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The document describes several eye conditions in patients: 1. Konjungtiva bleeding was observed in both eyes with bleeding noted on the conjunctiva. Medications including antibiotics and artificial tears were prescribed. 2. Pterygium was seen in both eyes with fibrovascular changes on the conjunctiva. Xylometazoline eye drops were prescribed. 3. The summary provides concise information about the key findings and treatments for the different eye conditions described in the document, including konjungtivitis, uveitis, bacterial conjunctivitis, and hordeolum palpebrae superior.

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86 views9 pages

Ulfa

The document describes several eye conditions in patients: 1. Konjungtiva bleeding was observed in both eyes with bleeding noted on the conjunctiva. Medications including antibiotics and artificial tears were prescribed. 2. Pterygium was seen in both eyes with fibrovascular changes on the conjunctiva. Xylometazoline eye drops were prescribed. 3. The summary provides concise information about the key findings and treatments for the different eye conditions described in the document, including konjungtivitis, uveitis, bacterial conjunctivitis, and hordeolum palpebrae superior.

Uploaded by

Aga Eustasskid
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Sub konjungtiva bleeding

OD. Status opthamologi. OS

N Palpebra N

Bleeding Konjungtiva Bleeding

N Iris N

N Kornea N

N Co A N

N Pupil N

N Sklera N

N Lensa N

Floxa ED s6ddgtt1 ods

Cendo lyters ED s4ddgtt1 ods


Pteregium

OD. Status opthamologi. OS

N Palpebra N

Jar fibro vaskular Konjungtiva jar fibro vaskular

N Iris N

N Kornea N

N Co A N

N Pupil N

N Sklera N

N Lensa N

Xytrol ED s3ddgtt1 ods

Cendo lyters ED s3ddgtt1 ods


Uveitis

OD Status opthamologi. OS

N Palpebra N

Injeksi siliar Konjungtiva injeksi siliar

N Iris N

N Kornea N

Flare+ Co A Flare +

N Pupil N

N Sklera N

N Lensa N

Floxa EDMD s6ddgtt1 ods

Cendo lyters ED s4ddgtt1 ods

Ibu profen 400mg tab 3x1


Konjungtivitas bakterial (sekret muko purulen)

OD Status opthamologi. OS

N Palpebra N

Injeksi Konjungtiva injeksi

N Iris N

N Kornea N

N Co A N

N Pupil N

N Sklera N

N Lensa N

Tobro EDMD s6ddgtt1 ods

Cendo lyter ED s4ddgtt1 ods


Hordeolum palpebra superior

OD. Status opthamologi. OS

Nodul Palpebra Nodul

N. Konjungtiva N

N Iris N

N Kornea N

N Co A N

N Pupil N

N Sklera N

N Lensa N

Loratadine tab 1x1

Gentamicin zalf 2x1 APL


Diagnosa : Konjungtivitis Viral

OD OS
20/20 Visus 20/20

Orthoforia Kedudukan Bulbus oculi Orthoforia


Trichiasis (-) Madarosis (-) Silia Trichiasis (-) Madarosis (-)
Hiperemis (-) nyeri tekan (-) Palpebra superior Hiperemis (-) nyeri tekan (-)
Edema (-) Edema (-)
Hiperemis (-) nyeri tekan (-) Palpebra inferior Hiperemis (-) nyeri tekan (-)
Edema (-) Edema (-)
Hiperemis (+) Papil (-) Konjungtiva palpebral Hiperemis (+) Papil (-)
Folikel (-) Folikel (-)
Hiperemis (+) Papil (-) Konjungtiva fornices Hiperemis (+) Papil (-)
Folikel (-) Folikel (-)
Injeksikonjungtiva(+) Konjungtiva bulbi Injeksikonjungtiva (+) Sekret
Sekret Purulen (+) Purulen (+)
Injeksi (+) Sclera Injeksi (+)
Arcus Senilis (-)edema (-), Kornea Arcus Senilis (-), edema (-),
infiltrate (-) infiltrate (-)
Sedang, pus (-) darah (-) Camera oculi anterior Sedang, pus (-), darah (-)
Kripta iris utuh Iris Kripta iris utuh
reflek cahaya (+) Pupil reflek cahaya (+)
Jernih Lensa Jernih

Terapi :

-usap dengan kapas setiap 2-3 x/hari

Medika mentosa :

Artificial Tears : Cendo Luyters EDMD S4 dd gtt 1 ODS

Kortikosteroid Topikal : Betametason ED S1 dd gtt 1 ODS


Diagnosa : Hordeolum Internum Palpebra Inferior OS

OD. Status opthamologi. OS

N Palpebra Inferior : edem (+), hiperemis (+), Pus(+)

N Konjungtiva Pars Palpebra : Nodul +, Hiperemi +, Nyeri tekan +

N Iris N

N Kornea N

N Co A N

N Pupil N

N Sklera N

N Lensa N

Penatalaksanaan

Fase Infiltratif:

▪ Kompres Hangat 3-4 kali sehari selama 10-15 menit.

▪ Antibiotik Topikal selama 7-10 hari, pada fase inflamasi. ( Gentamisin Zalf 2x1
APL)

▪ Antibiotik sistemik apabila terjadi selulitis. (Ciprofloxacin 500mg 2x1 tab)

Jika tidak membaik dalam 48 jam atau sudah fase abses, dilakukan insisi dan drainase
bahan purulen.
Fase Supuratif: Insisi dan drainase bahan purulen.

Cara Insisi :

▪ Berikan anestesi local (pantocain 2 % dan procain 2% secara infiltratif)

▪ GA pada anak-anak atau orang yang sangat takut.

▪ Hordeolum Internum : insisi di konjungtiva secara vertical.

▪ Hordeolum Externum : insisi di kulit luar secara horizontal.

▪ Sayatan di pencet untuk mengeluarkan sisa nanah.

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