OPHTALMOLOGY RECORD

PTERIGYUM

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

Observer:
Meylani Bith S.Ked
0961050125

DEPARTMENT OF EYE DISEASE

PERIOD 5 OCTOBER 7 NOVEMBER 2015
MEDICAL FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA
J AK AR TA
2015

OPHTHALMOLOGY RECORD

Name of Examiner

: Meylani Bith

NIM

: 0961050125

Date of Examination : November 3rd, 2015

Tutor

I.

II.

: Dr. Gilbert W.S Simanjuntak, SpM

PATIENT IDENTITY
Name

: Mrs. A

Sex

: Female

Age

: 49 years old

Education

: Senior High School

Occupation

: Housewife

Religion

: Christian

Address

: Cilitan RT 04 RW 04, East Jakarta .

Status

: Married

ANAMNESIS (Autoanamnesis, October 29th, 2015)

Main complaint

: Redness in her right eye since one week ago, patient also feels

theres white spot in the center of her right eye.

Additional complaint

: Itchy and watery eyes.

1

History of Disease
Patient came to UKI Hospital with main complaints redness in her right eye and feels
theres a white spot in the center of her right eye since one week ago. Patient actually has
already felt this white since two years ago, First she felt this white spot in the corner of her
right eye, but know she feels the white spot spreading to the center of her right eye. Patient
also complained of itchy eyes and more frequent watering at the eyes. Patient admitted, her
sight is still good and there is no vision problems at all. Patient doesnt feel any pain in her
eyes . Discharge of the eyes denied. Patients not using glasses or contact lenses.
Patient has been treated to the doctor's four months ago and was given eye drops
"Cendo Lyteers" used with a dose of 4 x 2 drops a day, but now shes not taking the eye
drops anymore.

Previous Disease History

Patient never had a complaint like this before. A history of food allergies and
medications allergies denied. History of hypertension, diabetes mellitus, cholesterol denied.
A history of trauma to the eye and a history of long-term drug use denied.

Family Disease History

There is no family history like her symptoms.

Personal Habit
The patient denied the using of contact lenses, smoke, and consume alcohol.

III.

IV.

GENERAL STATUS
General condition

: Mild appearance of illness

Consciousness

: Compos mentis

OPHTHALMIC STATUS
1. General Examination
General Examination

Right Eye

Left Eye

(Inspection and Palpation)

Periocular appearance
General condition of the

Quiet

Quiet

Unwell

Normal

Symmetric

Symmetric

Normal

Normal

Wide

Wide

eye
Eyeball position
Eyeball movement
Visual field

2. Systematic Examination

Right Eye

Left Eye

Visual acuity

Before correction

Correction

After correction

Supercilia

Cilia

Palpebrae
superior/inferior

Margo palpebrae
superior/inferior

6/6

6/9 pinhole 6/6

Normal,

Normal,

madarosis (-)

madarosis (-).

Normal,

Normal,

madarosis (-),

madarosis (-),

trichiasis (-).

trichiasis (-).

Edema (-),

Edema (-),

tumor (-),

tumor (-),

hordeolum (-),

hordeolum (-),

chalazion (-),

chalazion (-),

ptosis (-),

ptosis (-),

tenderness (-).

tenderness (-).

Tumor (-),

Tumor (-),

ptosis (-),

ptosis (-),

ectropion (-),

ectropion (-),

entropion (-).

entropion (-).

Tarsal conjunctiva sup/inf

Bulbar conjunctiva

Smooth surface,

Smooth surface,

bleeding (-),

bleeding (-),

hyperemic (-),

hyperemic (-),

cicatrical (-),

cicatrical (-),

secretion (-),

secretion (-),

papilar (-),

papilar (-),

follicle (-).

follicle (-).

Bleeding (-),

Bleeding (-),

ciliary injection (+),

ciliary injection (-),

cicatrical (-),

cicatrical (-),

secretion (-),

secretion (-),

pinguecula (-),

pinguecula (-),

pterygium that arise from

pterygium (-).

the medial canthus to

cornea past the corneal
limbus (+).
Fornix conjunctiva

Hyperemic (-)

Hyperemic (-)

Clear

Clear

infiltrate (-), ulcus (-),

infiltrate (-), ulcus

cicatrical (-), arch senile

(-), cicatrical (-),

(-).

arch senile (-).

Cornea

Sclera

Anterior chamber

Colour: white,

Colour: white,

bleeding (-),

bleeding (-),

cicatrical (-).

cicatrical (-).

Deep, clear, hypopion

Deep, clear,

(-), hyphema (-).

hypopion (-),
hyphema (-).

Iris

Pupil

Lens

V.

Radier,

Radier,

Colour: brown,

Colour: brown,

atrophy (-),

atrophy (-),

sinekia (-).
Round, isochor,

sinekia (-).
Round, isochor, 3

3 mm,

mm,

direct light reflex (+),

Direct light reflex

non direct light reflex

(+), non direct light

(+).

reflex (+).

Clear,

Clear,

shadow test (-).

shadow test (-).

RESUME
Mrs. A ,49 years old, came to UKI Hospital with main complaints redness in her right
eye and feels theres a white spot in the center of her right eye since one week ago. Patient
actually has already felt this white since two years ago, First she felt this white spot in the
corner of her right eye, but know she feels the white spot spreading to the center of her right
eye. Patient also complained of itchy eyes and more frequent watering at the eyes. Patient
admitted, her sight is still good and there is no vision problems at all. Patient doesnt feel

any pain in her eyes . Discharge of the eyes denied. Patients not using glasses or contact
lenses.
Patient has been treated to the doctor's four months ago and was given eye drops
"Cendo Lyteers" used with a dose of 4 x 2 drops a day, but now shes not taking the eye
drops anymore.

GENERAL STATUS
General condition

: Mild appearance of illness

Consciousness

: Compos mentis

Ophthalmological examination, in the right and left eyes :

Right Eye

Left Eye

Visual acuity

Before correction

Correction

After correction

Palpebrae

6/6

6/9 pinhole 6/6

Normal

Normal

Normal

Normal

Normal

Normal

Ciliary injection &

Quiet

superior/inferior
Margo palpebrae
superior/inferior
Tarsal conjunctiva sup/inf
Bulbar conjunctiva

Injeksi silier & there is

pterygium extends from
the medial canthus to
the corneal limbus.

Fornix conjunctiva sup/inf

Cornea

Sclera
Anterior chamber
Iris
Pupil

Lens

Normal

Normal

Clear

Clear

Colour: white
Colour: white
Deep & clear
Deep & clear
Radier, colour: brown Radier, colour: brown
Round, isochor,

Round, isochor,

3 mm,

3 mm,

direct light reflex (+),

direct light reflex (+),

non direct light reflex

non direct light reflex

(+).
Clear,

(+).
Clear,

shadow test (-).

VI.

VII.

VIII.

shadow test (-).

CLINICAL DIAGNOSE
Pterygium Grade III OD

DIFFERENTIAL DIAGNOSE

Pseudopterygium

Pinguecula

MEDICAL TREATMENT

Pre operation: Pantocaine eye drops (as the topical anesthesia).

Operation: combination techniques of excision the lesion with a Bare Sclera

techniques and Autograft conjunctival.
8

Post operation:
o Avoid the exposure of the smoke and dust in the eyes.
o Use a hat or a cap to avoid the direct exposure of ultraviolet rays into the eye.
o Use sunglasses to protect the eyes from ultraviolet rays.
o Control to the doctor after surgery.

IX.

RECOMMENDED EXAMINATION

X.

Corneal topography

PROGNOSIS

Ad Vitam

XI.

Right Eye
Bonam

Left Eye
Bonam

Ad Sanationum

Dubia ad Malam

Bonam

Ad Functionum

Dubia ad Malam

Bonam

COMPLICATION

Infection

Astigmatism

Corneal scar