OPHTALMOLOGY RECORD

IMMATURE CATARACT

Examiner:
Dr. Gilbert W S Simajuntak Sp.M (K)

Observer:
Risda Emilia
1261050187

DEPARTMENT OF EYE DISEASE

PERIOD OF OCTOBER 3st NOVEMBER 5rd , 2016
MEDICAL FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA
STATUS OPHTALMOLOGY
The Examine : Risda Emilia
Student number : 1261050187
Examiner : Dr dr. Gilbert W S Simajuntak Sp.M (K)

I. PATIENT IDENTITY
Name : Mr. M
Age : 60 years old
Address : Perinitis kemerdekaan, Yogyakarta
Occupation : Entrepreneur
Gender : Man
Religion : Moeslim
Status : Married

II. HISTORY
Anamnesis done at October 30th, 2016
Main complaint : Blurred vision in both eyes
Additional complaint : watery eyes, glare if the bright light such as sunlight and
vehicle light at night

History of present illness :

Patients come to the Eye Hospital dr. Yap with complaints of blurred vision in

both eyes since 6 months ago. The left eye feels more blurry than the right eye.

Complaints perceived to come on slowly and continuously. Initially the patient was

not clear when seeing people from far away, the longer felt increasingly blurred

eyesight. Now patients can only see people and objects that are close to him.

The problem start as a foggy vision that eventually growing and caused blurred

vision. Patients also complain sometimes watery eyes, glare if the bright light such as

sunlight and vehicle lights at night. Complaints of itchy and red eyes denied. The

pasien didnt use any medication yet. he also has not been to the doctor to treat the

complaint.

History of past illness:

 Patient never felt the same symptoms before. Patients never wore contact lenses. Or

eyeglasses. Patients denied the presence of a high blood pressure , allergy, or diabetes

mellitus.

History of family illness:

Denied

History of social life:

Patient not consumed alcohol and cigarrets. .

III. GENERALIST STATUS

General state : mild
Awareness : compos mentis
A Disease/ clinical symptom that has to do with complaints: denied

IV. OPHTHALMOLOGY STATUS

A. General examination
General examination OD OS
General state of the eye Mild Mild
The position of the
Symmetric Symmetric
eyeball
Eyeball movement All direction All direction
Eyeball pressure 11 mmhg 15 mmhg
Visual field Wide Wide

B. Systemic examination
Systemic examination OD OS
Acies visus 4/60 2/60
Correction Pinhole not advanced Pinhole not advanced
Super cilia Grow evenly Grow evenly
Cilia Grow evenly, good Grow evenly, good
position position
Palpebral superior Normal Normal
Color matches the color of
Color matches the color of
the skin
the skin
edema (-)
tumor (-) edema (-)
tumor (-)
Palpebral inferior Edema (-), ptosis (-), Edema (-), ptosis (-),
hyperemic (-) hyperemic (-)
Tarsal conjungtiva Hyperemic (-) Hyperemic (-)
 superior et inferior
Conjunctiva bulbi Injection conjungtiva (-) Injection conjungtiva(-)
Sclera Normal Normal
Cornea
a. Clarity Clear Clear
b. Infiltrate (-) (-)
c. Ulcers (-) (-)
d. Sikatriks (-) (-)
e. Neovascularization (-) (-)
f. Fluorescein test Not evaluated Not evaluated
g. Sensibility Not evaluated Not evaluated

Anterior chamber
a. Depth Superficial Superficial
b. Hyphema (-) (-)
c. Hypopyon (-) (-)
Iris Radier, brown, sinekia (-) Radier, brown, sinekia (-)

Pupil Round, isokor, diameter 3 mm,

Direct light refleks(+), Indirect light refleks (+)
Lens Turbid Turbid
Shadow test (+) Shadow test (+)

V. RESUME
Mr.M come to the Eye Hospital dr. Yap with complaints of blurred vision in both eyes
since 6 months ago. The left eye feels more blurry than the right eye. Complaints
perceived to come on slowly and continuously. Initially the patient was not clear when
seeing people from far away, the longer felt increasingly blurred eyesight. Now
patients can only see people and objects that are close to him.
The problem start as a foggy vision that eventually growing and caused blurred
vision. Patients also complain sometimes watery eyes, glare if the bright light such as
sunlight and vehicle lights at night. Complaints of itchy and red eyes denied. The
pasien didnt use any medication yet. he also has not been to the doctor to treat the
complaint.
GENERALIST STATUS
General state : Mild
Awareness : Compos mentis
Systemic examination OD OS
Acies visus 4/60 2/60
Anterior chamber Shollow Shollow

Lens Turbid Turbid

Shadow test (+) Shadow test (+)
 VI. CLINICAL DIAGNOSE
Right eye Left eye
Immature Cataract Immature Cataract

VII. DIFFERENTIAL DIAGNOSE

- Insipien cataract
- Matur cataract

VIII. SPECIFIC EXAMINATION

Slitlamp Biomicroscopy
Biometry

IX. MANAGEMENT
Medication:
Consult to the ophthalmologist for cataract surgery

X. COMPLICATION
Secondary Glaucoma

XI. PROGNOSIS
Right eye Left eye
Ad. Vitam Dubia ad Bonam Dubia ad Bonam
Ad. Fungsionum Dubia ad Bonam Dubia ad Bonam
Ad. Sanationum Dubia ad Bonam Dubia ad Bonam