CHAPTER III CASE

3.1. Patient identity Name Sex Age : Mrs. S : Female : 41 y.o.

Address : Karimunting, Kabupaten Bengkayang Job : Housewife

Religion : Islam Patient was examined on 18th February, 2014

3.2. Anamnesis Main complaint : Blurred vision in both eyes. History of disease : The patient gradually has blurred vision in both eyes since 5 months ago. Patient also get pain, lacrimation and redness of the eyes. Sometime patient felt sensitive to the light. The pain in the eyes become worsened when the patient worked hard, like washing or fetching water. Six month ago the patient complained about redness in the both eyes, then the patient give the eyes an alum water and the water of daun sirih but the redness became worsened and the eyes became blurred. The patient then use tropin three times a day for a week and the redness in the eyes was reduced but the eyes still blurred. There is no itching, purulent discharge (-), diplopia (-), and traumatic history (-). Past clinical history : Patient claims that there is no history of the same symptoms before. History of using contact lens (-), history of using another drugs (+), hypertension history (-), DM history (-), another disease (-).

Family history There is no one of his family occurs the same complaint

3.3. General Physical assessment Done on February, 18th 2014 General condition Awareness Vital sign: a. Blood Pressure : 120/80 mmHg b. Pulse : 84x/minute : 37,2oC : Good : Compos Mentis

c. Respiratory Rate: 22x/minute d. Temperature

3.4. Ophthalmological status Visual acuity: a. OD b. OS : 1/60 + pinhole (no correction) : 6/12 + pinhole (no correction)

Intra Ocular pressure (tonometry) : Not measured Visual field test (confrontation): OD OS : normal : normal

Eye ball movement OS

+ + + +

OD
+ +

OD Orthoforia Eye Ball Position Movement (+), Ptosis (-), Lagopthalmos (-), Edema(-) Redness (+), Discharge (-), Injection (+), Cilliary Injection, Ulcer (-), Foreign Body (-) Unclear, Keratic Precipitates (-) Edema (-), Ulcer (-), Sicatrics (+) Unclear, Deep, Hypopion (-) Anterior Chamber Iris Color : Brown, Posterior Synechia (+) Pupil: Irregular, Reflect (-), Isochore Clear Did Not Examined Did Not Examined Lenses Vitreous Fundus Iris/Pupil Cornea Conjunctiva Palpebral

OS Orthoforia

Movement (+), Ptosis (-), Lagopthalmos (-), Edema (-) Redness (+), Discharge (-), Injection (+), Cilliary Injection, Ulcer (-), Foreign Body (-) Clear, Keratic Precipitates (-) Edema (-), Ulcer (-),Sicatrics (-)

Clear, Deep, Hypopion (-)

Iris Color: Brown, Posterior Synechia (+) Pupil: Irregular, Reflect (-), Isochore Clear Did Not Examined Did Not Examined

3.5. Resume A female, 41 years old, came to ophthalmologic clinic with the complain of gradually blurred vision in both eyes since 5 months ago. Patient also get pain, lacrimation and redness of the eyes. Sometime patient felt sensitive to the light. The pain in the eyes become worsened when the patient worked hard, like washing or fetching water. Visual acuity is 1/60 for OD and 6/12 for OS. There are redness in both eyes conjunctiva, unclear cornea in the right eye, irregular shape of pupil, lost of pupil

reflex in both eyes. The funduscopy hardly examine in both eyes. There is decreased of intraocular pressure of both eyes.

3.6. Diagnosis Diagnose Diferential Diagnoses : Anterior Uveitis OD and OS : Keratitis and Panuveitis

3.7. Plan for laboratory and special investigations 1. Full blood counts 2. USG 3. Tonometry

3.8. Treatment 1. Prednisolone oral 1 mg/kg/day divided in 2 doses for 14 days, tapering off 2. Prednisolone acetate 1% 2 drops 4 times /day 3. Ranitidine 150 mg x 2 for 14 days 4. Atropine 1% 2 drops x 4 5. Combination of neomycin/polymixin B/gramicidin 2 drops x 6 (every 4 hours)

3.9. Prognosis OD : Ad vitam Ad functionam Ad sanationam : bonam : dubia ad malam : dubia ad malam

OS : Ad vitam Ad functionam Ad sanationam : bonam : dubia ad malam : dubia ad malam

CHAPTER IV DISCUSSION

A female, 41 years old, came to ophthalmologic clinic with the complain of gradually blurred vision in both eyes since 5 months ago. Patient also get pain, lacrimation and redness of the eyes. Sometime patient felt sensitive to the light. The pain in the eyes become worsened when the patient worked hard, like washing or fetching water. Visual acuity is 1/60 for OD and 6/12 for OS. There are redness in both eyes conjunctiva, unclear cornea in the right eye, irregular shape of pupil, lost of pupil reflex in both eyes. Red eyes are caused by enlarged, dilated blood vessels, leading to the appearance of redness on the surface of the eye. A red eye is a cardinal sign of ocular inflammation, which can be caused by several conditions. In this patient, the redness of the eye come from ciliary injection. Ciliary injection involves branches of the anterior ciliary arteries and indicates inflammation of the cornea, iris, or ciliary body. Ciliary injection have characteristics: immobile with movement of conjunctiva, lesser toward fornix area, seems purple. This kind of injection usually accompanied with pain sensation, lacrimation (no secret), and pupil irregular in size. Blurred vision refers to a lack of sharpness of vision resulting in the inability to see fine detail. This symptoms can come from the alteration of eyes refractive media or from the organic disease. In this patient, the decreased of vision acuity cannot be corrected by pinhole, which is indicated the organic disease of the eyes that lead to blurred vision. Blurred vision linked with inflammation of the eye usually because of the inflammation of the cornea or uveal tract. The patient also complaint about photophobia. Photophobia is intimately, likely inextricably, linked to pain sensation. The trigeminal nerve and its nuclei are the primary mediators of pain sensation to the head. The conjunctiva, cornea, sclera, and uvea (iris, ciliary body, and choroid) are densely innervated with trigeminal fibers, and exquisitely sensitive to pain. Any painful stimulus to these areas (e.g. iritis, uveitis) invariably causes photophobia.

Decreasing of visual acuity can caused by aging process there is weakness in ciliary muscle and sclerosing of the lens that can cause weakness of the accommodation process. Visual acuity also can decrease because of defect in the cornea, opacity in the lens, inflammation in the uveal tract, retinal impairment, etc. The visual acuity in the patient decreasing gradually can caused by defect in the cornea like keratitis or corneal ulcer, or from the uveal tract. Since the patient didnt complaint about any discharge from his eye, it can caused by inflammation in uveal tract such as anterior uveitis. The unclear findings of anterior chamber may indicate any inflammation at anterior chamber of the eye. Irregularity of iris, as the result of posterior synechia (adhesion of the iris to the capsule of the lens), indicating the inflammation of the iris. The adhesion may alter the sphincter pupils muscle movement, and make the eye loss of pupil reflex. The differential diagnoses for this case are keratitis and panuveitis. Keratitis can caused by viral, bacterial, or fungal infection with or without trauma before. The symptom is the patient feel usually blurred, there is watery or purulent discharge, change in corneal surface related to cause, there is cilliar injection and conjunctival injection, the pupil is normal or myosis but the pupil still reactive to the light. In the patient, there is no discharge, and the pupil is irregular and doesnt reactive to the light so keratitis can be disregard. Panuveitis is involvement of vitreous body and retina/choroid we should do USG to see that. Tonometry is needed. Accurate measurement of IOP is important for the initial diagnosis of anterior uveitis and as an ongoing monitor of the disease. The IOP may be high, low, or normal in acute anterior uveitis. Chronic forms of uveitis frequently are also associated with elevated IOP. Although IOP is frequently affected by anterior uveitis, other vision-threatening problems, such as retinal detachment, may affect IOP as well. The treatment of uveitis has three main goals: to prevent visionthreatening complications, to relieve the patient's complaints and, when feasible, to treat the underlying disease.

Corticosteroids are the drugs of choice in most types of uveitis. They inhibit the inflammatory process by suppressing the arachidonic acid metabolism and activation of complement. Depending upon the severity of the disease, oral prednisolone is started in a loading dose of 1 mg/kg/day. As the inflammation subsides, tapering of corticosteroids by 5-10 mg per week is begun within two to four weeks of initiating therapy. For the topical therapy we can use prednisolone acetate 1%. Topical therapy is only helpful in the treatment of the anterior segment therapy. The side-effects and complications of topical or systemic corticosteroids must be looked for at every follow-up visit of the patient. The histamine-2 blocker is given for prevent gastric ulcer. Mydriatic agent is given to promote comfort by relieving spasm of the ciliary muscle and pupillary sphincter and to break down recently formed posterior synechiae. For this patient we could use intensive atropine 1%, 2 drops up to four times daily. For the treatment of the ocular infection, and prevention for further inflammation, we can give the combination of neomycin/polymixin B/gramicidin combo, 2 drops every 4 hours for 7-10 days.

CHAPTER V CONCLUSION

A female, 41 years old, came to ophthalmologic clinic with the complain of gradually blurred vision in both eyes since 5 months ago. Patient also get pain, lacrimation and redness of the eyes. Sometime patient felt sensitive to the light. The pain in the eyes become worsened when the patient worked hard, like washing or fetching water. Visual acuity is 1/60 for OD and 6/12 for OS. There are redness in both eyes conjunctiva, unclear cornea in the right eye, irregular shape of pupil, lost of pupil reflex in both eyes. From the symptoms and physical examination of the patient, we can conclude that the patient having anterior uveitis with differential diagnoses keratitis and suspicion of involvement of the vitreous body and retina (panuveitis). The patient is treated by corticosteroid, mydriatic agent, antibacterial agent, and histamine-2 blocker.