Ny. Pitonah-edit2.ppt

Vitreo-Retina Subdivision

Mrs. P/ 53 y.o Admission on Dec, 27th 2017 Chief complain : Blurred on her right eyes • Blurred on her right eye since 1,5 months ago and gradually getting worsed. She also saw like threads that follow everytime she glance. Pain(-), redness(-), glare (+). • She also complained blurred on her left eye since 2 years ago. Pain(-), redness(-), glare (-). • History of trauma : • History of treatment : She got cataract surgery on her right eye since 3 years ago, and she got cataract surgery + use of silicon oil on her left eye since 4 year ago • History of previous eye diseases : cataract • History of allergic : (-) • History of heavy lifting : (-) • History of wearing spectacle : (+) • History of family : (-) • History of systemic disease : DM(-), HT(+) Not Controlled, Cholesterol (-)

General Condition

BP : 160/90 mmHg, HR 86x/m

Summary of Data Base Dec, 27th 2017 Right Eye 5/12 F spasm (-) edema (-) CI (-) PCI (-) Fl test (+) punctat Deep Radline Round, IOL on Place, PCO8,5mmHg

Left Eye Visual Acuity Eyelid Conjunctiva Cornea Anterior Chamber Iris Pupil Lens IOP

LP (-) spasm (-) edema (-) CI (-) PCI (-) Fl test (+) punctat, lekoma (+) Deep Radline Round, Ø3mm, PR (-) IOL on Place, PCO + 10,2 mmHg

Funduscopy Dec 27th 2017 Funduscopy : • RF : +/+dim • Media : Vitreous opacity gr I ec tobacco dust /opacity gr III ec PCO Detail OS : DTE Detail OD:

• ONH • Vascular • Retina • Macula

: round+, sharp margin+, c/d ratio 0,4, orange+, SV >7 : a/v 2/3+ ,scle-, cross: hemorrhage -, exudate -, detach +, tear + (horse shoe), scar post laser +,wrinkling + : FR + / macula on +

RLE USG (27/12/2017)

• Posterior Capsule: intact • Vitreous Anterior :Echodense (+) low spike Media : Ecodense (+) low -med spike Posterior: Echodense (+) low spike Retina: Continous line (?) • Choroid : within normal limit • ONH : on place

•Posterior Capsule: dte •Vitreus : Anterior : echo dense (+) med spike Media : echo dense (+) med spike Posterior : echo dense (+) med spike •Retina : dte •Choroid : dte •ONH : dte

Detachment Chart 27/12/2017

Diagnosis RE RRD with macula on + PVR gr B + post demarcation laser LE Silicon filled eye post Vitrectomy ec Susp RRD + PCO + corneal leucoma RLE pseudophakia + PEE

• • • • • •

• • • • • • • • • • • •

Hb Rbc Wbc Hct Trombocyte Diff Count • Eosinophile • Basophile • Neutrophile • Lymphocyte • Monocyte LED Hb-A1c 4,40 FBG 2HPP SGOT SGPT Ureum Creatinin Total Cholesterole TG HDL Cholesterole LDL Cholesterole

14,80 5,15 6,92 43,50 265

g/dl 106/ɥL 103/ɥL % 103/ɥL

5,3 0,6 60,5 26,2 7,4 4

% % % % % mm/hour

85 120 14 11 32,2 0,61 145 143 35 103

%

mg/dl mg/dl U/L U/L mg/dL mg/dL mg/dl mg/dl mg/dl mg/dl

Laboratory Result

29/12/2017

Cardiolog Dept

Follow Up Day 2 Dec, 28th 2017 Right Eye 2/50 ph 20/30 spasm (-) edema (-) CI (-), PCI (-) Fl test (+) punctat Deep Radline

Left Eye Visual Acuity Eyelid Conjunctiva Cornea Anterior Chamber Iris

LP (-) spasm (-) edema (-) CI (-) PCI (-) Fl test (+) punctat,lekoma (+) Deep Radline

Round, Midmidri IOL on Place

Pupil Lens

Round, 3mm, PR IOL on Place, PCO +,silicon filled eye

7,1mmHg

IOP

17,3 mmHg

Funduscopy Dec 28th 2017 Funduscopy : • RF : +/+dim • Media : Vitreous opacity gr I ec tobacco dust /opacity gr III ec PCO Detail OS : DTE Detail OD:

• ONH : round+, sharp margin+, c/d ratio 0,4, orange+, SV >7 • Vascular : a/v 2/3+ ,scle-, cross• Retina : hemorrhage -, exudate -, detach +, tear +, scar post laser +,wrinkling +,horseshoe tear + • Macula : FR +,macula on +

Diagnosis RE RRD with macula on + PVR gr B + post demarcation laser LE Silicon filled eye post Vitrectomy ec Susp RRD +PCO + corneal leucoma RLE pseudophakia + PEE

RE Pars Plana Vitrectomy +endodrainase+endolaser+silicon oil /GA Dec, 29th 2017 Diff : Comp : -

Post OP Treatment :

•Ciprofloxacin tab 2 x 500 mg (po) •Mefenamic acid tab 3 x 500 mg (po) •Vigamox ed 6 x 1 drop RE •Vosama ed 6 x 1 drop RE •SA 1% ed 3 x 1 drop RE •Bedrest with pronation position

Follow Up Day 3 Dec, 30th 2017 Right Eye 3/60 ph 20/50 Spasm -, Edema + CI + , PCI + min , SCH (+), chemosis + , secret (-) Striae(+) min,Edema(+) min, fl test + punctat Fl cell -,Deep Radline Round, Midri dt SA 1% Iol on place 7,1 mmHg

Visual Acuity

Left Eye LP (-)

Eyelid Conjunctiva

spasm (-) edema (-) CI (-) PCI (-)

Cornea Anterior Chamber Iris Pupil Lens IOP

Fl test (+) punctat,lekoma (+) Deep Radline Round, Ø 3mm, PR IOL on Place, PCO + 17,3 mmHg

Funduscopy Dec,30 th 2017 Funduscopy : • RF : +/+dim • Media : Clear /opacity gr III ec PCO Detail OS : DTE Detail OD: • ONH : round+, sharp margin+, c/d ratio 0,4, orange+, SV >7 • Vascular : a/v 2/3+ ,scle-, cross• Retina : hemorrhage +, exudate - , detach -, tear +, scar post laser +,wrinkling +, retina flat +, silicon oil + • Macula : FR +, macula on +

Detachment Chart 30/12/2017

USG (30/12/2017)

•Posterior Capsule: dte •Vitreus : Anterior : echo dense (+) med spike Media : echo dense (+) med spike Posterior : echo dense (+) med spike •Retina : dte •Choroid : dte •ONH : dte

•Posterior Capsule: dte •Vitreus : Anterior : echo dense (+) med spike Media : echo dense (+) med spike Posterior : echo dense (+) med spike •Retina : dte •Choroid : dte •ONH : dte

FOLLOW UP DAY 3 Dec, 30 th 2017

Detachment Chart Before

After

Before

After