OPHTALMOLOGY RECORD

PINGUECULA

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

Observer:
Putri Chera Apriliani
1261050074

DEPARTMENT OF EYE DISEASE

PERIOD OF APRIL 3rd MAY 6th, 2017
MEDICAL FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA
2017
STATUS OPHTALMOLOGY
The Examine : Putri Chera Apriliani
Student number : 1261050074
Examiner : Dr. dr. Gilbert W S Simajuntak Sp.M (K)

I. PATIENT IDENTITY
Name : Mr. J
Age : 47 years old
Address : Akalipa VI Street no.16, RT 009/013, Bekasi
Occupation : Entrepreneur
Gender : Male
Religion : Christian
Status : Married

II. HISTORY
Anamnesis done at April 7th, 2017
Main complaint : Lumps in both eyes
Additional complaint : Itchy and sore in both eyes

History of present illness:

Patients came to eye polyclinic UKI Hospital with complaints of lumps in both eyes
since a month ago. The lumps appeared suddenly, initially preceded by reddish eyes since
a month ago, then followed by the appearance of lumps that was initially small and then
became wider since two weeks ago. The patient also admits that his both eyes feels itchy
and sore. Patient admits that he was working as an entrepreneur and his eyes often being
exposed by sunlight and free air. Patient admits that he never used glasses to protect his
eyes even he already having a pair of glasses. The patient didnt use any medication yet,
he also has not been to the doctor to treat the complaint. Patients deny the presence of
diminished vision, glare at the sight of light, piles that stack and watery eyes.
 History of past illness:
Patient never felt the same symptoms before. Patients denied the presence of a high blood
pressure, allergy, diabetes mellitus. Patient wearing eyeglasses since 3 years ago, spheris
minus 2,75 in both eyes.

History of family illness:

Denied.

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 Quiet Quiet
The position of the eyeball Symmetric Symmetric
Eyeball movement All direction All direction
Eyeball pressure - -
Visual field Wide Wide

B. Systemic examination
Systemic examination OD OS
Acies visus (with glasses) 6/8 6/7
Correction - -
Super cilia Grow evenly Grow evenly
Cilia Grow evenly, good position Grow evenly, good position
Palpebral superior Normal Normal
 Color matches the color of Color matches the color of
the skin the skin
edema (-) edema (-)
tumor (-) tumor (-)
Palpebral inferior Edema (-), hyperemic (-) Edema (-), hyperemic (-)
Tarsal conjunctiva Hyperemic (-) Hyperemic (-)
superior et inferior
Fornices conjunctiva Hyperemic (-) Hyperemic (-)
superior et inferior
Conjunctiva bulbi Injection conjunctiva (-) Injection conjunctiva (-)
There is a yellowish white There is a yellowish white
bulbous lump with a size bulbous lump with a size
of 2 mm beside the of 2 mm beside the
limbus area in the nasalis limbus area in the nasalis
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 Deep Deep
b. Hyphema (-) (-)
c. Hypopyon (-) (-)
Iris Radier, brown Radier, brown
Pupil Round, isokor, diameter 3 mm,
Direct light reflex (+), Indirect light reflex (+)
Lens Clear Clear
 V. RESUME
Mr. J came to eye polyclinic UKI Hospital with complaints of lumps in both eyes since a
month ago. The lumps appeared suddenly, initially preceded by reddish eyes since a month
ago, then followed by the appearance of lumps that was initially small and then became
wider since two weeks ago. The patient also admits that his both eyes feels itchy and sore.
Patient admits that he was working as an entrepreneur and his eyes often being exposed by
sunlight and free air. Patient admits that he never used glasses to protect his eyes even he
already having a pair of glasses. The patient 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 (with glasses) 6/8 6/7
Conjunctiva bulbi There is a yellowish white There is a yellowish white
bulbous lump with a size bulbous lump with a size
of 2 mm beside the of 2 mm beside the
limbus area in the nasalis limbus area in the nasalis

VI. CLINICAL DIAGNOSE

Right eye Left eye
Pinguecula Pinguecula
Myopia Myopia

VII. DIFFERENTIAL DIAGNOSE

Pterygium
Pseudopterygium
Pinguecula irritancy

VIII. SPECIFIC EXAMINATION

Slitlamp Biomicroscopy
IX. MANAGEMENT
A. Non Medication:
- Avoid exposure to fog, dust, and wind
- Reduces exposure to sunlight
- Patient have to wear glasses every doing outdoor activity
B. Medication:
- The use of topical steroids may also be considered in patients with chronic
inflammation
- Excision is made for cosmetic reasons and large lesions that cause irritation

X. COMPLICATION
1. Red and irritated eye
2. Chronic scar on the conjunctiva and cornea

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