COMMUNITY EYE HEALTH CENTER

APRIL 27th, 2019

MORNING REPORT
DEPARTEMENT OF OPHTHALMOLOGY
A CORNEAL FOREIGN BODY

2
 PATIENT IDENTITY

Name : Mr. AM
Sex : Male
Age : 46 y.o
Address : Jl.Muh Jufri
Religion : Islam
Ethnic / Nation : Makassar / Indonesia
Occupation : Operator
Medical Record : 13 – 27 – 95
Date of Examination : 22th of April, 2019
HISTORY TAKING
Main Complaint : Painful red eye
Guaided Histroy :
An 46 years – old male patient visited to the Polyclinic of Opthalmologist in BKMM with painful red eye on
his right eye since 1 month ago. The patient said that the incident occurred when he was working without
wearing safety googles and a piece of grinding particles flying into his eyes. Initially, he claimed that his eye
was redness and ± 8 hours later it feels very painful. He has tried to remove it with water, and it’s not
working. Now, All of his complaints are getting severe.

Decreased vision (+) , excessive tearing (+), Photophobia (+), Foreign body sensation (+) especially when
he blinked his right eye. Other complaint such as itchy was denied. History of use glasses were denied.
History of Ocular Surgery was denied. History of the same disease (+) this incident has happened for the
ninth time.

History of Disease :
He didn’t have any history of Allergy
He didn’t have any history of Hypertension
He didn’t have any history of Diabetic

History Disease of Family : -

 OD Visus OS

EXAMINATION 20/30 Uncorrected visual acuity 20/25

OF
VISUAL ACUITY
- Correction -

- Best corrected visual acuity -

- Near visual acuity -

- Correction -

Best corrected near visual acuity

- -
 OD OS

Palpebral Oedema (-) Hyperemia (-), Oedema (-) Hyperemia (-), Crusta
Crusta (-) (-)
Cilia Scuama (-), Secret (-), Scuama (-), Secret (-), Madarosis
Madarosis (-) (-)
Lacrimal Lacrimation (+) Lacrimation (-)
ANTERIOR SEGMENT Apparatus
EXAMINATION Conjunctiva Hyperemia (+) Injectio Hyperemia (-), Injectio (-)
(+) mixed
Cornea Corpus alienum in Clear
cornea at 5 o’clock,
Rust ring (+)
Anterior Normal Depth Normal Depth
Chamber
Iris Brown, Crypt (+) Brown, Crypt (+)
Pupil Round, Central Round, Central
Direct / Inderct +/+ +/+
Light Reflex
RAPD - -

Lens Clear Clear

 EXAMINATION
OD OS
METHODS

PALPATION Tenderness (-) (-)

Tumor/Mass (-) (-)

Pre Auriculer gland Not palpable Not palpable

 EXAMINATION
OD OS
METHODS

INTRAOCULAR Palpation Tn Tn
PRESSURE
Non Contact
- -
Tonometry/ schiotz
PATIENT CLINICAL
DOCUMENTATION

Oculus Dextra & Sinistra

Oculus Dextra Oculus Sinistra

PATIENT CLINICAL
DOCUMENTATION

SLIT LAMP, OCULAR DEXTRA

 • DIAGNOSIS
DIAGNOSIS OD Coneal Corpus Alienum

• DIFFERENTIAL DIAGNOSIS
OD Bacterial keratitis
OD Corneal abration
OD Intraocular Corpus Alienum
 Oral :
Natrium Diclofenac 50 mg / 12 jam/ oral
Ciprofloxacin 500mg/ 12 jam/ oral

Topical : Polidemisin 5 ml 4dd1 gtt OD

TREATMENT

EDUCATION :

• Wear Safety googles in any situation

• Eye should not be rubbed
• If foreign body enter the eye, no attempt should be
made by the patient to remove the foreign body
 Quad Ad Vitam : Bonam
Quad Ad Functionam : Dubia ad Bonam
PROGNOSIS Quad Ad Cosmetican
Quad Ad Sanationam
: Bonam
: Bonam
THANK
YOU