Depth
b. Hyphema
c. Hypopyon
Iris
Pupil

Lens
a. Clarity
b. Turbidity
VI.

Deep
(-)
(-)
Radier, brown, sinekia (-)
Round, diameter 3 mm,

Deep
(-)
(-)
Radier, brown, sinekia (-)
Round, diameter 3 mm,

direct light reflex (+),

direct light reflex (+),

indirect light reflex (+),

indirect light reflex (+),

isokor

isokor

(-)
(-)

(-)
(-)

DIFFERENTIAL DIAGNOSIS
Bacterial Keratitis OD
Viral Keratitis OD

VII.

DIAGNOSIS
Fungal Keratitis OD

VIII.

WORKUP
Patient education
5

IX.

o Take care of hand and eyes hygiene

o Do not rub the eyes
o Use the eye drops according to the rules and regularly
o Patient should return in 1-3 weeks or sooner if the condition getting worse
Slit lamp
Fluorecein test
Consule to ophtalmologyst

MANAGEMENT
Antifungal : Natamycine 5% initially 1gtt/1-2 hours intervals OD. After 3-4 days,
frequency reduced to 1gtt/3-4 hours, continue for 14-21 days or until clinical

X.

XI.

resolution is seen)
Antibiotic : Ofloxacine 3mg/ml 1-2gtt/4-6 hours interval OD

COMPLICATION
Corneal ulcer OD
Corneal cicatrix OD
PROGNOSIS
Ad. Vitam
Ad. Fungsionum
Ad. Sanationum

OD
Dubia ad Bonam
Dubia ad Bonam
Dubia ad Bonam

OS
Dubia
Dubia
Dubia