ruptur sklera
TRANSCRIPT
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LAPORAN JAGA RESIDEN Sabtu, 11 - 02 - 2012 JAM 14.00 WIB
s/d Minggu, 12 - 02 - 2012 JAM 07.00 WIB
Residen Jaga : Jaga 2 : dr. Rudi Sinaga Jaga 1 : dr. Syarif Satya Graha Jaga Magang : dr. Iffah T
Konsulen JagaDR.dr. Anang Tribowo , SpM(K)
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Data Dasar Permasalahan ICD Assesment PlanningTn I / Lk/ 64 th/luar kotaKU : Mata kiri keluar darahRPP:± 16 jam hari yang lalu pada saat penderita bekerja di sawah menggunakan Traktor, tiba-tiba penderita terjatuh dan mata kirinya membentur setang traktor. Keluar darah (+), keluar cairan seperti putih telur (-), mata kabur (+), mata merah (+).Penderita kemudian Langsung ke RSUD Lahat dan penderita kemudian dirujuk ke RSMH.Penderita mendapat Obat tetes mata Floxa, cefotaxim, Transamin, Paracetamol
VOS 1/~ PSSTIOS: tidak dilakukan Palpebra : edemaKonjungtiva:Subkonjungtival bleeding (+), Kemosis (+)
BMD: darah (+) di seluruh BMDRFOS : (-)FOS : tidak bisa dinilai
H11.3
Trauma terbuka bola mata dengan komplikasi Suspek ruptur Sklera OS +Kemosis Konjungtiva OS Hifema gr IV
-Informed concent-MRS-Spooling RL+bethadine 0,5%- Floxa ED 1 tts/jam-pro repair Susp.ruptur sklera dengan eksplorasi + evakuasi darah dengan anestesi umum.- Lab darah rutin- Ro Thoraks.- Pro konsul PDL- Pro konsul Anesthesi - Pro USG besok.
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Keadaan Umum : Tampak sakit sedangSensorium : ComposmentisNadi : 80 x/menitRespiratory rate : 20 x/menitTemperatur : 36,8°C
Status Generalis
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OD OSVISUS 6/6 1/~ PSS
TIO 18,5 mmhg Tidak dilakukan
Krepitasi (-)
KBM SimetrisGBM 0 0
0 0
0 0
0 0
0 0
0 0
STATUS OPTHALMOLOGIKUS
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STATUS OPTHALMOLOGIKUS
Palpebra Tenang Edema (+)
Konjungtiva Tenang Subkonjungtival bleeding (+), Kemosis (+)
Kornea Jernih Edema, FT (-)
BMD Sedang darah (+) di seluruh BMD
Iris Gambaran baik Sulit dinilai
Pupil B,C,RC(+), ø 3 mm Sulit dinilai
Lensa Jernih Sulit dinilai
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…STATUS OPTHALMOLOGIKUS
Segmen Posterior: • RFOD (+) RFOS (-)
FOD: - Papil : bulat, batas tegas, warna merah normal, c/d 0,3, a/v 2:3 - Makula : RF (+) normal - Retina : kontur pembuluh darah baik
FOS: Sulit dinilai
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OSVISUS 1/~ PSSTIO 13,1 mmHgKBM Simetris
GBM 0 0
0 0
0 0
Palpebra Edema (+)
Konjungtiva Subkonjungtival bleeding (+),Kemosis (+), jahitan baik, darah (-), pus (-)
Kornea Edema
BMD Terbentuk ,Udara (+), clotting (+) di perifer
Iris Gambaran baik
Pupil B, C, RC (+)
Lensa Jernih
Follow up tanggal 13 Pebruari 2012
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Segmen Posterior RFODS (+)FOD : Papil : Bulat, batas tegas, warna merah normal, c/d 0,3 a/v 2/3Makula : RF (+)Retina : Kontur pembulauh darah baikFOS : detail sulit dinilai
Diagnosis : Trauma tertutup bola mata dengan komplikasi kemosis konjungtiva OS + parasentesis OS
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Penatalaksanaan
- Elevasi kepala 45 derajat - Ciprofloksasin 2 x 500 mg- Parasetamol 3 x 500 mg - Asam traneksamat 3 x 500 mg- Metylprednisolon 3 x 2 tab- Polimiksin neosmisin deksametason ED 8 x 1 tetes OS- Pro USG hari ini
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Foto Follow Up hr I
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terima kasih
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Source : Ferenc Kuhn,Tissue prolaps in Ocular_Traumatology__1st_ed.2008
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• Endoftalmitis : peradangan intra okular yang melibatkan bilik mata
depan dan bilik mata belakang, juga dapat mengenai retina dan koroid (aao sect 9. 2008-9; p 293)
• Endoftalmitis : infeksious : eksogen dan endogen steril (endoftalmitis dengan hasil kultur negatif)
• Endogen : meningitis, septikemia, endokarditis, dll• Eksogen :
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