CASES

REAL CASE
Patient History
Real case I studied is conjunctival wound laceration Patient name, Haslinawati Binti Jaafar
(RN 5064), 34 years old man came to Clinic Ophthalmology, Hospital Slim River for the
follow up on 18 July 2018 at 12.45 pm. The chief complaint she was made to doctor in
charged is he was having redness over the left eyes, since 3 days. The history of presenting
complaint she made is no blurry vision,alleged eye injury during shower. The past medical
history face by this patient is nil. This patient also got no surgical history,
From patient’s family history, we can know that this patient have 3 children.

From patient’s family history, we know that only husband have medical history . While her
daughter and his wife do not have any medical history.
From the drug history, we can know that this patient do not have any drug allergic. While the
social history of this patient shows that this patient is himself. At the same time, we can know
that this patient is not a smoker and alcoholic consumer.

The current vital sign of this patient is,

Blood pressure (BP) 136/62 mmHg

Pulse rate (PR) 96/min
Respiration rate (RR) 20/min
Body temperature (BT) 36.6 degree Celsius
Pain score 2/10

Cardiovascular system is shown dual rhythm no murmur (DRNM) and S1S2 heard clearly.
When auscultate the lungs, air entry show equal and clear. While during palpitation, stomach
shows in soft, non-tender and no mass condition and at the same time, bowel sound active were
found on the stomach.

While during the physical examination especially at eyes, we can see that this patient's had left
side of sclera conjunctiva wound laceration, lid look normal and aqueous humor also look deep
and quiet.

Differential diagnosis and Investigation

The differential diagnosis that can made is. After undergo the patient’s history, physical
examination and finding differential diagnosis, next doctor carry out some investigation. First
investigation is visual assessment (VA)/unaided. The result for visual assessment is as shown
below:

VA/unaided Result
Right eye 6/7.5-2
Left eye 6/18

Second investigation made by doctor is assessing for abnormalities of eyes using slit lamp.
During the assessment of abnormalities, the cornea and conjunctiva of the eye look clear, lid
look normal and aqueous chamber also look deep and quiet.But his left sclera has laceration
with wounds.
Other investigation made by doctor in slit lamp is check power vision. The result for power
vision by using slit lamp is as shown below

Power vision Result

Right eye +0.75/1.50x90 (6/24)
Left eye +2.00/1.00x70 (6/18)

Diagnosis

After undergo patient’s history, physical examination and investigation, finally patient is
diagnosed left conjunctiva wound laceration at 4.5mm

Management and Treatment

Management

The initial management that done in Clinic Ophthalmology is checked patient’s vital signs
include blood pressure, respiration rate, pulse rate, body temperature and pain score by medical
staff. After the medical staff checked vital sign, Optometrist also checked visual assessment of
this patient. Other initial management that done by the doctor in is asking some questions about
the patient's chief complaint and history of presenting complaint. Then doctor asked patient’s
history includes family, drug and social history.
While the specific management carry out by doctor at Clinic Ophthalmology is doctor explain
and suggested for the tips on caring the eyes from getting worse by providing several technique
and guideline. Not only have that, doctor also explained the objectives, procedure, risk and
complications regarding this type of trauma injury.
Treatment (Pharmacology)
The first pharmacology treatment given to this patient is ointment chlorpheniramine
Generic name Chlor-Trimeton
Trade name Piriton
Dose Instill 1-2 drops in affected eye(s) as needed.
Indication Symptomatic relif of severe dry eye
conditions and as lens lubricant during
ophthalmic diagnostic procedure.
Second medicine is Paracetamol 500 mg

Generic name Paracetamol 500mg Tab

Trade name Panadol tab
Dose 1g QID.
Indication Mild to moderate pain and pyrexia

Next pharmacology treatment is Mefenamic Acid 250mg

Generic name Mefenamic Acid 250mg Tab

Trade name Ponstan Tab
Dose 500mg tab
Indication Mild to moderate pain

Treatment (Surgery)

Beside pharmacology treatment, doctors plan to do cataract surgery which known as

phacoemulsification to this patient.

Advice

 Ask patient to follow up (TCA 2/52) at Klinik pakar Ophthamology, hospital Slim
River

 Diabetes mellitus and hypertension control advice given

 Eat medications followed by the dosage that has been prescribed by doctor
  Drink plenty of water

 Do simple exercise

 Take plenty of rest

 Take care personal hygiene to prevent infection

 Eat healthy and vitamin rich diet

ADVICES FOR SAFE AND SPEEDY WOUND RECOVERY

 Don't drive on first day

 wear sunglasses

 avoid bending over the head

 Don't do any heavy lifting or strenuous activity for a few weeks.

 Be careful walking around after surgery

 Don't rub your eye

 To reduce risk infection, avoid swimming or using a hot tab during first weeks after
surgery

Reference A
A sclera laceration can be a partial- or full-thickness injury to the sclera. A partial-thickness
injury does violate the globe of the eye (abrasion). A full-thickness injury penetrates
completely through the cornea, causing a ruptured globe. This topic discusses the full-thickness
injury.
History sometimes points to a discrete event after which the patient’s symptoms started;
however, this is not always the case. Small foreign bodies, digital trauma, or other more subtle
sources of damage may not be quickly recalled by the patient. The physician must be
meticulous in examining the sclera and periorbital structures if there is suspicion of a sclera or
sometimes corneal laceration. Typically, patients who present with this type of injury complain
of an intensely painful, profusely lacrimating eye.
The first priority in evaluating a corneal injury is to include or exclude a full-thickness injury
and the resulting ruptured globe. A full-thickness injury will allow aqueous humor to escape
the anterior chamber, which can result in a flat-appearing cornea, air bubbles under the cornea,
or an asymmetric pupil secondary to the iris protruding through the corneal defect
 Trauma

o surgery

o thermal, radiation, mechanical, chemical

o trichiasis

o entropion (see Clinical Management Guideline)

 Exposure

o ectropion (see Clinical Management Guideline)

o lagophthalmos and other distrubance of lid function

 Autoimmune

o ocular cicatricial pemphigoid (OCP)

o Stevens-Johnson syndrome (erythema multiforme major)

o graft versus host disease

 Infection (N.B. very few forms of infective conjunctivitis cause scarring)

o trachoma (recurrent infection by Chlamydia trachomatis [serotypes A-C])

 Allergy

o Vernal keratoconjunctivitis

o Atopic keratoconjunctivitis

 Ligneous conjunctivitis

o rare form of chronic conjunctivitis characterised by pseudomembranous lesions

of ‘woody’ consistency
Sign And Symptomp:symptom depends on severity and type of injury

Reduced tear components and compromised lid function both lead to dry eye

 grittiness, burning, foreign body sensation

 blurred vision in severe cases

Surgical and traumatic scarring

 focal, linear or diffuse scarring according to cause

OCP produces sequence of conjunctival changes

 bilateral (often asymmetrical)

 diffuse hyperaemia, papillae

 bullae leading to ulceration and pseudomembrane formation

 subepithelial fibrosis and shrinkage; sometimes symblepharon

 secondary corneal changes

Stevens-Johnson syndrome produces sequence of conjunctival changes

 acute bilateral mucopurulent conjunctivitis

 fibrosis and keratinisation follow acute phase

 secondary corneal changes due to tear deficiency, exposure, keratinisation of the tarsal
conjunctiva

Vernal keratoconjunctivitis

 tarsal sub-conjunctival fibrosis

 pannus (especially at upper limbus)

Atopic keratoconjunctivitis

 tarsal sub-conjunctival fibrosis

 conjunctival shrinkage

 forniceal shortening
Trachoma

 follicles (upper tarsus)

 pannus (especially at upper limbus)

 conjunctival inflammation leading to scarring and trichiasis

o Von Arlt’s line (horizontal line of scarring parallel to lid margin)

 Herbert’s pits (depressions at the upper limbus representing resolved limbal follicles)

 secondary corneal changes