OPHTALMOLOGY RECORD

CATARACT

Examiner:
Dr. dr. Gilbert. W. Simanjuntak, SpM (K)

Observer :
Melianti Togatorop
(1261050166)

DEPARTMENT OF EYE DISEASE

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

Examiner : Melianti Togatorop

NIM : 1261050166
Tutor : Dr.dr. Gilbert. W. Simanjuntak, SpM (K)

I. PATIENT IDENTITY
Name : Mr. KM
Age : 76 years old
Sex : Male
Religion : Islam
Address : Digiri Wayo Gua Tirto Dusun Gumpil Kariman Martosiwito
Occupation : Entrepreneur
Status : Married

II. ANAMNESIS
Anamnesis done at February 14th, 2018

Main complaint : Blurred vision on the left and right eyes since ± 2 years ago.

Additonal complaint : Glare vision

Chronology of disease :
Patient comes to Eye Centre RS DR YAP with blurred vision complaints on
the left and right eye since ± 2 years ago. Blur on the eyes felt the most severe on the
left eye then the right. Initially the patient just felt a foggy or cloudy vision starting
from the left eye then the right eyes. It is now felt that the burden is getting worse,
making it difficult for patients to see the near distance and far distance. Vision is also
felt in the daylight glare. Red eyes, and pain in the eyes are denied. The patient has
come to the Puskesmas and got referral to DR YAP Hospital for further examination.
Usage history of glasses since 2 months ago (patient forgot the size) with the use of
glasses does not help vision better.
 Previous disease :
Patients have never experienced such complaints before. History of allergy,
hypertension, history of diabetes mellitus, heart disease, history of trauma, history of eye
infections is denied.

History of family disease :

In families of patient has neversuffered like him.

III. GENERAL STATUS

General condition : Mild illness appearance
Conciousness : Composmentis

IV. STATUS OFTALMOLOGI

A. General examination
Parameter OD OS
Periocular Appearance Quiet Quiet
General Condition of The eye Mild Mild
Eyeball position Simetric Simetric
Eyeball movement All direction All direction
Visual field Wide Wide

B. Sistematic Examination
Parameter OD OS
Visual Acuity 5/60 1/300
Correction Pin hole 5/60 Pin hole 1/300

Supersilia Grow evenly Grow evenly

Silia Grow evenly, good Grow evenly, good
position 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 (-)
Fibrovascular in triangular Fibrovascular in triangular
shape (-) shape (-)
Cornea
 Clarity Fibrovascular (-) Fibrovascular (-)
 Infiltrate (-) (-)
 Ulcus (-) (-)

 Erosion (-) (-)

 Cicatrix (-) (-)

Sclera White White

Cicatrix (-) Cicatrix (-)
Anterior Chamber Shallow Depth
Hypopyon (-) Hypopyon (-)
Hyphema (-) Hyphema (-)
Iris Radier Radier
Brown Brown
Synechia (-) Synechia (-)
Pupil Round, isokor, diameter 3 Round, isokor, diameter 3
mm, Direct light mm, Direct light
refleks(+), Indirect light refleks(+), Indirect light
refleks (+) refleks (+)
Lens Cloudy lens Cloudy lens
Shadow test (+) Shadow test (-)
V. RESUME
Patient comes to Eye Centre RS DR YAP with blurred vision complaints on
the left and right eye since ± 2 years ago. Blur on the eyes felt the most severe on the
left eye then with the right. Initially the patient just felt a foggy or cloudy vision starting
from the left eye then the right eyes. It is now felt that the burden is getting worse,
making it difficult for patients to see the near distance and far distance. Vision is also
felt in the daylight glare. Red eyes, and pain in the eyes are denied. The patient has
come to the Puskesmas and got referral to DR YAP Hospital for further examination.
Usage history of glasses since 2 months ago (patient forgot the size) with the use of
glasses does not help vision better. Patients have never experienced such complaints
before. History of allergy, hypertension, history of diabetes mellitus, heart disease,
history of trauma, history of eye infections is denied. No patient's family experienced
the same complaints as the patient.

VI. GENERAL STATUS

General condition : Mild illness appearance
Conciousness : Compos mentis

From the ophtalmologic examination on both eyes founded

Parameter OD OS
Visual Acuity 5/60 1/300
Correction Pin hole 5/60 Pin hole 1/300
Cornea
 Clarity Fibrovascular (-) Fibrovascular (-)
 Infiltrate (-) (-)
 Ulcus (-) (-)

 Erosion (-) (-)

 Cicatrix (-) (-)

Bulbi conjungtiva Hyperemic (-) Hyperemic (-)

Injection conjungtiva (-) Injection conjungtiva (-)
Injection ciliar (-) Injection ciliar (-)
Fibrovascular in triangular Fibrovascular in triangular
shape (-) shape (-)
 Pupil Round, isokor, diameter 3 Round, isokor, diameter 3
mm, Direct light mm, Direct light
refleks(+), Indirect light refleks(+), Indirect light
refleks (+) refleks (+)
Lens Cloudy lens Cloudy lens
Shadow test (+) Shadow test (-)

VII. CLINICAL DIAGNOSE

OD : Imature senile cataracts
OS : Mature senile cataracts

VIII. DIFFERENTIAL DIAGNOSE

OD : Mature senile cataracts
OS : Imature senile cataracts

IX. MEDICAL TREATMENT

Refer to dr Ophthalmologist
Operation : Extracapsular Cataract Extraction + Intra Ocular Lens (IOL) ODS

X. RECOMMENDED EXAMINATION
 Keratometry
 Biometry
 Tonometry

XI. PROGNOSE
OD OS
Ad Vitam Bonam Bonam
Ad Sanasionum Bonam Bonam
Ad Fungsionum Bonam Bonam

XII. COMPLICATION
Glaucoma