Erliana Fani 2009061258 Monika Theresa P 2009061260 Hendrawan A 2009061264 Ricky Fernando 2009061266 Gerry Wonggo 2009061272 Ido Genesio 2009061273
Supervisor : dr. Abdi Kelana, Sp.M
Fakultas Kedokteran Universitas Katolik Atma Jaya Bagian Ilmu Penyakit Mata Periode 18 September 2011 22 Oktober 2011 1
CASE REPORT Patient Identity Name Sex Age Ethnic Religion Occupation Address : Tn. S : Male : 53 years old : Javanese : Moslem : Labour : Angke Indah
History Taking Chief complaint : Sudden blurry vision since 1 day before admission Additional complaint: Pain, watery and redness on his right eye since 1 day before admission. Headache since 1 day before admission. History of present illness: Since 1 day before admission, when patient was about to sleep, he felt a sudden blurry vision, pain, watery and redness. The blurry vision was lose his peripheral (side) vision. Patient felt throbbing headache especially around the right eye. History of trauma was denied. Usage of topical eye drops was denied. Halo around lights was denied. Nausea and vomiting was denied. Fever was denied. Past occular history : History of using eye-glasses was denied. History of past illneses Hypertension since 5 years ago, controlled with medication (captopril) He denied the following diseases: diabetes mellitus, allergy, asthma, and previous surgical operation, heart disease.
Familial medical history no previous history of similar complaint systemic disease malignancy
General Status General condition Level of consciousness Blood pressure Heart rate Respiratory rate Temperature : appearing sick : fully awake : 100/60 mmHg : 60 x/ minute : 20 x/ minute : 36,8oC
Ophtalamic Status Right eye Normal Redness Orthophoric Can move to 8 directions 1/300 Well from 8 directions Full symmetric Normal Hyperemic edema + tenderness nodule Well-positioned Hyperemic + Injection conjunctiva +, mucoid discharge Left eye Normal Normal Orthophoric Can move to 8 directions 5/5 Well from 8 directions Full symmetric Normal Hyperemic edema tenderness nodule Well-positioned Hyperemic Injection conjunctiva -, mucoid discharge -
Periocular appearence General condition Eyeball position Eyeball movement Visual acquity Light Projection Supercilia Cilia Palpebra
Sup/Inf Margo Palpebra Sup/Inf Tarsal Conjunctiva Bulbar conjunctiva
Cornea Clearness Edema Infiltrate Ulcer Crust Destruction Sikatriks Anterior Chamber Iris Pupil
Clear + Mild depth Clear Darkish brown Crypt (-) Center Round 4mm Light reflex (-)/(-) Isochoric Clear 69,3mmHg
Clear Normal depth Clear Darkish brown Crypt (+) Center Round 2mm Light reflex (+)/(+) Isochoric Clear 37,2mmHg
Lens Tonometry Schiotz
Summary 53 y.o. male, having blurry vision on his right eye, Pain, watery and redness on his right eye for 1 day, headache since 1 day Ophthalmic status of right eye: General Condition Visual acquity Palpebra : Red and swelling : 1/300 : Edema +
Superior/Inferior Tarsal Conjunctiva : Hyperemic + Bulbar Conjunctiva Cornea Anterior Chamber Iris Pupil Tonometry schiotz : Injection conjunctiva + : Edema + : Mild depth : Crypt : Mid dilatasi : 69,3 mmHg
Ophthalmic status of left eye: Tonometry schiotz : 37,2 mmHg
Clinical diagnosis OD Acute Glaucoma OS Primary Closed Angle Glaucoma Chronis
Differential Diagnosis OD Angle Closure Glaucoma OS Primary Open Angle Glaucoma
Treatment Topical : Pilocarpine 2% ED OD 1 drop/5 minutes ( for the first 1 hour), every hour ( for the first day) Timolol Hemihydrate 0,5% ODS 2x1 drop Oral : Asetazolamide 3x250 mg Kalium L-Aspartat 1x1 Asam Mefenamat 2 x500mg prn Surgery : Laser iridotomy/peripheral iridectomy to push iris back and increase angle.
Suggested examination Funduscopy Visual field test Gonioscopy Pachymetry Optic nerve imaging
Complications Complete and permanent blindness
Prevention Regularly visit their ophthalmologist every 6 months 1 year, avoidance ingesting large quantities of fluid.
Prognosis Quo ad vitam Quo ad functionam Quo ad sanationam : bonam : dubia ad malam : dubia ad malam
Discussion 1. Definition Glaucoma (after Mosby), is an abnormal condition of high pressure within an eye. It is caused by a blocking of the normal flow of the watery fluid in the space between the cornea and lens of the eye (aqueous humour). Acute (angle-closure, closed-angle, or narrow-angle) glaucoma happens if the pupil in an eye with a narrow angle between the iris and cornea opens too wide and causes the folded iris to block the flow of aqueous humour. Chronic (open-angle or wideangle) glaucoma is much more common, often occurring in both eyes; it develops slowly and is an inherited disease. Acute glaucoma happens with extreme eye pain, blurred vision, a red eye, and an abnormally wide-open pupil. Nausea and vomiting may occur. If untreated, acute glaucoma results in complete and permanent blindness within 2 to 5 days. Chronic glaucoma may show no symptoms except for gradual loss of side vision over a period of years. Sometimes headaches, blurred vision, and dull pain in the eye are present. Halos around lights and blind spots in the centre of the field of vision begin to occur after the condition has developed for a while. Acute glaucoma is treated with eye drops to close the pupil and draw the iris away from the cornea, drugs that lower pressure, drugs that reduce fluid in the eye, and surgery to produce a pathway for aqueous humour. Chronic glaucoma can usually be controlled with eye drops. All adults should have their eyes examined for glaucoma every three to five years. It is also a good idea for patients who have glaucoma to wear a medical identification tag. Thus, Glaucoma is a disorder in which increased intraocular pressure leads to eventual vision impairment and possibly to degeneration of the optic nerve. It may be a primary condition, or it may be secondary to other ocular disease. Glaucoma is classified as open angle, or closed angle (Pictures below - Acute Glaucoma). 2. Causes and Incidence The aetiology of primary glaucoma is unknown, but predisposing factors include heredity, hyperopia, and vasomotor instability. It is estimated that 1.5% to 2% of Europeans over 40 years of age have glaucoma, and more than 12% of newly diagnosed cases of blindness are attributable to glaucoma. Blacks and those with a family history are most susceptible. Ninety percent of primary glaucoma cases are the open-angle type, which occurs most often after age 65 (Picture right - Glaucoma fundus in chronic open-angle type). 3. Pathophysiology Increased intraocular pressure (IOP) is related to an imbalance in the production, inflow, and outflow of aqueous humour. Inflow occurs through the pupil and outflow through the meshwork at the juncture of the iris and cornea. In secondary glaucoma the meshwork
becomes clogged by blood, fibrin, or inflammatory cells produced by an underlying ocular disorder Primary open-angle glaucoma is marked by degenerative changes to the meshwork that block outflow. In primary closed-angle glaucoma, the anterior chamber is shallow, the filtration angle is narrow, and the iris obstructs the meshwork at Schlemm's canal. Sometimes dilation of the pupil or trauma pushes the iris forward, narrowing the angle and resulting in obstruction in an acute attack. Primary or secondary glaucoma may be congenital; the condition is hereditary (primary) or is caused by foetal defects in the ocular structure or underlying congenital systemic disorders (secondary).
4. Classification glaucoma Open-angle glaucoma is the most common form. Some people have other types of the disease. A) low-tension or normal-tension glaucoma, optic nerve damage and narrowed side vision occur in people with normal eye pressure. Lowering eye pressure at least 30 percent through medicines slows the disease in some people. Glaucoma may worsen in others despite low pressures. A comprehensive medical history is important to identify other potential risk factors, such as low blood pressure, that contribute to low-tension glaucoma. If no risk factors are identified, the treatment options for low-tension glaucoma are the same as for open-angle glaucoma. B) In angle-closure glaucoma, the fluid at the front of the eye cannot drain through the angle and leave the eye. The angle gets blocked by part of the iris. People with this type of glaucoma may have a sudden increase in eye pressure. Symptoms include severe pain and nausea, as well as redness of the eye and blurred vision. If you have these symptoms, you need to seek treatment immediately. This is a medical emergency. If your doctor is unavailable, go to the nearest hospital or clinic. Without treatment to restore the flow of fluid, the eye can become blind. Usually, prompt laser surgery and medicines can clear the blockage, lower eye pressure, and protect vision. C) congenital glaucoma, children are born with a defect in the angle of the eye that slows the normal drainage of fluid. These children usually have obvious symptoms, such as cloudy eyes, sensitivity to light, and excessive tearing. Conventional surgery typically is the suggested treatment, because medicines are not effective and can cause more serious side effects in infants and be difficult to administer. Surgery is safe and effective. If surgery is done promptly, these children usually have an excellent chance of having good vision. D) Secondary glaucomas can develop as complications of other medical conditions. For example, a severe form of glaucoma is called neovascular glaucoma, and can be a result from
poorly controlled diabetes or high blood pressure. Other types of glaucoma sometimes occur with cataract, certain eye tum