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OPHTALMOLOGY RECORD

CATARACT

Examiner :

dr. Gilbert. W. Simanjuntak, SpM

Observer :

Angga Meda Mahardhika


1161050235

DEPARTMENT OF EYE DISEASE


PERIOD OF JANUARY 22nd – FEBRUARY 24th , 2018
MEDICAL FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA
2018
OPHTALMOLOGY RECORD

Examiner : Angga Meda Mahardhika

NIM : 1161050235

Tutor : dr. Gilbert. W. Simanjuntak, SpM

I. PATIENT IDENTITY
Name : Mrs. M
Age : 79 years old
Sex : Female
Religion : Moslem
Address : Kedung Rejo, Ngawi, Yogyakarta
Occupation : Retired
Status : Married

II. ANAMNESIS
Anamnesis done at February 17th, 2018

Chief complaint : Blurred visions on both eyes since three month ago

Additonal complaint : Glare of her eyesight when she sees the light

Chronology of disease :
A 79 years old female patient came to Dr. Yap Eye Hospital with the chief
complaint about blurred visions on both eyes since 3 months ago. She feels that her eyes
seems blur like there’s a fog infront of her. In the beggining she felt her eyes start to blur
like there’s a fog and cloud infront of her and its getting worse days by days. Besides that
problem she felt glare on her eyesight in the day or when she sees the light. This
complaint is disturbing patient daily activities. At first patient still can see far, but
overtime patient can only see at close distance. Trauma to the eye is denied. Sore eyes,
Redness of the eyes and itchy eyes is denied by the patient. Diabetes Mellitus is denied
by the patient. Patient never wore glasses.

Previous disease :
The patient never felt the same symptoms before. Patient’s denied the presence
of a high blood pressure, diabetes melitus, and allergy.

History of family disease :


Patient’s families had never suffered the same problems like her.

III. GENERAL STATUS


General condition : Mild illness appearance
Conciousness : Compos mentis
Diseases / Symptompts which related to the problem : Diabetes mellitus

IV. STATUS OFTALMOLOGI


A. General examination
Parameter OD OS
Periocular Appearance Quiet Quiet
General Condition of The Mild Mild
eye
Eyeball position Simetric Simetric
Eyeball movement All direction All direction
Visual field Wide Wide
Intra Ocular Pressure Resistance (-), pain (-) Resistance (-), Pain (-)
(Palpation)
B. Sistematic Examination
Parameter OD OS
Visual Acuity 1/60 1/60
Corection Pin hole : no change Pin hole : no change
Supersilia Grow evenly Grow evenly
Silia Grow evenly, good position Grow evenly, good position
Palpebra Normal Normal
Superior/inferior Color matches the color of Color matches the color of
the skin the skin
edema (-) edema (-)

tumor (-) tumor (-)

Tarsal conjungtiva Hyperemic (-) Hyperemic (-)


Superior/inferior Cicatrical (-) Cicatrical (-)

Papilar (-) Papilar (-)

Forniks conjungtiva Hyperemic (-) Hyperemic (-)


Superior/inferior
 Bulbi conjungtiva Hyperemic (-) Hyperemic (-)

Injection conjungtiva (-) Injection conjungtiva (-)

Injection ciliar (-) Injection ciliar (-)


Cornea
 Clarity Clear, Arcus Senilis (+) Clear, Arcus Senilis (+)
 Infiltrate (-) (-)
 Ulcus (-) (-)

 Erosion (-) (-)

 Cicatrix (-) (-)

Sclera White White


Cicatrix (-) Cicatrix (-)
Anterior Chamber Deep depth Deep depth
Hypopyon (-) Hypopyon (-)
Hyphema (-) Hyphema (-)
Iris Radier Radier
Brown Brown
Synechia (-) Synechia (-)

Pupil Round, isokor, diameter 3 Round, isokor, diameter 3


mm, Direct light refleks(+), mm, Direct light refleks(+),
Indirect light refleks (+) Indirect light refleks (+)
Lens Cloudy Cloudy

V. RESUME
A 79 years old female patient came to Dr. Yap Eye Hospital with the chief
complaint about blurred visions on both eyes since 3 months ago. She feels that her eyes
seems blur like there’s a fog infront of her. In the beggining she felt her eyes start to blur
like there’s a fog and cloud infront of her and its getting worse days by days. Besides that
problem she felt glare on her eyesight in the day or when she sees the light. This
complaint is disturbing patient daily activities. At first patient still can see far, but
overtime patient can only see at close distance.

GENERAL STATUS
General condition : Mild illness appearance
Conciousness : Compos mentis

From the ophtalmologic examination on both eyes founded


Parameter OD OS
Visual Acuity 1/60 1/60
Corection Pin hole : no change Pin hole : no change
Cornea
 Clarity Clear, Arcus Senilis (+) Clear, Arcus Senilis (+)
Pupil Round, isokor, diameter Round, isokor, diameter
3 mm, Direct light 3 mm, Direct light
refleks(+), Indirect light
refleks (+)
refleks(+), Indirect light
refleks (+)

Lens Cloudy Cloudy

VI. CLINICAL DIAGNOSE


OD : Immature Senile Catarat
OS : Immature Senile Catarct

VII. DIFFERENTIAL DIAGNOSE


- Mature Senile Cataract

VIII. MEDICAL TREATMENT


- Non medicamentosa : -
- Medicamentosa :-
- Operation : Cataract Extraction by ophthalmologist

IX. RECOMMENDED EXAMINATION


- Slit lamp
- Keratometry
- Biometry
- Tonometry
- Funduscopy

X. PROGNOSE

OD OS
Ad Vitam Dubia ad Bonam Dubia ad Bonam

Ad Sanasionum Dubia ad Bonam Dubia ad Bonam

Ad Fungsionum Dubia ad Bonam Dubia ad Bonam

XI. COMPLICATION
- Secondary Glaucoma