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Morning Report Mata

This morning report summarizes the examination of a 64-year-old female patient named Ny. M who presented with complaints of bilateral eye tightness and blurry vision for the past month. On examination, she was found to have edema and haziness of the cornea in the left eye, as well as cataracts in the left lens. She has a history of glaucoma and previous glaucoma surgery in both eyes. The assessment is suspected acute primary closed angle glaucoma in the left eye and immature senile cataracts in the left eye. The treatment plan includes beta-blocker eye drops, artificial tears, and new bifocal glasses.

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Youngky Putra
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107 views

Morning Report Mata

This morning report summarizes the examination of a 64-year-old female patient named Ny. M who presented with complaints of bilateral eye tightness and blurry vision for the past month. On examination, she was found to have edema and haziness of the cornea in the left eye, as well as cataracts in the left lens. She has a history of glaucoma and previous glaucoma surgery in both eyes. The assessment is suspected acute primary closed angle glaucoma in the left eye and immature senile cataracts in the left eye. The treatment plan includes beta-blocker eye drops, artificial tears, and new bifocal glasses.

Uploaded by

Youngky Putra
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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MORNING REPORT

Pembimbing: dr. Ululil Chusaida, Sp.M.

Oleh:
Ricki Yudhanata
Maya Aulia Lukitasari
Identitas

• Nama : Ny. M
• Usia : 64 tahun
• Alamat : Surabaya
• Pekerjaan : -
• Pendidikan : SMP
• Agama : Islam
• Tanggal Pemeriksaan : Jumat, 22 Maret 2019
Anamnesis
• Keluhan Utama : Kedua mata kenceng-kenceng
• Keluhan Tambahan : kedua mata kabur

• RPS : Pasien datang ke Poli Mata dengan keluhan kedua mata


kenceng – kenceng sejak ± 1 bulan terakhir. Pasien juga
mengeluhkan kedua mata terasa kabur. Pasien mempunyai
riwayat glaukoma. Mata kanan pernah di operasi glaukoma, mata
kiri operasi laser. Riwayat memakai obat tetes mata Timolol mata
kiri & kanan
• RPD : DM (-), HT (-)
• Riwayat glaukoma (+), mata kanan post op glaukoma
• mata kiri post op laser glaukoma
• Alergi obat (-)
• RPK : mengalami sakit yg sama (-), DM (-), HT (-)
• Rsos : merokok (-), konsumsi alcohol (-)
Pemeriksaan Fisik
- Keadaan Umum: Baik
- Pemeriksaan Visus:
Auto Refractor  OD: S+0,50 / C-1,50 / axis 150
OS: S-0,25 / C-0,50 / axis 95

Kacamata Lama  OD: S-0,50


OS: S-0,75
Add: +3,00

Visus Koreksi VOD: 0,6 f cc C -1,00 / x 130  0,8 F Ph tetap


VOS: 0,5 f cc S -0,50 / C - 0,50 / x 90  0,8 F Ph tetap
Add : + 3.00 PD: 64/62
- Tekanan Intra Okuler:
TOD: 14,6 mmhg
TOS: 14,6 mmhg
- Pergerakan Bola Mata:
OD OS

Baik Segala Arah Baik Segala Arah


OD Keterangan OS

Edema (-) Hiperemi (-), rima okuli Palpebra Edema (-) Hiperemi (-), rima okuli
D et S simetris D et S simetris
Arah pertumbuhan normal, sekret Silia Arah pertumbuhan norml, sekret(-)
(-)
Hiperemi (-) Edema (-) Konjungtiva Hiperemi (-) Edema (-)

Edema (+), Jernih Kornea Edema (+) Jernih

Jernih, dangkal Bilik Mata Depan Jernih, dangkal

Warna coklat, iris shadow (+) Iris Warna coklat, iris shadow (+)

Bulat, isokor, Pupil Bulat, isokor,

Diameter 3 mm, Diameter 3 mm,

RL/RTL (+) RL/RTL (+)

Keruh Lensa Keruh


Kornea Edema Kornea Edema

Lensa keruh
Lensa keruh
OD
OS
OD Keterangan OS
+ Fundus Reflek +
CD Ratio 0,4 Papil Nervus 2 CD ratio 0,4
Hemorrage (-), Retina Hemorrage (-),
eksudat (-) eksudat (-)
A /V = 2 /3 Vaskuler A/V=2/3
Reflek fovea (+) Makula Reflek fovea (+)
Jernih Vitreous Jernih
RESUME

• Ny. M, 64 th
• Kedua mata kenceng – kenceng sejak 1 bulan yll
• Kedua mata kabur
• TIO  OD: 14,6 OS: 14,6
• Riwayat glaukoma (+)
• OD post op glaucoma, OS post op laser glaukoma
• SA : ODS BMD dangkal, edema kornea (+) ODS, lensa
keruh ODS
• SP : CDR ODS 0,4
Assesment

1. Susp. ODS Katarak Senile Imature

2. Susp. ODS Primary Acute Closed Glaucoma


dd: ODS Normal-Tension Glaucoma
Planning
• Diagnosis : • Monitoring :
– Pemeriksaan Lapang Pandang  – TIO
Humphrey Visual Field Test – Visus
– Pemeriksaan gonioskopi – Segmen anterior
– Segmen posterior
– Keluhan pasien
• Terapi :
– Beta-blocker  Timolol 0,5 eye drop % 2 x 1
ODS
– Artificial tears  Cendo lyteers eye drop 4 x
1 ODS
– Pemberian Kacamata Bifocal dengan
ukuran:
OD: C -1,00 / x 130
OS: 0,5 f cc S -0,50 / C - 0,50 / x 90
Add: +3,00 PD: 64/62
Edukasi
 Menjelaskan pada pasien dan keluarga mengenai hasil
pemeriksaan yang didapatkan
 Menjelaskan pada pasien dan keluarga mengenai penyakitnya
dan perjalanan penyakit serta faktor resiko penyebabnya
 Menjelaskan pada pasien dan keluarga mengenai komplikasi dan
prognosis dari penyakit pasien
 Menjelaskan pada pasien dan keluarga mengenai tatalaksana
yang akan dilakukan
 Menganjurkan pasien untuk segera kembali ke dokter apabila
keluhan bertambah
TERIMAKASIH

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