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This duty report summarizes the examination and treatment of a 43-year-old female patient who presented with left eye pain and blurry vision after being punched in the eye by her husband. On examination, she had a grade IV left eye corneal laceration with luxated lens and suspected globe rupture. She underwent left eye corneal suturing surgery. Follow up examinations on subsequent days found sutures in place with chemosis and suprachoroidal hemorrhage seen on ultrasound. She was treated with antibiotics, steroids and analgesics.
This duty report summarizes the examination and treatment of a 43-year-old female patient who presented with left eye pain and blurry vision after being punched in the eye by her husband. On examination, she had a grade IV left eye corneal laceration with luxated lens and suspected globe rupture. She underwent left eye corneal suturing surgery. Follow up examinations on subsequent days found sutures in place with chemosis and suprachoroidal hemorrhage seen on ultrasound. She was treated with antibiotics, steroids and analgesics.
This duty report summarizes the examination and treatment of a 43-year-old female patient who presented with left eye pain and blurry vision after being punched in the eye by her husband. On examination, she had a grade IV left eye corneal laceration with luxated lens and suspected globe rupture. She underwent left eye corneal suturing surgery. Follow up examinations on subsequent days found sutures in place with chemosis and suprachoroidal hemorrhage seen on ultrasound. She was treated with antibiotics, steroids and analgesics.
Ophthalmologist : Dr. dr. Trilaksana Sp.M Senior Resident : dr. Habibi Junior Resident : dr. Risa Identity • Name : Mrs. Mei Monah • Age : 43 yo • Address : Semarang History • Chief Complaint : Pain in her left eye • Recent History : ± 1,5 hours before admission,her left eye was punched by her husband, pain on his right eye(+), the left eye difficult to open, watery eye (+), bleeding (+), redness in her left eye (+), blurry vision (+), jelly like subs (+). Previously, her son take her to the Dr. Karyadi Hospital • Medical History : he didn’t use any medicine • Past Medical History : - Trauma history (+) - Since childhood her eye already blurry, there is whiteness on her left eye - Alergy (-), DM (-), HT (-),spectacles (-) • Sosioeconomic History : patient is a factory workers RE LE Visual acuity 6/6 1/300 Digital IOP N - Eyelid Edema (-), spasm (-) Spasme(+), hematom (+), edema (-), laceration (-) Conjunctiva injection (-) Hiperemis (+), minimal chemosis (+), SKB (-), laceration (-) Cornea Clear (+) Clear (+), lekoma(+), laceration (+) full thickness, ±6mm, Humor Aquous(+) active, CV (+) on laceration, iris pigment (+) on cornea endothel Anterior chamber The depth of enough One chamber (Iridodialisis total), clot (+), CV (+) Iris Kripte (+) Pupil Round, central, regular, Ø 3mm, RP (+) N Can't evaluated Lens clear (+) impressed aphakia Fundus Reflex Bright Dark Funduscopy Normal limits Can't evaluated
Ocular Trauma Score: 2
- Hand Movement : 70 - Globe Rupture : -23 Raw Score Sum : 47 USG B scan: • Lens in Cavum Vitreous, Vitreous Haemorrhage • Diagnosis : OS Cornea Laceration grade IV + Luxated lens, Susp. Rupture Bulbi • Treatment : • Hospitalize • examination laboratory • EKG • Pro: OS Cornea Hecting + Exploration Bulbi / GA • Vigamox ED/2 hr OS • P. Pred ED/ 2hr OS • SA 1 % ED/8 hr OS • IVFD RL 20 tpm • Ceftriaxon 1gr/12 hr iv • Methyl prednisolone 125mg/ 12 hr iv • Consult to Anesthesia division • Education for patient: OS Dubia ad malam OS Cornea Hecting / GA Dr. dr. Trilaksana Sp.M / HB, RFS Saturday, 1 July 2017/ ok 1/ 03.00-04.00
Durante Op: Laceration on sclera
(-) Treatment post op: • Vigamox ED/2 hr OS • P. Pred ED/ 2hr OS • SA 1 % ED/8 hr OS • Ceftriaxon 1gr/12 hr iv • Methyl prednisolone 125mg/ 12 hr iv • Analgetic → Anesthesia division Follow Up Post Op I RE LE Visual acuity 6/6 1/~ LPB Digital IOP N N Eyelid Edema (-), spasm (-) Spasme(+), hematom (+), edema (+) minimal Conjunctiva injection (-) SKB (+), chemosis (+) Cornea Clear (+) Suture is tight, lekoma(+), seidel test (-) Anterior chamber The depth of enough Difficult to be evaluated
Iris Kripte (+) Difficult to be evaluated
Pupil Round, central, regular, Ø 3mm, RP (+) N Difficult to be evaluated
Lens clear (+) Difficult to be evaluated Fundus Reflex Bright Dark Funduscopy Normal limits Can't evaluated Diagnosis: OD Post Cornea Hecting H1 Treatment: • Vigamox ED/2 hr OS • P. Pred ED/ 2hr OS • SA 1 % ED/8 hr OS • Ceftriaxon 1gr/12 hr iv • Methyl prednisolone 125mg/ 12 hr iv • Analgetic → Anesthesia division Follow Up Post Op II RE LE Visual acuity 6/6 1/~ LPB Digital IOP N N Eyelid Edema (-), spasm (-) Spasme(+), hematom (+), edema (+) minimal Conjunctiva injection (-) SKB (+), chemosis (+) Cornea Clear (+) Suture is tight, lekoma(+), seidel test (-) Anterior chamber The depth of enough Difficult to be evaluated
Iris Kripte (+) Difficult to be evaluated
Pupil Round, central, regular, Ø 3mm, RP (+) N Difficult to be evaluated
Lens clear (+) Difficult to be evaluated Fundus Reflex Bright Dark Funduscopy Normal limits Can't evaluated Diagnosis: OD Post Cornea Hecting H 2 Treatment: • Vigamox ED/2 hr OS • P. Pred ED/ 2hr OS • SA 1 % ED/8 hr OS • Ceftriaxon 1gr/12 hr iv • Methyl prednisolone 125mg/ 12 hr iv • Analgetic → Anesthesia division • USG B scan → Suprahoroidal Haemorrhage