DUTY REPORT

Monday, September 9th 2019

Ophthalmologist : dr. Wisnu Sadasih, Sp.M
Senior Resident : dr. Rigan
Junior Resident : dr. Prianka
IDENTITY
• Name : Mr. W
• Age : 29 y.o
• Address : Cepu
• MR : C775302
Chief Complaint : Pain in the left eye

Recent medical history :

• ± 4 hours before admission, the patient was nailing the wall and the
nail bounce off, tearing patient’s left eye. He felt discomfort in his left.
Pain (+), redness (+), blurry vision (+), lacrimation (+), there was a
black-brown substance coming out from his left eye (+), jelly-like
substance (-).
• History of diabetes (-), hypertension (-), trauma (-), spectacles usage
(-), allergy (-), asthma (-), past operation (-), heart disease (-), kidney
disease (-)
 RE LE
Visual Acuity 6/6 1/60
IOP Tdig N Was not performed
Palpebra Edema (-), spasm (-) Edema (-), spasm (-)
Conjunctiva Conjunctival injection (-) Mixed injection (+)
Cornea Clear (+) Laceration (+) full-thickness ± 5mm from
6 o’clock direction to the central cornea
Anterior Chamber VH grade III-IV Shallow depth
Iris Crypt (+) Iris prolapse (+)
Pupil Round, central, regular, Ø 3 mm, pupillary Irregular, Ø 5 mm, decreased pupillary reflex
reflex (+) normal (+)
Lens Clear (+) Clear (+)
Corpus Vitreum Clear (+) Cannot be evaluated
Fundus Reflex Bright (+) Decreased fundus reflex (+)
Funduscopy Within normal limit Was not performed
 Left Eye

Iris prolapse (+). Fluorescein test was not performed.

 Left Eye

LE Ultrasonography. We didn’t find point-like lesion, membrane-like

lesion, or mass-like lesion. We use the floating-technique
ultrasonography to acquire this printout
• Working diagnosis :
LE Full-Thickness Corneal Laceration + Iris Prolapse

• Management :
• Hospitalized the patient
• Pro LE Corneal Sutures + Iris Reposition with General Anesthesia
• Check routine hematoanalyzer, ureum, creatinine, PPT, PTTK, HbsAg, blood
sugar level, and electrolytes
• Consult anesthesia + internal medicine department for cito surgery
• Vigamox ED / 1-hour LE
• ATS injection
• Viccilin (Ampicillin-Sulbactam) injection 3x1 (1500 mg)
• Methylprednisolone injection 2x125 mg
• Ranitidine injection 2x1
 Left Eye

Pre-operation on the operating table.

 Left Eye

Durante-operation on the operating table.

 Left Eye

Post-operation on the operating table.

POST-OPERATION 1st DAY
 RE LE
Visual Acuity 6/6 ½ /60
IOP Tdig N Tdig N (gently)
Palpebra Edema (-), spasm (-) Edema (-), spasm (-)
Conjunctiva Conjunctival injection (-) Mixed injection (+), subconjunctival bleeding (+)
Sclera Injection (-) 4 closed-stitches (+) at 6 o’clock direction
Cornea Clear (+) 5 closed-stitches (+) at 6 o’clock direction,
1 closed-stitch (+) at 11 o’clock direction
Anterior Chamber VH grade III-IV Shallow depth, there was an air-bubble filling 1/3
of superior anterior chamber
Iris Crypt (+) Crypt (+), atrophy (-)
Pupil Round, central, regular, Ø 3 mm, pupillary reflex Irregular, Ø 5 mm, decreased pupillary reflex (+)
(+) normal
Lens Clear (+) Clouded (+) not distributed evenly
Corpus Vitreum Clear (+) Cannot be evaluated
Fundus Reflex Bright (+) Decreased fundus reflex (+)
Funduscopy Within normal limit Was not performed
 Left Eye

Post-Operation 1st Day

• Working diagnosis :
LE Post Corneal Sutures + Scleral Sutures + Iris Reposition 1st Day on indication
LE Full-Thickness Corneal Laceration + Iris Prolapse

• Management :
• Vigamox ED / 1-hour LE
• Sulfas Atropine 1% ED / 8-hour LE
• P-Pred ED / 4-hour LE
• Eyefresh Plus ED / 4-hour LE
• Methylprednisolone 16mg tablet 2-0-1
• Ranitidine tablet 2x1
• Levofloxacin 500mg tablet 1x1
• Glaucon-KCl tablet 1x125mg
IDENTITY
• Name : Mr. M
• Age : 20 y.o
• Address : Semarang
• MR : C775308
Chief complaint : Pain in both eyes

Recent medical history :

• ± 12 hours before admission, the patient was welding irons, did not wear
protective goggles, and unfortunately both of his eyes were struck by weld
sparks. He immediately bought Insto ED, dripped it to both of his eyes and
he said that it felt much better.
• ± 9 hours later, the patient complains that both of his eyes were very painful
to the point he unable to even keep his eyes open. Redness (+), lacrimation
(+), blurry vision (+), and the patient said that something was up in his
eyelids. Then, the patient was brought to Kariadi Hospital.
• History of diabetes (-), hypertension (-), trauma (-), spectacles usage (-),
allergy (-), asthma (-), past operation (-), heart disease (-), kidney disease (-)
 W RE LE
Visual Acuity 6/6 6/6
IOP Tdig N Tdig N
Palpebra Edema (-), spasm (-), there was a gram in Edema (-), spasm (-), there were grams in the
the upper eyelid upper and lower eyelid
Conjunctiva Mixed injection (-) Mixed injection (+)
Cornea Punctate defect (+) at paracentral-inferior Punctate defect (+) evenly distributed
region throughout the corneal surface
Anterior Chamber VH grade III VH grade III
Iris Crypt (+) Crypt (+)
Pupil Round, central, regular, Ø 3 mm, pupillary Round, central, regular, Ø 3 mm, pupillary
reflex (+) normal reflex (+) normal
Lens Clear (+) Clear (+)
Corpus Vitreum Clear (+) Clear (+)
Fundus Reflex Bright (+) Bright (+)
Funduscopy Within normal limit Within normal limit
 Right and Left Eye

Right Eye Left Eye

• Working diagnosis :
RE LE Keratitis et causa Conjunctival Corpus Alienum
• Management :
• NaCl irrigation on both eyes, with and without eyelids everted
• Levofloxacin ED / 2-hour RE LE
• Paracetamol 500mg tablet 3x1
• Vitamin C tablet 1x1
• Advise the patient to control to Merpati Eye Clinic on 11th September 2019
THANK YOU