Weekly Report

Pediatric Ophtalmology and

Strabismus Subdivision
PUR/DCA/ASA/DES/FIT

Ch. N/4 m.o

Adm, January 17th 2017
Chief complain : Whitish on his both eyes
Whitish on his both eyes was noticed by parents since 2
months ago, gradually getting thicker. Redness (-), pain (-),
tearing (-), wearing spectacle (-).
History of surgery (-)
History of past illness : (-)
History of trauma : (-)
History of birth : normal, 32 week, 1900 gram
Antenatal care : routinely controlled by midwife, leukorea (+),
fever (+), common cold (-) they have a pet(+)

Pedigree

4 m.o

General Condition
RBS : 121 mg/dL
IgM anti rubella (+): 3,40
IgG anti rubella: 32,77

Right Eye
Blink refleks seems (+)

Summary
of
Data Base
Visual Acuity

Left Eye

Blink refleks seems (+)

Globe Position
Orthophoria

Spasm -, Edema CI (-) , PCI (-)

Clear, Nystagmus (-) 8 mm
Deep
Radline
Round, 3 mm, PR(+)
Homogen opacity @ central
n/p

Eyelid
Conjungtiva
Cornea

Spasm (-), Edema (-)

CI (-), PCI (-)
Clear, Nystagmus (-) 8 mm

Anterior Chamber Deep

Iris
Radline
Pupil
Lens
IOP

Round, 3 mm, PR(+)

Homogen Opacity @ central
n/p

Right Eye
FR (-) , detail dte

Funduscopy

Left Eye
FR (-), detail dte

Right Eye

Left Eye
Posterior capsule: intact
RE USG

Posterior capsule: intact

Anterior vitreous: echodense (-)
Media-post vitreous : echodense (-)
Optic nerve head: on place
Retina : on place
Choroid : on place

USG

Anterior vitreous: echodense (-)

Media-post vitreous : echodense (-)
Optic nerve head: on place
Posterior capsule: intact
Retina : on place
Anterior
vitreous:
echodense (-)
Choroid
: on place
Media-post vitreous : echodense (-)

Optic nerve head: on place

Retina : on place

Choroid : on place

RO THORAX

WNL

LABORATORY FINDINGS
Result

Normal Value

Hemoglobin

12.90 g/dL

11.4-15.1

Eritrocyte

4.75x106 /L

4.0-5.0

Leucocyte

11.99 x103 /L

4.7-11.3

Hematocrite

38.10 %

38-42

Trombocyte

499 x103 /L

142-424

Hemostasis Function
-PPT
-APTT

11.10 second (10.9 second)

32.60 second (26.1 second)

9.3-11.4
24.5-32.8

Hepar Function
-SGOT
-SGPT

52 U/L
34 U/L

0-32
0-33

RBG

121 mg/dL

<200

Renal Function
-Ureum
-Creatinine

11.60 mg/dL
0.23 mg/dL

16.6-48.5
<1.2

Electrolyte serum
-Natrium
-Kalium
-Clorida

136 mmol/L
5.21 mmol/L
107 mmol/L

136-145
3.5-5.0
98-106

LABORATORY FINDINGS
Result

Normal Value

Anti Toxoplasma IgM

Neg: <0.8 COI

Intermediate: 0.8-<1.0 COI
Positive: 1.0

Anti Toxoplasma IgG

Neg: <1 IU/ml

Intermediate: 1-<3 IU/ml
Positive: 3 IU/ml

Anti CMV IgM

Neg: <0.7 COI

Intermediate: 0.7-<1.0 COI
Positive: 1.0

Anti CMV IgG

Neg: <0.5 IU/ml

Intermediate: 0.5-<1.0 IU/ml
Positive: 1 IU/ml

Anti Rubella IgM

3.40

Neg: <0.8 COI

Intermediate: 0.8-<1.0 COI
Positive: 1.0

Anti Rubella IgG

32.77

Neg: <10 IU/ml

Positive: 10 IU/ml

Diagnosis
RLE Congenital Cataract dt. Rubella Syndrome

Treatment

Hospitalized
Education and information about the disease and risk
Education and information about the planning therapy
Pro RLE ECCE / GA

Treatment
RLE ECCE /GA
Performed January, 18th 2017
Diff
: Compl : -

Post Op Treatment :
Cefadroxyl Syr 2 x cth 1/2 po
Proris Syr 3 x Cth 1/2 po
Metylprednisolone 3 x 2 mg po
Vigamox e.d 6 x1 RLE
Vosama e.d 6 x 1 RLE

Follow Up
Day 1
Right Eye
Blink refleks (+)
Spasm -, Edema
CI (-) , PCI (-), SCH (+)
Clear, suture (+) 3, tight good app
Deep
Radline, coloboma dte
round, PR (+) 3 mm, PR (+)
afakia
n/p
FR (+) dim, detail dte

Left Eye
Visual Acuity
Globe Position
Eyelid
Conjungtiva
Cornea

Blink refleks (+)

Spasm (-), Edema (-)
CI (-), PCI (-), SCH (+)
Clear, suture (+) 3, tight good app

Anterior Chamber Deep

Iris
Radline, coloboma dte
Pupil
Lens
IOP
Funduscopy

round, 3mm, PR (+)

afakia
n/p
FR (+) dim, detail dte

DIAGNOSIS
DAY 1
January, 19th 2017

RLE Afakia post ECCE day I dt. Congenital Cataract dt.

Rubella Syndrome

TREATMENT
Cefadroxyl Syr 2 x cth 1/2 po
Proris Syr 3 x Cth 1/2 po
Metylprednisolone 3 x 2 mg po
Vigamox e.d 6 x1 RLE
Vosama e.d 6 x 1 RLE
Patient Discharge

 Before

After