CATARACT

AND
REFRACTIVE SURGERY
SUBDIVISION

IKA/TEV/FAS/DHA/YAC
CATARACT SURGERY REPORT

NO NAME/AGE RE/ VA PRE OP VA POST SURGERY

LE OP
1. Mr. k/63 y.o RE 0.5/60 ph 5/40 20/70 PH OD Phaco +
20/40 IOL/LA
2. Mrs. S. A/23 LE 1/300 20/150 ph OD Phaco +
yo 20/70 IOL/LA
3. Mrs. Y/55 yo RE 1/300 cor(-) ph(-) 20/150 ph (-) OS SICS +
IOL/LA
 MR. M / 76 Y.O
ADM. JAN, 29 TH 2018
Chief complain : Blurred vision on her right eye
Blurred on her right eye since 7 month ago, gradually and
getting worse. Pain (-), redness (-), tearing (-), glare (-)
History of wearing spectacle :-
History of surgery : Cataract surgery on December 2017,
Tumorectomy mammae in 2015
History of disease : DM(+) on therapy, HT (-), breast cancer
in 2015, CVA thrombosis, dyslipidemia
History of therapy : ASA, Simvastatin, Gabapentin, MST,
and she has finished chemotherapy on October 2017
History of trauma :-
GENERAL CONDITION
BP: 130/80 mmHg
FBS : 182 mg/dL
Cholesterol : 211 mg/dl
Trigliserida : 219 mg/dl
LDL : 158 mg/dl
 SUMMARY OF
DATA BASE
Right Eye Left Eye
LP (+) BP Visual 5/12f cc C-2.25 x 100  5/5f ph (-)
Acuity
spasm (-), edema (-) Eyelid spasm (-), edema (-)
CI (-) , PCI (-)Conjungtiva CI (-), PCI (-)
Clear Cornea Clear
Deep AC Deep
Radline Iris Radline
Round, midri d.t midriatyl, PR (- Pupil Round, midri d.t midriatyl, PR (-)
)
Not homogen opacity, opacity @ Lens IOL on place
subcapsular posterior
14,6 mmHg IOP 17,3 mmHg
FR (+) dim, detail dte Funduscopy FR (+) dim, detail wnl
 Dte ec visus Retinometri 0.8

KR 1: 8.00/42.50x100 Keratometry KR 1: 7.90/42.50x1450

KR 2: 7.80/43.00X1000 KR 2: 7.80/43.00X600

AXL : 23.63 mm Biometri AXL : 23.46 mm

ACD : 3.02 mm ACD : 2.44 mm
Lens : 3.84 mm Lens : 3.81 mm
Ext IOL : +21.00 D IOL : +21.00 D
 USG
RE USG LE USG

Posterior capsule : intact Posterior capsule : intact

 Vitreous:  Vitreous:
anterior , media, posterior: echo anterior , media, posterior: echo
dense (-) dense (-)
 Retina : on place  Retina : on place
 Choroid : wnl  Choroid : wnl
 PNII : on place  PNII : on place
INTERNAL MEDICINE DEPARTMENT

Assesment DM type 2

Glimepiride 4mg-0-0
Planning
therapy
NUEROLOGY DEPARTMENT

Assesment CVA Thrombosis

Planning ASA 1 x 80 mg
therapy
Simvastatin 0-0-20mg
Gabapentin 0-0-30mg
Diagnosis

• RE Cataract Br Gr III + PSC

• LE Pseudophakia

Treatment

• Hospitalized
• Education and information about the
disease and risk
• Education and information about the
planning therapy
• Pro RE SICS + IOL / LA
 TREATMENT

Performed Feb, 12nd 2018

 Diff :

 Compl : -
IOL inserted: +21.00 D

Post Op Ciprofloxacin tab 2 x 500 mg

Treatment
Mefenamic acid tab 3x500mg (if needed)

Levocin e.d 1 drop/hour RE

Fluorometholone e.d 1 drop/hour RE

 FOLLOW UP
DAY 1
Right Eye Left Eye
20/150 ph (-) Visual Acuity 5/12f cc C-2.25 x 100  5/5f ph (-)
spasm (+), edema (-) Eyelid spasm (-), edema (-)
Chemosis (+), SCH (+), CI (-) , PCI (-) Conjungtiva CI (-), PCI (-)
Suture 5 tight good app, edema (+), Cornea Clear
striae(+)
Fl cell gr IV, shallow, retained nucleus AC Deep
(+) @ 5 o’clock, coagulum <1/3 AC,
hyphema (+)
Iridodialysis @ 1 o’clock, radline Iris Radline
not round, PR (-) Pupil Round, 3 mm, PR (+)
IOL on place Lens IOL on place
5 mmHg IOP 14,6 mmHg
FR (+) detail dte Funduscopy FR (+) detail wnl
KR 1: 8.20/41.00x150 Keratometry
KR 2: 7.30/46.00X1000
ASSESSMENTF:OLLOW UP DAY 1
• RE Pseudophakia post SICS/LA day – 1
• LE Pseudophakia

TREATMENT :
• Ciprofloxacin tab 2x500 mg
• Methylprednisolone tab 3x8 mg
• Mefenamic acid tab 3x500mg (if needed)
• Levocin e.d 1 drop/hour RE
• Fluorometholon e.d 1 drop/hour LE
• Peribulbar injection Dexamethasone : Gentamycin = 1:1
• RE Patching
BEFORE

AFTER
THANK YOU