OPTHALMIC RECORD

Examiner

: Dyan Esikha

NIM

: 00-086

Date of exam

: April 12th, 2006

Tutor

: Dr. Gilbert . S, SpM.

I.

Patient Identity

Name

: Mr. M

Sex

: Male

Age

: 30 years old

Occupation

: Farmer

Address

: Babelan, Bekasi

Interview ( April 12th, 2006 )

II.

Main complain

: Red eye, pain, and blurred vision on the right eye

Additional complain : Watering and cant stand on the light

Chronology of disease
Patient came to Bekasi General Hospital with main complain red eye, pain, and blurred
vision on the right eye since two weeks ago. He also complained that his right eye was
watering and he couldnt stand on the light while outdoors. He told that 14 days before the mud
water of the farm was getting into his right eye while he was working in the farm. Patient tried
to take a traditional treatment with sirih leaves water, but it didnt make any better.
He never had the same symptom like this before and the same complains were not
found in member of family.
Previous disease
Unremarkable

III.

General Status

General Condition

: Appearance of mild illness

Complains related symptom : Unremarkable

IV.

Ophtalmic Status

IV.1. General Examination

Periocular Appearance
General Condition of the Eye
Eyeball Position
Eyeball Movement

Right Eye
Quiet
Mild illness
Symetric
Normal

Left Eye
Quiet
Well
Symetric
Normal

Right Eye
6/18
Quiet
Quiet
Normal
Hyperemic
Hyperemic
Ciliary injection

Left Eye
6/6
Quiet
Quiet
Normal
Quiet
Quiet
Quiet

IV. 2. Systemic Examination

Visual acuity
Correction
Supercilia
Cilia
Sup/inf margo palpebra
Sup/inf tarsalis conjunctiva
Sup/inf fornices conjunctiva
Bulbar conjunctiva

Right Eye

Left Eye

Cornea
-

Infiltrat

Found (numular)

Not found

Ulcer

Not found

Not found

Cicatric

Not found

Not found

Not found

Not found

Clear
Radier
Round, light reflex (+)
Clear
+

Clear
Radier
Round, light reflex (+)
Clear
+

- Neovascularization
Anterior Chamber
Iris
Pupil
Lens
Fluorescent test
Sensibility test

V.

Resume

The patient, male, 30 years old came to Bekasi General Hospital with main
complain red eye, pain, and blurred vision on the right eye since two weeks ago. He also
complained that his right eye was watering and . he couldnt stand on the light while
outdoors. He told that 14 days before the mud water of the farm was getting into his right
eye while he was working in the farm.
The result from systemic examination on the right eye found :
Visual acuity
: 6/18
Tarsalis conjunctiva : hyperemic
Fornices conjunctiva : hyperemic
Bulbar conjunctiva
: ciliary injection
Cornea
: infiltrate (numular)

VI.

Clinical Diagnose
Numular Keratitis OD

VII. Differential Diagnose

Disiformis Keratitis OD

VIII. Medical Treatment

Topical :

Cendo Citrol 1 drop, 6 times daily.

Cendo Tropin 1 drop, 3 times daily.

Systemic:

IX.

Vitamin : Vitalux 1 tab per day.

Complication
Cornea ulcer

X.

Prognose
Right Eye

Ad vitam
Ad sanationum
Ad functionum

Bonam
Dubia ad bonam
Dubia ad bonam

OPHTALMOLOGY RECORD

KERATITIS NUMULARIS

EXAMINER:
Dyan Esikha
00-086

DEPARTEMENT OF OPHTHALMOLOGY
MEDICAL FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA 2006