EXAMINATION OF

PEDIATRIC OPHTHALMOLOGY
SUBDIVISION

Tri Winarti
Ophthalmology Department
Faculty of Medicine Gadjah Mada University

Patients Identity

Name
: ZA
Age
: 9 mo
Sex
: Female
Address
: Cilacap
MR number : 01.66.32.91
Date of visit : August 25th , 2014

Anamnesis
Chief Complaint :
White spot on both eyes (referred by
Ophthalmology Department, Cilacap District
Hospital)

History of Present Illness

Birth : Peeling of the skin referred to SGH hospitalized
in NICU ( 30 days) routinely controlled to Pediatric
Department, Dermatology Department, Ophthalmology
Department of Cilacap District Hospital

2 weeks ago : RE : White spot (+), redness (-), tearing (-)

Ophthalmologist Protagent A ed/1 hour,
Gentamicin eo/6 hours

History of Present Illness

1 day ago : RLE : white spot (+), redness (-),tearing
(-) SGH

History of Delivery
Gestational age : 9 months
Birth weight
: 2600 g
Birth
: spontaneously,

attended by a midwife

History of Family Illness

No member of her family had the similar

condition like her

Family Pedigree

40 yo

16 yo

36 yo

12 yo

9 mo

General Condition
General impression : thick and hard skin

with deep splits

Consciousness : alert
Nutritional status
: bad
Body weight
: 5 kg
Vital sign
Pulse rate
: 70 x/minute
RR
: 15 x/minute
t
: afebrile
9

Ophthalmological Status
Left Eye

Right Eye
Likely present
Ectropion +, eyelash -

Visual Acuity

Within normal limit

Conjunctiva

Ulcer +
Deep, clear
Round, central,
3 mm, LR +/+
Difficult to be
assesed

Eye Lid

Cornea
AC
Iris / Pupil

Lens

Likely present
Ectropion +, eyelash Within normal limit
Ulcer +
Deep, clear
Round, central,
3 mm, LR +/+
Difficult to be
assesed

Ophthalmological Status
Vitreous
body
Papilla N II
Difficult to be
assesed

Macula

Difficult to be
assesed

Retina
N

IOP

Free

OM

Free

Patient Photograph

Patient Photograph

Patient Photograph

Diagnosis

Collodion baby
Bilateral ectropion
RLE corneal ulcer

Management

Protagent A ed / 1 hours RLE

Corneal swabing and culture sensitivity
Consult to :
Dermatology department
Pediatric department

Management

Corneal swabing and culture sensitivity

bacteria (-), fungus (-)
Levofloxacin ed/2 hour RLE
Tobramycin ed/6 hour RLE
Protagent A ed/1 hour RLE
Dermatology department emollient
Pediatric department hospotallized refuse

ThankYou