GLAUCOMA

SUBDIVISION
TAN/EGA/ANG/EKA/FAS/IIN
Mr. R / 52 y.o
Admission on July, 19th 2018
Chief complain : Pain on his right eye
• Patient had felt pain on his right eye since 3 weeks ago, redness(+), halo (+) glare (+),
discharge (-), epiphora (-), vomiting (-) headaches (+), nausea (+), blurred vision (+) .
Patient was refered from ophtalmologist with RE Acute Glaucoma.
• history of treatment : he got glauseta, KSR, timol 0.5% 2x1 RE and vosama 6x1 RE
from ophthalmologist
◦ history of previous eye diseases (-)
◦ history of allergic (-), history of trauma (-)
◦ history of wearing spectacle : (-)
◦ history of family disease : (-)
◦ history of surgery : RLE cataract surgery in 2016
◦ history of systemic disease : DM(+) routinely controlled since 18 years ago, HT(+)
on treatment.
General Condition

BP : 140/90 mmHg, HR 82x/m

RBS: 89 mg/dL
 Summary of Data Base
July, 19th 2018

Right Eye Left Eye

1/300 Visual Acuity 6/24 ph 6/7.5
spasm (+) edema (+) Eyelid spasm (-) edema (-)
CI (+) PCI (+) Conjunctiva CI (-) PCI (-)
Microcystic edema (+) Cornea Clear
VH III, flare cell dte Anterior Chamber VH IV
Radline, rubeosis iridis not seen Iris Radline
Round, midmidriasis, PR (+) Slow Pupil Round, ø 3 mm, PR +
IOL On Place Lens IOL On Place
52 mmHg IOP 12 mmHg
 Right Eye Left Eye

FR : + dim Funduscopy FR : +
Media : Opacity gr IV dt corneal Media : clear
ONH : round, sharp margin, c/d
edema & vitreous opacity 0.3, orange, LC -, Bay -, Nas -,
Detail dte nvd (-)
Vasa : a/v 1/3, cross+, scle +,
m.a.+
Retina : exu + hem + (dot blot)
Macula : RF -, exu +
dte Gonioscopy IV

dte dte IV IV

dte IV
 RLE USG
• Posterior Capsule: intact
• Vitreous
Anterior : echo dense(-),
Media : echo dense (+) medium spike
Posterior: echo dense (+) medium spike
• Retina: continous line (-)
• Choroid : on place
• ONH : on place
• Posterior Capsule: intact
• Vitreous
Anterior : echo dense(-),
Media : echo dense(-),
Posterior: echo dense (-)
• Retina: continous line (-)
• Choroid : on place, thickening(-)
• ONH : on place
• Hb 13,60 g/dl Laboratory Result
• Rbc 5,61 106/ɥL
• Wbc 8,15 103/ɥL
• Hct 40,80 %
• Trombocyte 369 103/ɥL
• Diff Count
• Eosinophile 2,7 %
• Basophile 0,9 %
• Neutrophile 64.1 %
• Lymphocyte 25,8 %
• Monocyte 6,4 %
• RBS 89 mg/dl
• Ureum 43.60 mg/dL
• Creatinine 1.68 mg/dL
Assessment
• RE secondary glaucoma ec susp. neovascular ec susp. PDR+ pseudophakia +
vitreous opacity dt susp. vitreous hemorrhage dt susp. PDR (USG)
• LE pseudophakia + severe NPDR + CSME + hypertension retinopathy KW III

Planning
•Hospitalized
•Education and information about the disease, complication, planning therapy and
visual prognosis
•Pro RE trabeculectomy/LA July 20th 2018
•Glaucon tab 3x250 mg PO
•KSR tab 1x1 PO
•Timol 0,5% ed 2x1 RE
•Azopt ed 3x1 RE
•Vosama ed 6x1 RE
•Pro Mannitol 20% inf 1 g/ kgBW (50kg 50 g). IOP evaluation 1 hour post mannitol
inf. (with Internal Medicine approval)
•Consult to Vitreo-retina subdivision
•Consult to Internal Medicine Department

Monitoring IOP 1 hour post Mannitol :

RE : 32 mmHg
Mannitol
LE :12 mmHg
Internal Medicine Department
Assesment
◦ DM Type II on OAD
Normoglycemia
◦ CKD st III newly diagnosed
Planning
◦ Diet DM 1700 kkal/day
◦ Patients may be given
mannitol after rehydration
with NaCl inf 0.9% 1000cc /
hour.
◦ Re-check Ur/Cr 24 hr post
mannitol 20% inf
◦ Avoid nephrotoxic drugs
 July, 20th 2018

Right Eye Left Eye

1/300 Visual Acuity 20/100 ph 20/30
spasm (+) edema (+) Eyelid spasm (-) edema (-)
CI (+) minimal, PCI (+) Conjunctiva CI (-) PCI (-)
minimal
edema (+) minimal Cornea Clear
VH III, fl cell - Anterior Chamber VH IV
Radline, rubeosis iridis (+) Iris Radline
Round, midmidri, PR (+) Slow Pupil Round, ø 3 mm, PR +
IOL On Place Lens IOL On Place
22 mmHg IOP 12 mmHg
 Right Eye Left Eye

FR : + dim Funduscopy FR : +
Media : Opacity gr III dt vitreous Media : clear
hemorrhage ONH : round, sharp margin, c/d
Detail dte 0.3, orange, LC -, Bay -, Nas -,
nvd -
Vasa : a/v 1/3, cross+, scle +,
m.a.+
Retina : exu + haem +
Macula : RF -, exu +
III Gonioscopy IV

III III IV IV

II IV
Neovascularization (+)
 RE Trabeculectomy / LA
Performed July 20th, 2018
 Diff :-
 Compl :-

Post OP Treatment :
• Vigamox e.d 6x1 drop RE
• Vosama e.d. 6x1 drop RE
• Ciprofloxacin tab 2x500 mg (P.O)
• Methylprednisolone tab 3x8 mg (P.O)
• Mefenamic acid tab 3x500 mg (P.O) if needed
• Ranitidine tab 2x 150 mg (P.O)
Follow Up Right Eye (July, 21th 2018) Right Eye (July, 22th 2018)
Visual Acuity 1/300 1/300

Eyelid spasm (-) edema (-) spasm (-) edema (-)

Conjunctiva CI (-) PCI (-), SCH (+), suture +, CI (-) PCI (-), SCH (+), suture +,
covered by conjunctiva, bleb flat covered by conjunctiva, bleb flat
Cornea clear, fl test (-) edema (+), fl test (-)
AC VH III, flare cell gr III, coagulum (+) VH III, flare cell gr III, coagulum (+)
Iris Radline, artificial coloboma @ 1 Radline, artificial coloboma @ 1
o’clock, rubeosis iridis (+) o’clock, rubeosis iridis (+)
Pupil Round, midmidri ec SA1%, PR - Round, midmidri ec SA1%, PR -
Lens IOL on place IOL on place
IOP 12 mmHg 30 mmHg
Funduscopy • RF + dim • RF + dim
• Media : Opacity gr III ec edema • Media : Opacity gr III ec edema
cornea + vitreous opacity. cornea + vitreous opacity.
• Detail dte • Detail dte
 Left Eye (July, 21-22th 2018)
Visual Acuity 20/100 ph 20/30

Eyelid spasm (-) edema (-)

Conjunctiva CI (-) PCI (-)

Cornea Clear
AC VH IV
Iris Radline
Pupil Round, ø 3 mm, PR +
Lens IOL On Place
IOP 12 mmHg
Funduscopy • FR : +
• Media : clear
• ONH : round, sharp margin, c/d 0.3,
orange, LC -, Bay -, Nas -, nvd -
• Vasa : a/v 1/3 ; cross+, scle +, m.a +
• Retina : exu + haem + (dot blot)
• Macula : RF -, exu (+)
 21 Jul 2018
Assessment •RE secondary glaucoma ec
neovascular ec susp PDR post
trabeculectomy day 1
+ pseudophakia + vitreous opacity dt
vitreous hemorrhage dt susp PDR
(USG)
•LE severe NPDR + CSME + HT
Retinopathy KW III+pseudophakia
Planning •Vigamox e.d 6x1 drop RE
•Vosama e.d. 6x1 drop RE
•Ciprofloxacin tab 2x500 mg (P.O)
•Methylprednisolone tab 3x8 mg (P.O)
•Mefenamic acid tab 3x500 mg (P.O)
•Ranitidine tab 2x 150 mg (P.O)
•Vitreoretina subdivision:
•RE Vitrectomy / GA (outpatient clinic)
•LE Grid Laser / LA (outpatient clinic)
•Blood sugar & Blood pressure
regulation ≈ internal medicine dept
22 Jul 2018
•RE secondary glaucoma ec
neovascular ec susp PDR post
trabeculectomy day 2
+ pseudophakia + vitreous opacity dt
vitreous hemorrhage dt susp PDR
(USG)
•LE severe NPDR + CSME + HT
Retinopathy KW III+pseudophakia
•Vigamox e.d 6x1 drop RE
•Vosama e.d. 6x1 drop RE
•Timol 0.5 % ed 2x1 RE
•Azopt ed 3x1 RE
•Ciprofloxacin tab 2x500 mg (P.O)
•Methylprednisolone tab 3x8 mg (P.O)
•Mefenamic acid tab 3x500 mg (P.O)
•Ranitidine tab 2x 150 mg (P.O)
•Patient discharged
•Vitreoretina subdivision:
•RE Vitrectomy / GA (outpatient clinic)
•LE Grid Laser / LA (outpatient clinic)
•Blood sugar & Blood pressure
regulation ≈ internal medicine dept
BEFORE

AFTER
 Follow up at
oupatient clinic
July, 24th 2018
Right Eye Left Eye
1/300 Visual Acuity 6/24 ph 6/7.5
spasm (-) edema (-) Eyelid spasm (-) edema (-)
CI (-) PCI (-), SCH (+) ↓, suture +, Conjunctiva CI (-) PCI (-)
covered by conjunctiva, bleb flat
edema (+) min, fl test (-) Cornea Clear
VH III, flare cell gr II, coagulum (+) Anterior Chamber VH IV
Radline, artificial coloboma @ 1 Iris Radline
o’clock, rubeosis iridis (+)
Round, midmidri ec SA1%, PR - Pupil Round, ø 3 mm, PR +
IOL On Place Lens IOL On Place
48 mmHg IOP 12 mmHg
 Right Eye Left Eye

• FR : + dim
• Media: Opacity gr III ec edema
cornea + vitreous opacity.
• Detail dte
Funduscopy • FR : +
• Media : clear
• ONH : round, sharp margin, c/d
0.3, orange, LC -, Bay -, Nas -,
nvd -
• Vasa : a/v 1/3 ; cross+, scle +,
m.a.+
• Retina : exu + haem +
• Macula : RF -, exu +
Assessment :
• RE secondary glaucoma dt neovascular dt susp PDR post
trabeculectomy day 4+ pseudophakia + vitreous opacity dt
vitreous hemorrhage dt susp PDR (USG)
• LE Severe NPDR + CSME + HT Retinopathy KW
III+pseudophakia
Planning :
• RE Aff suture/ LA
• Vigamox e.d 6x1 drop RE
• Vosama e.d. 6x1 drop RE
• Timolol 0.5 % ed 2x1 RE → Stop
• Azopt ed 3x1 RE → Stop
• Ciprofloxacin tab 2x500 mg (P.O)
• Methylprednisolone tab 3x8 mg (P.O)
• Mefenamic acid tab 3x500 mg (P.O)
• Ranitidine tab 2x 150 mg (P.O)
 RE Aff Suture / LA
Performed July 24th, 2018
 Diff :-
 Compl :-

Post Op Treatment :
◦ Vigamox e.d 6x1 drop RE
◦ Vosama e.d. 6x1 drop RE
◦ Timolol 0.5 % ed 2x1 RE → Stop
◦ Azopt ed 3x1 RE → Stop
◦ Ciprofloxacin tab 2x500 mg (P.O)
◦ Methylprednisolone tab 3x8 mg (P.O)
◦ Mefenamic acid tab 3x500 mg (P.O)
◦ Ranitidine tab 2x 150 mg (P.O)
 Follow up at
outpatient clinic
July, 27th 2018
Right Eye Left Eye
1/300 Visual Acuity 6/24 ph 6/7.5
spasm (-) edema (-) Eyelid spasm (-) edema (-)
CI (-) PCI (-), SCH (+) ↓, suture +, Conjunctiva CI (-) PCI (-)
covered by conjunctiva, bleb
slightly elevated, siedl test -
edema (+) min, fl test (-) Cornea Clear
VH II @temporal, VH III, flare cell Anterior Chamber VH IV
gr II, coagulum (+)
Radline, artificial coloboma @ 1 Iris Radline
o’clock, rubeosis iridis (+)
Round, midmidri ec SA1%, PR - Pupil Round, ø 3 mm, PR +
IOL On Place Lens IOL On Place
6 mmHg IOP 12 mmHg
 Right Eye Left Eye

• FR : + dim
• Media: Opacity gr III ec edema
cornea + vitreous opacity.
• Detail dte
Funduscopy • FR : +
• Media : clear
• ONH : round, sharp margin, c/d
0.3, orange, LC -, Bay -, Nas -,
nvd -
• Vasa : a/v 1/3 ; cross+, scle +,
m.a.+
• Retina : exu + haem +
• Macula : RF -, exu +
Assessment :
• RE secondary glaucoma ec neovascular ec susp PDR
post trabeculectomy day 7+ pseudophakia + vitreous
opacity dt vitreous hemorrhage dt susp PDR (USG)
• LE severe NPDR + CSME + HT Retinopathy KW
III+pseudophakia
Planning :
• Vigamox e.d 6x1 drop RE
• Vosama e.d. 6x1 drop RE
• Timolol 0.5 % ed 2x1 RE → Stop
• Azopt ed 3x1 RE → Stop
• Ciprofloxacin tab 2x500 mg (P.O)  stop
• Methylprednisolone tab 3x8 mg (P.O)  stop
• Mefenamic acid tab 3x500 mg (P.O)  stop
• Ranitidine tab 2x 150 mg (P.O)  stop