PTERYGIUM

Case report
By : Kiki Rizki Elvandari, S.Ked
Preceptor : dr. Rahmat Syuhada, Sp.M
Patient identity

 Name : Mrs. U
 Age : 61
 Sex : Female
 Occupation : Farmer
 RM Numbers : 080184
 Hospitalized : 04/07/2017
 ANAMNESIS

Autoanamnesis , 04 july 2017

Main complaint:
There is a membrane in the left eye
 Additional Complaints:
The eyesight is disturbed, the eyes are sore and like
there is a wedge.
 Disease History Now

 Since ± 1 year ago patients complained of a membrane

in the left eye. The membranes appear increasingly
radiating from edge to center of the eyeball. (+)
Aqueous (-), glare at sight (-), headache (-). Trauma (-).
Past disease history

Past eye disease history (-)

History wearing glasses (-)
The history of hypertension is denied
History of diabetes mellitus is denied
Family Disease History

 The history of both parents wearing glasses (-)

 The history of the disease with the same complaint in the
family is denied
PHYSICAL INVESTIGATION

Patient Status
 General Condition : mild illness
 Awareness : compos mentis
 Blood Pressure : 130/80 mmHg
 Nadi : 88 x / min regular
 Temperature : 36.5 C
Ophthalmological status

OD OS
20/30 Visus 20/40

+0,50 Correction +1,00

orthoforia Bulbus oculi position Orthoforia

Trichiasis (-) silia Trichiasis (-)

Madarosis (-) Madarosis (-)
Hiperemis (-) tenderness(-) Palpebra superior Hiperemis (-) tenderness(-)
Edema (-) Edema (-)
Hiperemis (-) tenderness(-) Palpebra inferior Hiperemis (-) tenderness(-)
Edema (-) Edema (-)
Ophthalmological status

OD OS
Papil (-) Conjungtiva palpebra Papil (-)
Folikel (-) Folikel (-)
Papil (-) Conjungtiva fornices Papil (-)
Folikel (-) Folikel (-)
Injeksi (-) Conjungtiva bulbi Injeksi (+)
Fibrovaskular tissue (-) fibrovaskular tissue(+)
Injeksi (-) sclera Injeksi (-)
 Ophthalmological status

OD OS
Clear Cornea fibrovaskular tissue (+) from the
limbus cornea to the edges of the
cornea >1 mm
mild, pus (-) blood (-) Camera oculi anterior mild, pus (-) blood (-)

Kripta iris normal, brown color Iris Kripta iris normal, brown color

Spherical, d: 3mm, light reflex (+) Pupil Spherical, d: 3mm, light reflex (+)

Clear Lensa Clear

DIAGNOSIS OF WORK

Pterigium Simplex Occuli Sinistra Grade III

DIFFERENT DIAGNOSIS

Pseudopterigium
Pinguekula
Kista dermoid
Simblefaron
PROGNOSA
 Quo ad vitam : dubia ad bonam
 Quo ad functionam : dubia ad bonam
 Quo ad Sanationam : dubia ad bonam
Treatment
 medicamentosa
 ANTIBIOTIC + CORTICOSTEROID
 R/ CENDO XITROL ED NO 1
S 4 DD GTT 1 OS
 ARTIFICIAL TEARS
 R/ CENDO LYTEERS ED NO 1
S 3 DD GTT I OS
 Non medicamentosa
 Exstripasi and autograft conjungtiva sinistra
 DISCUSSION

 Pterigium is a conjunctival fibrocular

growth that is degenerative and
infasif. This growth is usually located in
the gap of the nasal passage and the
temporal conjunctiva that extends
into the cornea. Pterigium shaped
triangle with a peak in the central or
central part of the cornea.
 ETIOLOGY

 Increased exposure to ultraviolet light, including living in

temperate and subtropics tropical regions.

 Doing work and requires activities outside the home as

well as people living in areas with plenty of sun, sandy
areas or windy areas.
PATOFISIOLOGI

 Ultraviolet light, wind, and dust can

irritate the surface of the eye, this
will interfere with the regeneration
of conjunctival tissue and
replaced by an overgrowth of
fibrous tissue containing blood
vessels
 Classification
Based on location
 Pterigium Simplex; if it happens only in nasal /
temporal only.
 Pterigium Duplex; if it occurs in the nasal and
temporal.

Based on pterigium area

 Grade I: if only limited to the corneal limbus
 Grade II: if it has passed the limbus but not more
than 2 mm past the cornea
 Grade III: if it has exceeded degree II but does not
exceed the edge of the pupil eye in the light state
(the pupil is in normal condition around 3-4mm)
 Grade IV: if growth has passed through the pupil
thus disturbing the vision
Symptoms: Varied

• Red eye
• Swelling of the eyes
• Itchy eyes
• Irritation
• Blurry vision
• Feel there that grows on the cornea
• Vision is impaired
DIFFERENTIAL DIAGNOSIS

PSEUDOPTERIGIUM PINGUEKULA
DIFFERENTIAL DIAGNOSIS

SIMBLEFARON KISTA DERMOID

treatment

Giving antibiotics
Administration of corticosteroids
Artificial tearing
Surgery if needed
Education to patients
THANK YOU :*