RS SALEWANGANG MAROS

12nd APRIL 2019

Siti Ramdhani YP
A. Nur Chamidah Wulandari
Case Report
Os Endoftalmitis+Ulkus
Kornea
Name : Mr. M
Age : 24 yo
Medical Record : 244568
Address :Jl.
Occupation : farmers
Date of Examination: 8th April 2019
Main Complaint : pain and redness in the eyes
Guided history :

A man 24 years old came to the Salewangang Hospital with a history of

being exposed to rice accompanied by complaints of pain in the left eye,
red and watery eyes since 4 days ago, complaints began to feel very itchy
eyes then turned red. patients also complained of decreased vision in the
left eye. There is no dirt on the eyes (+). history of trauma (+) history of
treatment at the puskesmas and hospital (+)

History of Disease :
He didn’t have any history of Hypertension, Allergy, Diabetes.

History of Medicine :
Netacen ED / 5x1 gtt OS
A. VISUAL ACUITY EXAMINATION
OD Visus OS
Uncorrected Visual
20/20 1/300
Acuity
- Correction -
Best corrected visual
- -
acuity
- Near visual acuity -
- Correction -
Best corrected near
- -
visual acuity
B. ANTERIOR SEGMENT EXAMINATION
OD OS

Palpebra Oedema (-) Hyperemis (-) Oedema (+) Hyperemis (+)

Squama (-) Inward Squama (-) Inward

Cilia
Eyelashes (-), secret (-) eyelashes(-),secret (-)
Lacrimal Apparatus Lacrimation (-) Lacrimation (+)
Conjunctiva Injectio (-) Injectio (+)
Cornea Clear Central ulcer
Anterior Chamber Normal depth Hypopion ¼ BMD
Iris Brown, Crypt (+) Brown, Crypt (+)
Pupil Round, Central difficult to evaluate
Direct/Indirect Light
+/+ Difficult to evaluate
Reflex
RAPD - -
Lens Clear difficult to evaluate
C. PALPATION

OD OS
Ocular Pressure TN TN
Tumor/Mass (-) (-)
Pre Auriculer gland Not palpable Not palpable
DIAGNOSIS
OS Endoftalmitis+Ulkus kornea

DIFFERENTIAL DIAGNOSIS
Panoftalmitis
Uveitis
 TREATMENT
01 Farmakologi 02 Education
- Infus RL 16 tpm - Tell the patients and
- Ceftriaxone families not to rub their
1gr/12jam/iv eyes.
- Dexamethasone 1 - Wear protective
amp/8j/iv glasses10%
- Netacen ED 5x1 gtt
OS
- Polygran ED/ 5x1 gtt
OS
- Ketokonazole tab
4x400 mg
- As. Mefenamat 3x500
mg
THANK YOU