CHAPTER III

CASE REPORT
A. Patient Identity
Name
: Ny. Salamah
Sex
: Female
Age
: 42 years old
Address : Dusun Fajar Karya RT 004/RW 003, Desa Kubu, Kecamatan Kubu
Ethnic
: Melayu
Job
: Farmer
Religion : Islam
Patient was examined on May 15th, 2012.

B. Anamnesis

Main complaint: lost eyesight in right eye.

History of disease
:
Patient complained loss of eyesight on ocular dextra after it has penetrated by branch
of mangrove tree on April 24th 2012 at 11.00 am. She could not see anything and
differentiated between light and dark with her right eye. A few hours after that
accident, patient came to primary health service in her district. Patient confessed that,
in primary health service, her right eye was cleaned with water and gave white
powder, and then, it was covered by bandage. After 2 days, patient complained that she
felt her right eye become swollen. So, she came again to primary health service, and
she got a similiar treatment like she have gotten before.
After a few days, patient decided to open the bandage and clean her right eye everyday
because she thought theres no healing improvement on her right eye.
On May 15th 2012, patient come to RSUD dr Soedarso, and she complained that she
couldnt see anymore with her right eye. She felt just a little of pain her right eye and
did not felt any headache. She also complain a little bit itchy on palpebra dextra and

there are some purulent discharge on her right eye.

Past clinical history:
Patient claims that there is no history of the same symptoms before. History of using
contact lens (-), history of using another topical drugs (-) history of using
kortikosteroid (-) history of skin disease/lessions such as varicella, vesicular rash (-)
history of fever more than 3 days (-), history of systemic disease such as DM,

immunocompromised disease (-), history of neuronal disease (-).

Family history : There are no one of his family have the same complain with her.

C. General Physical Assessment

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General condition

: Good

Awareness

: Compos mentis

Vital Signs
Heart Rate

: 80 x/minute

Respiration freq.

: 24 x/minute

Blood Pressure

: 140/80 mmHg

Temperature

: 37,2oC

D. Ophthalmological status
Visual acuity:

OD
OS

:0
: 6/6

Right eye
Ortho

Eye ball position

Ocular Dextra
Negatif, only a little
Eye ball movement
horizontal movement.
ptosis (-), lagoftalmos
(-), edema (+)
Redness (+)
(subconjunctival
hemmorage),
discharge (+),
Oedem (+), Ulcer (+),
perforation (+)
Unclear, become
shallow, hypopion (+)

Palpebra

Conjungtiva

Cornea
COA

Left eye
Ortho
Ocular Sinistra
Can move to eight
directions of eye
movement examination
ptosis (-), lagoftalmos (-),
edema(-)
Redness (-), discharge (-) ,
fibrovascular growth (-)
Clear, edema (-), ulcer (-),
infiltrate (-)
clear, deep
Iris colour : brown

Unclear

Iris and pupil

Pupil: circular, 3mm,

isokor, reactive to light
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Can not be observed

Can not be observed

Lens
Vitreous

Can not be observed

Fundus

Clear
Clear
Fundus Reflex (+)Normal
papil with demarcated
edge, C/D ratio 0,4
(aproximately)

Visual field test (confrontation) : Normal (just OS have examined)

Corneal Sensibility test

Eye ball movement

: Positive (just OS have examined)

OS

OD
-

+
+

+
+

+
+

E. Resume
Patient complained loss of eyesight on ocular dextra after it has penetrated by branch
of mangrove tree on April 24th 2012 at 11.00 am. Patient confessed that there were just
a little blood with a painful on her right eye. She could not see anything and
differentiated between light and dark with her right eye. A few hours after that
accident, patient came to primary health service in her district. Patient confessed that,
in primary health service, her right eye was cleaned with water and gave white
powder, and then, it was covered by bandage. On May 15 th 2012, patient come to
RSUD dr Soedarso, and she complained that she cant see by her right eye anymore.
She felt just a little of pain and itchy on her right eye and did not felt any headache.
And there are some purulent discharge on her right eye
She and her family have not any same of symptoms like she had before.
On examination, in general, she has a good condition in general physical assesment,
but she has a little high of blood pressure.
On eye examination, she has a normal visual acuity and normal condition on her left
eye. On the right eye, she has zero of visual acuity, no eye movement, palpebra
oedema, subconjunctival hemmorage, purulent discharge, corneal oedema, ulcer and

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perforation on right eyes cornea. Camera oculi anterior and vitreus body can not be
assessed.

F. Diagnose
Working Diagnose:

OD : Corneal Ulcer with perforation, Endophthalmitis

OS : Hypertension grade I

G. Examination
USG of Ocular Dextra
Supposition :
There are semi-compact dissemination
in vitreous body, suspecious : extensive
vitreous inflamation.

Corneal Smear (if possible)

Blood Laboratory examination (Complete Blood Test and Chemical Blood Test)
Rontgen Thorax PA

H. Treatment
-

Medicamentous

Per oral : Asam mefenamat 3 x 500 mg

Surgery : evisceration of eye ball OD

I. Prognosis
OD
Ad vitam

: malam

Ad functionam

: malam

Ad sanactionam : malam
OS
Ad vitam

: bonam

Ad functionam

: bonam
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Ad sanactionam : bonam

J. Follow Up
J.1 Pre-operation ( May, 22nd 2012)
General condition

: Good

Awareness

: Compos mentis

Vital Signs
Heart Rate

: 76 x/minute

Respiration freq.

: 24 x/minute

Blood Pressure

: 140/90 mmHg

Temperature

: 37 oC

Complain

: nause (-), vomitting (-), headache (-)

Patient start to fasting 6 hours before operation.

Laboratory examination result :
Hb

14,2 g/dl

Ht

42 %

WBC

10,3 K/ul

Platelet

562 K/ul

PGR
88 mg/dl
Bleeding time
2 minutes
Clotting time
7 minutes
Ureum
11 mg/dl
Creatinin
0,8 mg/dl
Radiology examination result :
Theres not any disorder that have been seen in thorax PA radiology.
J.2 Operation ( May, 23rd 2012)
Operator : dr. Muhammad Iqbal, Sp.M, M. Kes.
Assitant operator : Yenni, AMK
Operations start at 14.00 WIB
Patient slept with supine position by general anesthesia
In pre-evisceration, operator found foreign body (branch of plant) with 1
centimeter length and diameter 1 milimeter that still sticked in cornea, trichiasis,

and symblepharon of occular dextra.

Operator pulled out the foreign body
Operator did evisceration and operation finish at 14.45 WIB
As long as operation, patient was in good general condition.

J.3 Post Operation ( May, 24th 2012)

Patient was examined at 13.30 WIB
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General condition

: Good

Awareness

: Compos mentis

Vital Signs
Heart Rate

: 76 x/minute

Respiration freq.

: 20 x/minute

Blood Pressure

: 120/80 mmHg

Temperature

: 37,0oC

Right eye of patient still bandaged, and have been cleaned in the morning.
Complaint

: nause (+), vomitting (+), headache (+), pain (-), itchy (+)

Actual Treatment

: RL 20 drops per minute; Cefotaxim iv 2x1; Ketorolac 2x1;

Ranitidin 2x1; gentamycin 6x1.

J.4 Post Operation ( May, 25th 2012)

Patient was examined at 10.30 WIB
General condition

: Good

Awareness

: Compos mentis

Vital Signs
Heart Rate

: 84 x/minute

Respiration freq.

: 20 x/minute

Blood Pressure

: 110/70 mmHg

Temperature

: afebril

Right eye of patient still bandaged, and it openned to examine the ocular dextra.

Finding points in exmn.: hard to open eyelid, blepharospasme, conjungtiva redness (+),
theres protruding of conjungtiva in medial cantus, suture path
horizontally layed in central 1,5 centimeters length.
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Complaint

: nause (-), vomitting (-), headache (-), pain (-), itchy (+), hard
to open the eyelid

Actual Treatment

: RL 20 drops per minute; Cefotaxim iv 2x1; Ketorolac 2x1;

Ranitidin 2x1; gentamycin 2x1.

Patient went home at 15.00 pm

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