Raisa Janet Ariestha

I11109041
Case Report
Name : Mrs. D
Gender : Female
Address : Jl. KH Wahid Hasyim
Age : 55 years old
Occupation : House Wife
Ethnic : Melayu-Bugis
Religion : Islam
Patient was examined on January 27, 2014;
at 12.20 pm

Patient Identity
Main Complaint
Watery eye with pain and headache
ocular sinistra


Clinical History
History of Disease
Patient complains pain in the left eye and
headache since 6 months ago, with a little bit
decreased vision with cloudy. Since 4 months
ago, pain in her eye and head are become
worse, with the decreased vision is also
become blurred. Patient have felt the pain in
the eye ball and around the eye. About a
week ago, pain in her left eye and head are
become worse than before, with watery eye
and a poignant sensation in her nose.

Clinical History
On 20 January 2014, she come to an
ophthalmologist, and diagnosed as Acute
Congestive Glaukoma and treated with
oral acetazolamide and potassium
chloride, eye drops latanoprost, timolol,
pilocarpine and polydex. Patient will
schedule for surgery. On 27 January 2014,
patient come for control, the complain has
been reduced. Patient complains
coughing since 3 days ago.
Clinical History
Past Clinical History
Hypertension (-)
Diabetes Mellitus (-)
Traumatic (-)
Family History
There is no family have symptom like the
patient. There is no history of hypertension
and diabetes mellitus in patient family.

Clinical History
General Status
General condition : Good
Awareness : Compos mentis
Vital Sign
Blood Pressure : 130/90 mmHg
Pulsation : 80 times/minute
Respiratory rate : 20 times/minute
Temperature : 36.4C

Physical Examination
Visual Acuity : OD 6/15
OS 6/60
Eye Position : OD ortho
OS ortho
Eye Movement:



Ophtalmological Status
Right eye Left eye
ptosis (-), lagoftalmos (-),
edema (-)
Palpebra ptosis (-), lagoftalmos (-),
edema(-)
Redness (-), discharge (-) ,
degeneration plaque (-),
foreign body (-), injection
(-)
Conjungtiva Redness (-), discharge (-) ,
degeneration plaque (-),
foreign body (-), injection (-)
Clear, edema (-), ulcer (-),
infiltrate (-), synechiae (-)
Cornea Clear, edema (-), ulcer (-),
infiltrate (-), synechiae (+)
Clear, deep COA Shallow to moderate, clear
Iris colour : brown
Pupil: circular, anisokor,
reactive to light
Iris and pupil Iris colour : brown
Pupil: dilated,
irreguler,anisokoria, reflex (-)
Clear Lens Cloudy
- Shadow Test +
C/D ratio 0,6 Fundus C/D ratio 0,8
21 mmHg IOP 16 mmHg
normal Visual Field Test Visual defect 45 temporal
A woman, 55 years old, came to
ophthalmologist with the complain pain in the
left eye and headache since 6 months ago,
with a little bit decreased vision with cloudy.
Since 4 months ago, pain in her eye and head
are become worse, with the decreased vision
is also become blurred. Patient have felt the
pain in the eye ball and around the eye.
About a week ago, pain in her left eye and
head are become worse than before, with
watery eye and a poignant sensation in her
nose.


Resume
On 20 January 2014, she come to an
ophthalmologist, and diagnosed as Acute
Congestive Glaukoma and treated with
oral acetazolamide and potassium
chloride, eye drops latanoprost, timolol,
pilocarpine and polydex. Patient will
schedule for surgery. On 27 January 2014,
patient come for control, the complain has
been reduced. Patient complains
coughing since 3 days ago.
Resume
Visual acuity is 6/15 for OD, 6/60 for OS.
There is no complain with the right eye. For
the left eye, the cornea is clear; camera
oculi anterior seems shallow to moderate;
and there is posterior synechiae; the pupil
is dilate, irreguler, and have (-) reflex; the
lens seems cloudy. Intraocular presure for
OD 21 mmHg, for OS 16 mmHg. Cup disk
ratio for OD 0,6 and OS 0,8. Shadow test for
left eye is positive. Confrontation test for
the right eye is normal, and for the left eye,
there is visual defect 45 temporal.

Resume
OD : -
OS : Post Acute Congestive Glaucoma
with Immature Cataract

Diagnosis
OD : -
OS :
Pharmacological
Oral : acetazolamide and potassium
chloride
Eye drops : latanoprost, timolol, pilocarpine
and polydex
Surgery : Iridektomi

Treatment
OD
Ad vitam : dubia ad bonam
Ad functionam : dubia ad bonam
Ad sanactionam : dubia ad bonam
OS
Ad vitam : dubia ad bonam
Ad functionam : dubia ad bonam
Ad sanactionam : dubia ad bonam

Prognosis
Discussion
Glaucoma is a condition that involves
distinctive changes in the optic nerve and
visual field.
It is marked by functional and structural
abnormalities in the eye in which optic
nerve damage can ordinarily be alleviated
and inhibited by sufficiently reducing
intraocular pressure (IOP).
Differential diagnosis for normal eye with
gradually vision loss : cataract, glaucoma and
retinopathy.
Because of the patient doesnt have history
about systemic disease especially diabetes
mellitus and hypertension, we can eliminate
the retinopathy.
Patient complain cloudy vision in the left eye
-> suspicious cataract
From the examination there is cloudy lens and
positive result for shadow test -> immature cataract
in left eyes
According to the patient complain, there
are severe pain in the left eye and head,
and the eye also watery, with decreased
vision -> suspicious glaucoma
Trias glaucoma :
Increased IOP, decreased of the visual
field, and papil atrofi

In the examination, there is
1. Shallow to moderate COA





2. Posterior synechiae


3. Dilate pupil, irreguler, and reflex (-)





4. TIO normal
5. Visual defect 45 temporal
6. C/D ratio OD 0,6 ; OS 0,8

According to the clinical history, the
patient have angle-closure glaucoma
Angle-closure glaucoma
1. Prodorma Phase (Non Congestive Phase)
In this stadium, there may a blurred vision,
seems like a halo around the light, with
headache, pain in the eye, and
accomodation weakness. Can happen
in weeks or months even years before it
become acute congestive glaucoma.

Angle-closure glaucoma
2. Acute Congestive Stadium
In this stadium, patient will feel severe
headache. Acute glaucoma causing the
decreased of visual acuity with a powerful
pain inside the eye ball. Nausea and
vomiting may occur.
For the acute congestive glaucoma :
Pharmacological
Oral : acetazolamide and potassium
chloride
Eye drops : latanoprost, timolol, pilocarpine
and polydex
Surgery : Iridektomi
Treatment
Intumescence of the Lens
The lens may take up considerable fluid
during cataractous change, increasing
markedly in size. It may then encroach
upon the anterior chamber, producing
both pupillary block and angle crowding
and resulting in acute angle closure.
Treatment consists of lens extraction once
the intraocular pressure has been
controlled medically.

Immature Cataract and
Glaucoma
Phacolytic Glaucoma
Some advanced cataracts may develop
leakiness of the anterior lens capsule, which
allows passage of liquefied lens proteins into
the anterior chamber. There is an
inflammatory reaction in the anterior
chamber, and the trabecular meshwork
becomes edematous and obstructed with
lens proteins, leading to an acute rise in
intraocular pressure. Lens extraction is the
definitive treatment once the intraocular
pressure has been controlled medically and
intensive topical steroid therapy has reduced
the intraocular inflammation.

Immature Cataract and
Glaucoma
When patient come for control, the
complain has been reduced.
Treatment or the immature cataract :
Surgery



The diagnosis of this patient is Post Acute
Congestive Glaucoma with Immature
Cataract for the left eye. The therapy for
OS is doing the treatment of glaucoma
and surgery for the iridektomi.
Conclusion
Thankyou