OPHTALMOLOGY RECORD

PTERYGIUM

Examiner :

dr. Gilbert. W. Simanjuntak, SpM

Observer :

Nadia Luthfiana Vashti

(1261050282)
 DEPARTMENT OF EYE DISEASE
PERIOD OF JANUARY 23rd FEBRUARY 25th , 2017
MEDICAL FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA
2017
 OPHTALMOLOGY RECORD

Examiner : Nadia Luthfiana Vashti

NIM : 1261050282

Tutor : dr. Gilbert. W. Simanjuntak, SpM

I. PATIENT IDENTITY

Name : Mr. E

Age : 41 years old

Sex : Male

Religion : Islam

Address : Cililitan Besar RT. 01 RW. 014, East Jakarta

Occupation : Entrepreneur

Status : Married

II. ANAMNESIS

Anamnesis done at February 20th, 2017

Main complaint : Something like a fat grew on both eyes

Additonal complaint :

Itchy and watery eyes.

Chronology of disease :

A 41 years old male came to the Department of Eye Disease at UKI Hospital
with the main complaint about something like a fat grew on both eyes since 5 months
ago. Patient actually felt this fat even more spreading to the center of his eyes recently.
Patient also complained of redness appearance and itchy eyes sometimes. Patient
admitted, his sight is still good and there is no vision problems at all.

Previous disease :

The patient never felt the same symptoms before. Patients never wore contact
lenses or eyeglasses. Patients denied the presence of a high blood pressure, allergy and
diabetes mellitus.

History of family disease :

 In families of patient has never suffered like him.

III. GENERAL STATUS

General condition : Mild illness appearance

Conciousness : Compos mentis

IV. STATUS OFTALMOLOGI

A. General examination

Parameter OD OS
Periocular Appearance Quiet Quiet
General Condition of The eye Mild Mild
Eyeball position Simetric Simetric
Eyeball movement All direction All direction
Visual field Wide Wide
A.

A Sistematic Examination

Parameter OD OS
Visual Acuity 1,0 1,0
 Supersilia Grow evenly Grow evenly
Silia Grow evenly, good Grow evenly, good
position position
Palpebra Normal Normal
Superior/inferior
Color matches the color of Color matches the color of
the skin the skin

edema (-) edema (-)

tumor (-) tumor (-)

Tarsal conjungtiva Hyperemic (-) Hyperemic (-)
Superior/inferior Cicatrical (-) Cicatrical (-)

Papilar (-) Papilar (-)

Forniks conjungtiva Hyperemic (-) Hyperemic (-)

Superior/inferior
Bulbi conjungtiva Hyperemic (-) Hyperemic (-)

Injection conjungtiva (-) Injection conjungtiva (-)

Injection ciliar (-) Injection ciliar (-)

Fibrovascular in triangular Fibrovascular in triangular

shape (+) shape (+)
 Cornea
Clarity Fibrovascular (+) Fibrovascular (+)

Infiltrate (-) (-)

(-) (-)
Ulcus
(-) (-)
Erosion
(-) (-)
Cicatrix
Sclera White White
Cicatrix (-) Cicatrix (-)
Anterior Chamber Medium in depth Medium in depth
Hypopyon (-) Hypopyon (-)
Hyphema (-) Hyphema (-)
Iris Radier Radier
Brown Brown
Synechia (-) Synechia (-)
Pupil Round, isokor, diameter 3 Round, isokor, diameter 3
mm, Direct light mm, Direct light
refleks(+), Indirect light refleks(+), Indirect light
refleks (+) refleks (+)

Lens Clear Clear

A.
I RESUME

A 41 years old male came to the Department of Eye Disease at UKI Hospital
with the main complaint about something like a fat grew on both eyes since 5 months
ago. Patient actually felt this fat even more spreading to the center of his eyes recently.
Patient also complained of redness appearance and itchy eyes sometimes. Patient
admitted, his sight is still good and there is no vision problems at all.

GENERAL STATUS

General condition : Mild illness appearance

Conciousness : Compos mentis

From the ophtalmologic examination on both eyes founded

Parameter OD OS
Visual Acuity 1,0 1,0 (Add +1.00)
Cornea
Clarity Fibrovascular (+) Fibrovascular (+)

Infiltrate (-) (-)

(-) (-)
Ulcus
(-) (-)
Erosion
(-) (-)
Cicatrix
 Bulbi conjungtiva Hyperemic (-) Hyperemic (-)

Injection conjungtiva (-) Injection conjungtiva (-)

Injection ciliar (-) Injection ciliar (-)

Fibrovascular in triangular Fibrovascular in triangular

shape (+) shape (+)

Pupil Round, isokor, diameter 3 Round, isokor, diameter 3

mm, Direct light mm, Direct light
refleks(+), Indirect light refleks(+), Indirect light
refleks (+) refleks (+)

Lens Clear Clear

VI. CLINICAL DIAGNOSE

OD : Pterygium grade II

OS : Pterygium grade I

V. DIFFERENTIAL DIAGNOSE

- Pinguecula

- Pseudopterygium
I MEDICAL TREATMENT

- Non medicamentosa : Use sunglasses to protect the eyes from ultraviolet rays

- Medicamentosa :-

- Operation : Referral to eye specialist to get pterygium excision

I RECOMMENDED EXAMINATION

- Funduscopy

I PROGNOSE

OD OS

Ad Vitam Bonam Bonam

Ad Sanasionum Bonam Bonam

Ad Fungsionum Bonam Bonam

I COMPLICATION

- Recurrent pterygium

- Diplopia