Kompetensi kualifikasi tambahan FELLOWSHIP yang telah dilaksanakan

selama 3 tahun terakhir (bidang medical retina)

Keterampilan diagnosis medical retina

Pernyataan Disetujui oleh

pemohon
No Diagnosis reviewer
*centang
*diisi oleh peer
kompetensi yang
reviewer
telah dikuasai

KELAINAN MAKULA

1 Wet Age Macular Degeneration (AMD)

2 Sindrom histoplasmosis okular
3 Angioid Streak
4 Myopia Patologis
5 Choroidal Neovascularization (CNV) Idiopatik
6 Cystoid macular oedema
KELAINAN PEMBULUH DARAH RETINA
Retinopati Diabetik Proliferatif/ Proliferative Diabetic
7
Retinopathy (PDR)
8 Branch Retinal Vein Occlusion (BRVO)
9 Central Retinal Vein Occlusion (CRVO)
10 Sindroma iskemik okular
11 Branch Retinal artery Occlusion (BRAO)
12 Central Retinal Artery Occlusion (CRAO)
13 Oklusi aretri Cilioretinal
14 Oklusi Arteri Ophthalmica
15 Makroaneurisma Arterial
16 Retinopati Sickle Cell
17 Vaskulitis
18 Coats Disease
19 Telangiektasis Parafoveal
20 Penyakit Von Hippel-Lindau
21 Sindrom Wyburn -Mason

Paraf atasan : Paraf Pemohon :

22 Retinal Cavernous Hemangioma
23 Retinopati akibat Radiasi
24 Retinopati Valsalva
25 Purtscher-and Purtscherlike Retinopathy
26 Sindrom Terson
27 Retinopathy of Prematurity (ROP)
KELAINAN KOROID

28 Central Serous Choroidopathy (CSC)

29 Choroidal Perfusion Abnormalities

30 Hemangioma koroid

31 Uveal Effusion Syndrome

32 Bilateral Diffuse Uveal Melanocytic Proliferation

INFLAMASI KOROID DAN RETINA

33 White Dot Syndromes

34 Choroidal Autoimmune Conditions

35 Sympathetic Ophthalmia

36 Intraocular Lymphoma

37 Retinitis Cytomeglovirus (CMV)

38 Non-CMV Necrotizing Herpetic Retinitis

39 Endophthalmitis

40 Tuberculosis ocular

41 Chorioretinitis syphilis

42 Cat-scratch Disease

43 Retinochoroiditis Toxoplasma

44 Toxocariasis

45 Lyme Disease

46 Diffuse Unilateral Subacute Neuroretinitis

Paraf atasan : Paraf Pemohon :

 CONGENITAL AND STATIONARY RETINAL DISEASE

47 Colour Vision (cone system) abnormalities

48 Night Vision (rod system) abnormalities

HEREDITARY RETINAL AND CHOROIDAL DYSTROPHIES

49 Retinitis Pigmentosa

50 Leber Congenital Amaurosis

51 Cone Dystrophies

52 Stargardt Disease

53 Vitelliform Degenerations

54 Pattern Dystrophies

55 Sorsby Macular Distrophy

56 Choroidal Dystrophies

57 X-Linked Retinoschisis

58 Enhanced S-cone Syndrome

DEGENERASI RETINA

59 Bardet-Biedl Syndrome

60 Usher Syndrome

61 Retinal Albinism

SYSTEMIC-DRUG-INDUCED RETINAL TOXICITY

62 Drug causing RPE + Photoreceptor abnormalities

63 Drug causing Occlusive Retinopathy

64 Drug causing Ganglion cells + Optic nerve abnormalities

65 Drug causing Macular Oedema

66 Drug causing Crystalline Retinopathy

67 Drug causing Colour vision and ERG abnormalities

Paraf atasan : Paraf Pemohon :

 ABLASI RETINA (Retinal Detachment)

68 Retinal Breaks

69 Posterior Vitreous Detachment (PVD)

70 Lattice Degeneration

71 Vitreoretinal Tufts

72 Meridional Folds

73 Paving-stone Degeneration

74 Hyperplasia Retinal Pigment Epithelium (RPE)

75 Hypertrophy Retinal Pigment Epithelium (RPE)

DISEASES OF THE VITREOUS AND VITREORETINAL INTERFACE

76 Asteroid Hyalosis

MANIFESTASI TRAUMA PADA SEGMEN POSTERIOR

77 Ruptur koroid

Paraf atasan : Paraf Pemohon :

 Keterampilan Klinis Medical Retina
Pernyataan Disetujui oleh
pemohon reviewer
No Keterampilan Klinis *centang
*diisi oleh
kompetensi yang
peer reviewer
telah dikuasai

1 Pemeriksaan dan interpretasi Indocyanine Green (ICG)

2 Laser PDT
3 Laser indirect ophthalmoscope
Laser fotokoagulasi pada kelainan makula (focal, grid dan
4
micro pulse)
Laser retinopexy (demarcation) pada kasus isolated retinal
5
breaks.

Mengetahui, ……………….….,…….…./…………/…….……..
Atasan langsung Pemohon,

Materai 6000

Nama : …………………………………….
……………………………………..
Jabatan : ………………………………………