OPTHALMIC RECORD

Tutor:
Dr. Gilbert W.S. Simanjuntak SpM
Examiner:
Anastasia Anggita Saraswati
1161050064

DEPARTMENT OF OPHTHALMOLOGIC
FACULTY OF MEDICINE
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA 2013

OPHTHALMIC RECORD
Name of Examiner

: Anastasia Anggita Saraswati

NIM

: 1161050064

Date of examination

: August , 2015

Tutor

: dr Gilbert W.S. Simanjuntak SpM

PATIENT IDENTITY
Name

: Mrs. Tianur Simanjuntak

Age

: 52 years old

Address

: Jl. Cempaka V No. 28, East Jakarta

Occupation

: Home stayed mom

Religion

: Christian

I. ANAMNESIS (August 19th , 2015)

Main complaint
Blurry vision in both eyes
Additional complaint
Glare
History of disease
Patient came to hospital with main complaint blurry vision in both eyes since
1 year ago. The right eye feels more blurry than the left eye. This complaint
was continously and getting worse in near dan far sight seeing. The problem
start as a foggy vision that eventually growing and caused blurred vision.
Complaints of itchy, red eyes and secrete discharge

denied. Patient use

glasses to correct near sight vision but cant remember the size of her glasses.

Previous disease
The patient said that she never had this situation before.The presence of
diabetes or high blood pressure is denied. History of physical trauma, history
of using long-term drug, allergies and history of contact lenses used are
denied.
II.

GENERAL STATUS
General condition

: illness

Symptom or illness related to the complaint : None

III.

OPHTHALMIC STATUS
A. General Examination
Periocular appearance
General condition of the eye
Eyeball position
Eyeball movement

Right Eye
Quiet
Normal
Symmetric
Normal

Left Eye
Quiet
Normal
Symmetric
Normal

B. Systematic Examination
Right Eye

Left Eye

Visual acuity

1/60

2/60

Correction

Super cilia

Normal,
Madarosis (-)

Normal,
Madarosis (-)

Cilia

Normal,
Madarosis (-), Trichiasis (-)

Normal,
Madarosis (-), Trichiasis (-)

Margo Palpebra superior

Edema (-), tenderness (-),

ectropion (-), entropion
(-), ulcus (-), crusting (-)
Edema (-), tenderness (-),
ectropion (-), entropion
(-), ulcus (-), crusting (-)

Edema (-), tenderness (-),

ectropion (-), entropion
(-), ulcus (-), crusting (-)
Edema (-), tenderness (-),
ectropion (-), entropion
(-), ulcus (-), crusting (-)

Tarsal conjunctiva superior

Hyperemic (-), Papilar (-),

Follicle (-), Bleeding (-)

Hyperemic (-), Papilar (-),

Follicle (-), Bleeding (-)

Tarsal conjuntiva inferior

Hyperemic (-), Papilar (-),

Follicle (-), Bleeding (-)

Hyperemic (-), Papilar (-),

Follicle (-), Bleeding (-)

Bulbar conjunctiva

Conjunctiva injection (-), Conjunctiva injection (+),

Margo Palpebra inferior

pinguekula (-), pterigium

(-), secretion (-)
Clear
Infiltrate (-) Ulcus (-)
Arch senile (-)
Normal in depth,
Bleeding (-), hyphema(-)

pinguekula (-), pterigium

(-), secretion (-)
Clear
Infiltrat (-) Ulkus (-)
Arch senile (-)
Normal in depth,
Bleeding (-),hyphema(-)

Iris

Radier
Colour : Brown

Radier
Colour : Brown

Pupil

Round, isochor
3mm
Light Reflexs : (+)
Clear
Shadow test (-)

Round, isochor
3mm
Light Reflexs : (+)
Turbid
Shadow test (-)

Cornea
Anterior chamber

Lens

IV.

RESUME
A 52 years old female came to hospital with main complaint. blurry vision in
both eyes. The right eye feels more blurry than the left eye. This complaint
was continously and getting worse in near dan far sight seeing. The problem
start as a foggy vision that eventually growing and caused blurred vision.
Complaints of itchy, red eyes and secrete discharge

denied. Patient use

glasses to correct near sight vision but cant remember the size of her glasses

History of physical trauma denied, history of using long-term drug denied,

allergies and history of contact lenses used denied.

Ophthalmic Examination
Right Eye

Left Eye

1/60

2/60

Palpebra

Normal

Normal

Tarsal
conjunctiva
superior

Normal

Normal

Bulbar conjunctiva

Normal

Normal

Cornea

Clear

Clear

Anterior Chamber

Normal in depth

Normal in depth

Iris

Radier

Radier

Pupil

Round, light reactive (+)

Round, light reactive (+)

Lens

Clear

Turbid

Visual acuity
Margo
superior

V.

CLINICAL DIAGNOSE

Right Eye

Left Eye

Mature Cataract

Mature cataract

VI.

Differential Diagnose

Right Eye

Left Eye

Immature Cataract

Immature Cataract

VII.

TREATMENT

Warm compresses 3-4 times daily for 10-15 minutes.

Topical antibiotic ointment.
Surgery : incision

VIII. SPECIFIC EXAMINATION

There is no specific examination for this case.
IX. PROGNOSIS

Ad vitam
Ad sanationum
Ad functionum
X.

MEDICAL

Right Eye

Left Eye

Bonam
Bonam
Bonam

Bonam
Dubia ad bonam
Bonam

COMPLICATIONS
Secondary Glaucoma