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    Case Report: Sharp Trauma

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    Ciptadi Permana Wijaya
    A 26-year-old male bartender presented with right eye pain and blurred vision following an assault with glass 10 hours prior. Examination found multiple lacerations of the right eye including the superior palpebra, conjunctiva, cornea, and sclera with prolapse of the iris, vitreous, and choroid. The right eye had no light perception and fundus reflex. Treatment planned included hospital admission, surgical repair under general anesthesia, antibiotics, analgesics, and topical antibiotics for the right eye.

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    Case Report: Sharp Trauma

    Uploaded by

    Ciptadi Permana Wijaya
    10 views6 pages
    A 26-year-old male bartender presented with right eye pain and blurred vision following an assault with glass 10 hours prior. Examination found multiple lacerations of the right eye including the superior palpebra, conjunctiva, cornea, and sclera with prolapse of the iris, vitreous, and choroid. The right eye had no light perception and fundus reflex. Treatment planned included hospital admission, surgical repair under general anesthesia, antibiotics, analgesics, and topical antibiotics for the right eye.

    Original Description:

    Eye sharp trauma

    Original Title

    Sharp Trauma

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    A 26-year-old male bartender presented with right eye pain and blurred vision following an assault with glass 10 hours prior. Examination found multiple lacerations of the right eye including the superior palpebra, conjunctiva, cornea, and sclera with prolapse of the iris, vitreous, and choroid. The right eye had no light perception and fundus reflex. Treatment planned included hospital admission, surgical repair under general anesthesia, antibiotics, analgesics, and topical antibiotics for the right eye.

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    © All Rights Reserved
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    10 views6 pages

    Case Report: Sharp Trauma

    Uploaded by

    Ciptadi Permana Wijaya
    A 26-year-old male bartender presented with right eye pain and blurred vision following an assault with glass 10 hours prior. Examination found multiple lacerations of the right eye including the superior palpebra, conjunctiva, cornea, and sclera with prolapse of the iris, vitreous, and choroid. The right eye had no light perception and fundus reflex. Treatment planned included hospital admission, surgical repair under general anesthesia, antibiotics, analgesics, and topical antibiotics for the right eye.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    Download as pptx, pdf, or txt
    of 6

    CASE REPORT

    Sharp Trauma

    CASE REPORT
    PATIENT IDENTITY
    Name
    :J
    Age
    : 26 years
    Gender : Male
    Occupation : Bartender
    Religion
    : Kristen Protestan

    History Taking
    Chief
    Complaint
    Onset
    Chronology

    Quality
    Quantity
    Modifying
    Factor
    Additional
    Symptoms
    Past History

    Pain of the right eye


    From 10 hours ago before admission
    Patient referred with diagnosis multiple open wound on
    faces, globe rupture on right orbita, and suspect
    blinded of right eye. Patient complained pain on his
    right eye since 10 hours BATH after hit by glass. In that
    time, patient was talking and suddenly someone hit
    him on the face with glass. He didnt sure it was bottle
    or glass. He fully alert at the time. No complain of
    vomiting and nausea.
    Severe pain and disturbed his activities
    Always feel pain since 10 hours ago and along the day
    Blurred vision, bleeding
    He got tetanus vaccination 8 month ago

    Family
    History

    His mother suffered from hypertension

    Social
    History

    He worked as bartender

    Past
    Medication

    - IVFD NS 2000 cc in 2 hour


    - Fentanyl 100 mcg IV
    - Midazolam 2 mg IV
    - Broadcet (Ceftriaxone) 1 gram IV
    - Right temporal artery ligation under local
    anesthesia

    Allergy

    RE
    LP bad projection

    Ophthalmology
    Examination
    Visual Acuity

    LE
    6/6

    Superior palpebral laceration full


    thickness 15 mm from medial
    cantus 50 mm in length oblique to
    forehead.

    Palpebra

    Conjunctival laceration, CVI (+), PCVI


    (+)

    Conjungtiva

    Calm

    Cornea

    Clear

    Laceration at 11 7 oclock trough


    limbus until sclera
    Narrow
    Prolapse iris

    normal

    Anterior chamber Normal


    iris

    Round, regular

    Irregular, pupillary reflex (-)

    pupil

    Pupillary reflex
    (+)

    Cant be evaluated

    lens

    Clear

    Prolapse vitreous

    Vitreous humor

    Clear

    Prolapse choroid

    Choroid

    Clear

    Fundus reflex (-)

    Funduscopy

    Fundus reflex
    (+)

    Assesment
    RE sharp trauma with complication superior
    palpebral laceration, conjunctival laceration,
    corneoscleral laceration, choroid and vitrous
    prolapse

    PLANNING

    Hospitalization
    RE pro palpebral + corneo sclera laceration repair with GA
    Laboratory examination
    Head CT Scan
    Ceftriaxone 2 x 1 gram injection IV
    Ketorolac 3 x 30 mg injection IV
    LFX e.d @ hour on RE

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