Case Oculi

8/12/2019 Case Oculi

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CHAPTER I

INTRODUCTION

A cataract is a clouding of the eye's natural lens, which lies behind the iris and the

pupil. The lens works much like a camera lens, focusing light into the retina at the back of the

eye. The lens also adjusts the eye's focus, letting us see things clearly both up close and far

away.

Aging is the most common cause of cataract (esp. persons over 65-70 years) but many

other factors can be involved, including trauma, toxins, systemic disease, and heredity. Age

related cataract is a common cause of visual impairment. Cataract usually happens in both

eyes, but traumatic cataract may happen in only one eye. The sexes are equally affected.Cataracts also run in families. The condition is estimated to have blinded more than 25

million people worldwide.

The crystalline lens is implicated as a causative element in producing several forms of

glaucoma. Etiologically they represent a diversity in the presentation of the glaucomatous

process. These conditions include glaucoma related to: lens dislocation (ectopia lentis), lens

swelling (intumescent cataract), classical pupillary block, aqueous misdirection - ciliary

block, phacoanaphylaxis, lens particle, and phacolytic glaucoma. In normal eye, there is a

balance between the production and outflow of the aqueous. When its blocked, the

intraocular pressure increased leads to the damage of optic nerve.The management of

elevated intraocular pressure often requires altering the intraocular relationship of anatomic

structures surrounding the lens or lens removal. In glaucoma there is a weakness in eye

function caused of the visual field decreased and anatomical damage and the degeneration of

the optic disc which can resulting blindness.


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CHAPTER II

LITERATURE REVIEW

Anatomy and Physiology of lensThe crystalline lens focuses a clear image on the retina. The lens is suspended by thin

filamentous zonules from the ciliary body between the iris anteriorly and the vitreous

humor posteriorly. Contraction of the ciliary muscle permits focusing of the lens. The

lens is enclosed in a capsule of transparent elastic basement membrane. The capsule

encloses the cortex and the nucleus of the lens as well as a single anterior layer of

cuboidal epithelium. The lens has no innervation or blood supply. Nourishment comes

from the aqueous fluid and the vitreous.

The normal lens continues to grow throughout life. The epithelial cells continue to

produce new cortical lens fibers, yielding a slow increase in size, weight, and density over

the years. The normal lens consists of 35% protein by mass. The percentage of insoluble

protein increases as the lens ages and as a cataract develops.

Definition of CataractA cataract is any opacity or discoloration of the lens, whether a small, local opacity or

the complete loss of transparency. Clinically, the term cataract is usually reserved foropacities that affect visual acuity because many normal lenses have small, visually

opacities. A cataract is described in terms of the zones of the lens involved in the opacity.

These zones of opacity may be subcapsular, cortical, or nuclear and may be anterior or

posterior in location. In addition to of the nucleus and cortex, there may be a yellow or

amber color change to the lens. A cataract also can be described in terms of its stage of

development. A cataract with a clear cortex remaining is immature. A mature cataract

has a totally opacified cortex.

EpidemiologyAge-related cataract is responsible for 48% of world blindness, which represents

about 18 million people, according to the World Health Organization (WHO). In many

countries surgical services are inadequate, and cataracts remain the leading cause of

blindness. As populations age, the number of people with cataracts is growing. Cataracts

are also an important cause of low vision in both developed and developing countries.

Even where surgical services are available, low vision associated with cataracts may still


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metabolites can enter the cells of the lens nucleus via the epithelium and cortex occurs

with a subsequent decrease in the rate of transport of water, nutrients, and antioxidants.

Consequently, progressive oxidative damage to the lens with aging takes place,

leading to senile cataract development. Various studies showing an increase in products of

oxidation (eg, oxidized glutathione) and a decrease in antioxidant vitamins and the enzyme

superoxide dismutase underscore the important role of oxidative processes in

cataractogenesis.

Another mechanism involved is the conversion of soluble low-molecular weight

cytoplasmic lens proteins to soluble high molecular weight aggregates, insoluble phases,

and insoluble membrane-protein matrices. The resulting protein changes cause abrupt

fluctuations in the refractive index of the lens, scatter light rays, and reduce transparency.

Other areas being investigated include the role of nutrition in cataract development,

particularly the involvement of glucose and trace minerals and vitamins.

6. StageIn clinical, senile cataract devided to 4 stage:

1) Insipient CataractsIn this stadium opacity start from marginal equator to anterior and posterior cortex.

This opacity can arised poliopia because refraction index is not same in the all of lens.

2) Immature CataractsOpacity at a part of lens. In this stadium lens volume will increase and make osmotic

pressure increase too. Subsequently, lens more convex and occure block pupil,finally can

arise secunder glaucoma.

3) Mature CatarctsOpacity can found in all of lens. This opacity can occure because there is calcium

depotitions in the lens. Fluid in the lens will remove out so that lens will back at normal

size, anterior chambers back at normal depth and there isnt iris image at the opaque lens

so shadow test is negative.

4) Hipermature CataractsMass lens move out from the lens capsule so lens becomes small,yellow colored and

dry. In the examination seen anterior chamber is deep and there is lens capsule fold. If

cataract process continued accompanied with thicken capsule so cortex degeneration can


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not move out and can seen like a milk pack accompanied nucleus that concentrate in basal

lens cortex. This condition called Morgagni Cataract.

Symptoms and Signa. Symptoms

Many patients complain of blurred vision, which is usually worse when viewing

distant objects. If the patient is unable to read small print, the surgeon might suspect that

other pathology, such as macular degeneration, could be present. One must bear in mind

that some elderly patients say that they cannot read when it is found that they can read

small print if carefully tested. It is a curious fact that when the cataract is unilateral, the

patient can claim that the loss of vision has been quite sudden. Elucidation of the history

in these cases sometimes reveals that the visual loss was noted when washing and

observing the face in the mirror.

When one hand is lowered before the other, the unilateral visual loss is noticed for the

first time and interpreted as a sudden event. The history in cataract cases might be further

confused by a natural tendency for patients to project their symptoms into the spectacles,

and several pairs might be obtained before the true cause of the problem is found. In order

to understand the symptoms of cataract, it is essential to understand what is meant byindex myopia. This simply refers to the change in refractive power of the lens, which

occurs as a preliminary to cataract formation. Index myopia can also result from

uncontrolled diabetes. If we imagine an elderly patient who requires reading glasses (for

presbyopia) in the normal way but no glasses for viewing distant objects, the onset of

index myopia will produce blurring of distance vision, but also the patient will discover to

his or her surprise that it is possible to read again without glasses. In the same way, the

hypermetropic patient will become less hypermetropic and find that it is possible to see

again in the distance without glasses. The ageing fibres in the precataractous lens become

more effective at converging light rays so that parallel rays of light are brought to a focus

more anteriorly in the eye. A part from blurring of vision, the cataract patient often

complains of monocular diplopia.

Sometimes even a slight and subtle opacity in the posterior part of the lens can cause

the patient to notice, for example, that car rear lights appear doubled, and this can be

reproduced with the ophthalmoscope light. Monocular diplopia is suspect symptom, the

suggestion being that if a patient continues to see double, even when one eye is closed,


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then he or she might not be giving an accurate history. In actual practice nothing could be

further from the truth and this is quite a common presenting feature of cataract. Glare is

another common presenting symptom.

Picture 2. Opaque areas in the lens can be seen clearly

against the red reflex.

The patient complains that he or she cannot see so well in bright light and might even

be wearing a pair of dark glasses. Glare is a photographic term but here it refers to a

significant reduction in visual acuity when an extraneous light source is introduced.

Light shining from the side is scattered in the cataractous lens and reduces the quality

of the image on the retina. Glare becomes an important consideration when advising

an elderly cataractous patient on fitness to drive. The visual acuity might be within the

requirements laid down by law (seeing a number plate at 20.5 m) but only when the

patient is tested in the absence of glare.

A consideration of all these factors makes itrelatively easy to diagnose cataract even

before examining the patient. To summarise, a typical patient might complain that the

glasses have been inaccurately prescribed, that the vision is much worse in bright

sunlight, that sometimes things look double and that there is difficulty in recognising

peoples faces in the street rather than difficulty in reading. Patients with cataracts

alone do not usually complain that things look distorted or that straight lines look

bent, nor do they experience pain in the eye. Rarely, cataracts become hypermature;

that is to say, the lens enlarges in the eye and this in turn can lead to secondary

glaucoma and pain in the eye. Urgent surgery might be needed under these


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circumstances. In its late stages, acataract matures and becomes white, so that

exceptionally a patient might complain of a white spot in the middle of the pupil.

b. Signs1) Reduced Visual Acuity

A reduction in visual acuity can, of course, be an early sign of cataract formation but this

is not always the case. Some patients see surprisingly well through marked lens opacities, and

the effect on visual acuity as measured by the Snellen test type depends as much on the

position of the opacities in the lens as on the density of the opacities.

2) Findings of OphthalmoscopyThe best way of picking up a cataract in its early stages is to view the pupil through the

ophthalmoscope from a distance of about 50 cm. In this way, the red reflex is clearly seen.

The red reflex is simply the reflection of light from the fundus and it is viewed in exactly the

same manner that one might view a cats eyes in the headlamps of ones car or the eyes of

ones friends in an illjudged flash photograph. In fact, such a flash photo could well show up

an early cataract if an elderly relative were included in the photograph. When using the

ophthalmoscope, the opacities in the lens are often seen as black spokes against the red

reflex. It is important to focus ones eyes onto the plane of the patients pupil if the cataract isto be well seen, and it is preferable to dilate the pupil beforehand or at least examine in a

darkened room. Typical age-related lens opacities are wedge shaped, pointing towards the

centre of the pupil. At the same time, the central nucleus of the lens can take on a yellowish-

brown colour, the appearance being termed lens sclerosis, and ultimately, the lens can

become nearly black in some instances. After inspecting a cataract with the ophthalmoscope

held at a distance from the eye, one must then approach closer and attempt to examine the

fundus. Further useful information about the density of the cataract can be obtained in this

way. It is generally true that if Cataract Opaque areas in the lens can be seen clearly against

the red reflex. the observer can see in, the patient can see out. If there is an obvious

discrepancy between the clarity of the fundus and the visual acuity of the patient, some other

pathology might be suspected. Sometimes the patient might not have performed too well on

subjective testing and such an error should be apparent when the fundus is viewed. Some

types of cataract can be misleading in this respect and this applies particularly to those seen in

highly myopic patients. Here, there is sometimes a preponderance of nuclear sclerosis, which

simply causes distortion of the fundus while the disc and macula can be seen quite clearly.1


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ManagementAt the present time, there is no effective medical treatment for cataract in spite of a

number of claims over the years. A recent report has suggested that oral aspirin can delay the

progress of cataract in female diabetics. Although this might be expected to have some effect

on theoretical grounds, any benefit is probably marginal. Occasionally, patients claim that

their cataracts seem to have cleared, but such fluctuation in density of the lens opacities has

not been demonstrated in a scientific manner. Cataracts associated with galactosaemia are

thought to clear under the influence of prompt treatment of the underlying problem. Cataract

is, therefore, essentially a surgical problem, and the management of a patient with cataract

depends on deciding at what point the visual impairment of the patient justifies undergoing

the risks of surgery. The cataractoperation itself has been practiced since pre-Christian times,

and developments in recent years have made it safe and effective in a large proportion of

cases. The operation entails removal of all the opaque lens fibres from within the lens capsule

and replacing them with a clear plastic lens. Common Eye Diseases and their Management In

the early part of the last century the technical side of cataract surgery necessitated waiting for

the cataract to become ripe.Nowadays no such waiting is needed and it is theoretically

possible to remove a clear lens. The decision to operate is based on whether the patient will

see better afterwards. Modern cataract surgery can restore the vision in a remarkable way and

patients often say that theyhave not seen so well for many years. Indeed, many patients have

quite reasonable vision without glasses but this cannot be guaranteed and, because the plastic

lens implant gives a fixed focus, glasses will inevitably be needed for some distances.

Probably the worst thing that can happen after the operation is infection leading to

endophthalmitis and loss of the sight of the eye. Although this only occurs in about one out of

a thousand cases, the patient contemplating cataract surgery needs to be aware of the

possibility. Before the operation, it is now a routine to measure the length of the eye and the

corneal curvature.Knowing these two measurements, one can assess the strength of

lensimplant that is needed. When deciding on thestrength of implant, it is necessary to

considerthe other eye. The aim is usually to make the two eyes optically similar because

patients find it difficult to tolerate two different eyes.


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b. When To Operate

Even though the decision to operate on a cataract must be made by the ophthalmic

surgeon, optometrists and the nonspecialist general practitioner need to understand the

reasoning behind this decision. Elderly patients tend to forget what they have been told in the

clinic and might not, for example, understand why cataract surgery is being delayed when

macular degeneration is the main cause of visual loss. An operation is usually not required if

the patient has not noticed any problem, although sometimes the patient can deny the

problem through some unexpressed fear. The requirements of the patient need to be

considered; those of the chairbound arthritic 80-year-old subject who can still read small print

quite easily are different from the younger business person who needs to be able to see a car

number plate at 20.5 m in order to drive. The visual acuity by itself is not always a reliable

guide.Some patients who have marked glare might need surgery with a visual acuity of 6/9,

whereas others with less visual demands might be quite happy with a vision of 6/12 or 6/18.

Early surgery might be needed to keep a joiner or bus driver at work for which good

binocular vision is needed.

b. The Cataract Operation

The definitive management for senile cataract is lens extraction. Over the years, various

surgical techniques have evolved from the ancient method of couching to the present-day

technique of phacoemulsification. Almost parallel is the evolution of the IOLs being used,

which vary in ocular location, material, and manner of implantation. Depending on the

integrity of the posterior lens capsule, the 2 main types of lens surgery are the intracapsular

cataract extraction (ICCE) and the extracapsular cataract extraction (ECCE). Below is a

general description of the 3 commonly used surgical procedures in cataract extraction,

namely ICCE, standard ECCE, and phacoemulsification. Reading books on cataract surgeriesfor a more in-depth discussion of the topic, particularly with regard to technique and

procedure, is also recommended.4

1). Intracapsular cataract extraction

Prior to the onset of more modern microsurgical instruments and better IOLs, ICCEwas the preferred method for cataract removal. It involves extraction of the entire

lens, including the posterior capsule. In performing this technique, there is no need to

worry about subsequent development and management of capsular opacity. The


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technique can be performed with less sophisticated equipment and in areas where

operating microscopes and irrigating systems are not available.

However, a number of disadvantages and postoperative complications accompanyICCE. The larger limbal incision, often 160-180, is associated with the following

risks: delayed healing, delayed visual rehabilitation, significant against-the-rule

astigmatism, iris incarceration, postoperative wound leaks, and vitreous incarceration.

Corneal edema is a common intraoperative and immediate postoperative

complication.

Furthermore, endothelial cell loss is greater in ICCE than in ECCE. The same is trueabout the incidence of postoperative cystoid macular edema (CME) and retinal

detachment. The broken integrity of the vitreous can lead to postoperative

complications even after a seemingly uneventful operation. Finally, because the

posterior capsule is not intact, the IOL to be implanted must either be placed in the

anterior chamber or sutured to the posterior chamber. Both techniques are more

difficult to perform than simply placing an IOL in the capsular bag and are associated

with postoperative complications, the most notorious of which is pseudophakic

bullous keratopathy.5

Although the myriad of postoperative complications has led to the decline inpopularity and use of ICCE, it still can be used in cases where zonular integrity is too

severely impaired to allow successful lens removal and IOL implantation in ECCE.

Furthermore, ICCE can be performed in remote areas where more sophisticated

equipment is not available.

ICCE is contraindicated absolutely in children and young adults with cataracts andcases with traumatic capsular rupture. Relative contraindications include high myopia,

Marfan syndrome, morgagnian cataracts, and vitreous presenting in the anterior

chamber.

2. Extracapsular cataract extractionIn contrast to ICCE, ECCE involves the removal of the lens nucleus through an

opening in the anterior capsule with retention of the integrity of the posterior capsule.

ECCE possesses a number of advantages over ICCE, most of which are related to an

intact posterior capsule, as follows:

A smaller incision is required in ECCE, and, as such, less trauma to the cornealendothelium is expected.


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Short- and long-term complications of vitreous adherence to the cornea, iris, andincision are minimized or eliminated.

A better anatomical placement of the IOL is achieved with an intact posterior capsule.

An intact posterior capsule also (1) reduces the iris and vitreous mobility that occurswith saccadic movements (eg, endophthalmodonesis), (2) provides a barrier

restricting the exchange of some molecules between the aqueous and the vitreous, and

(3) reduces the incidence of CME, retinal detachment, and corneal edema.

Conversely, an intact capsule prevents bacteria and other microorganismsinadvertently introduced into the anterior chamber during surgery from gaining access

to the posterior vitreous cavity and causing endophthalmitis.

Secondary IOL implantation, filtration surgery, corneal transplantation, and woundrepairs are performed more easily with a higher degree of safety with an intact

posterior capsule.

The main requirement for a successful ECCE and posterior capsule IOL implantation

is zonular integrity. As such, when zonular support is insufficient or appears suspect to

allow a safe removal of the cataract via ECCE, ICCE or pars plana lensectomy should be

considered.

3.Standard ECCE and phacoemulsificationStandard ECCE and phacoemulsification are similar in that extraction of the lens

nucleus is performed through an opening in the anterior capsule or anterior capsulotomy.

Both techniques also require mechanisms to irrigate and aspirate fluid and cortical

material during surgery. Finally, both procedures place the IOL in the posterior capsular

bag that is more anatomical than the anteriorly placed IOL.

Needless to say, significant differences exist between the 2 techniques. Removal of the

lens nucleus in ECCE can be performed manually in standard ECCE or with an

ultrasonically driven needle to fragment the nucleus of the cataract and then to aspirate

the lens substrate through a needle port in a process termed phacoemulsification.

The more modern of the 2 techniques, phacoemulsification offers the advantage of

using smaller incisions, minimizing complications arising from improper wound closure,

and affording more rapid wound healing and faster visual rehabilitation. Furthermore, it

uses a relatively closed system during both phacoemulsification and aspiration with better

control of intraocular pressure during surgery, providing safeguards against positive


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vitreous pressure and choroidal hemorrhage. However, more sophisticated machines and

instruments are required to perform phacoemulsification.

Ultimately, the choice of which of the 2 procedures to use in cataract extraction

depends on the patient, the type of cataract, the availability of the proper instruments, and

the degree at which the surgeon is comfortable and proficient in performing standard

ECCE or phacoemulsification

GLAUCOMA

A condition of increased fluid pressure inside the eye so it make the compression of the

retina and the optic nerve then make the nerve damage end.

Glaucoma can cause partial vision loss, with blindness as a possible eventual outcome

one of the leading causes of blindness, is estimated to affect 1 of every 50 adults. This is

the diagram of pathophysiology of glaucoma.

There are some risk factor of glaucoma:

Age Family History Drug consumption (steroid) Trauma Severe Hypermethrophya Other systemic disease (ex ; DM, Hypertension)

The classification may include:


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1. Open Angle Glaucoma2. Angle closure glaucoma3. Congenital Glaucoma4. Secondary glaucoma

Glaucoma can be divided roughly into two main categories, "open angle" and "closed angle"

glaucoma.

Open Angle Glaucoma

Primary open-angle glaucoma (POAG), the most common form of glaucoma, accounts

for 6070% of all glaucomas and 9095% of primary glaucomas. POAG is a bilateral,

chronic progressive condition that typically appears in individuals over 60 years of

age.

Symptoms

a) asymptomatic (as moderately elevated IOP usually causes no symptoms but the IOP is

still high enough to cause glaucomatous optic neuropathy)

b) loss of part of their visual field cf tunnel vision

c) blindness in one or both eyes (advanced optic nerve damage)

Genetic factors are important and therefore the family history should be considered.

Signs

a) open angle

b) elevated IOP

c) glaucomatous optic nerve cupping

d) may have visual field loss

Mild glaucomatous cupping Advanced glaucomatous cupping

The goal is to maintain IOP less than 21 mmHg and continued visual field loss should be

minimal. In fact, medications have been shown to control IOP in 6080% of patients over


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a five-year period. Various treatmentmodalities include medical treatment, laser

therapy,and surgery. Patients will initially start with topical ocular drug therapy.

Prognosis : If discovered early and treated adequately, the prognosis for POAG is excellent.

Closure Angle Glaucoma

Less than 5% of all primary glaucomas. Requires immediate attention within hours to

avoid dramatic vision loss. In primary the pathophysiology is a shallow ocular anterior

chamber so the angle between the cornea and iris become narrow.This creates a situation

where pupil dilation can physically occlude the trabecular meshwork. And secondary

angle-closure glaucoma results from any type of blockage throughout this drainage

pathway.

figure. Primary close angle glaucoma

Diagnosis is determined by visualization of the angle by gonioscopy as well as provoking an IOP

increase through mydriasis (dark room test) or by gravity (prone test).

Treatment of angle-closure glaucoma

Requires a rapid reduction in IOP to prevent a hypertensive event and ultimately preserve vision.

For an acute hypertensive attack it can be given pilocarpine or secretory inhibitors (topical B-blockers, a2-agonists, CAIs). At IOPs greater than 60 mmHg, the iris becomes ischemic and may

be unresponsive to pilocarpine even at high and frequent doses. An osmotic agent (oral glycerin,

oral isosorbide, and intravenous Mannitol) is usually administered because of its rapid lowering

of IOP. A peripheral iridectomy should be performed only when IOP is controlled.

Normal-Tension Glaucoma

Condition in which optic nerve damage and vision loss have occurred despite a normal pressure

inside the eye (TIO< 21 mmHg). The patient has open, normal-appearing angles. In fact, the

features of normal-tension glaucoma are similar to primary open-angle glaucoma.


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The pathogenesis because of abnormal sensitivity to intraocular pressure caused by vascular or

mechanically in the optical nerve

Others sign & symptoms:

Spasm of phertpheral vesselChepalgiaHipotension at nightDecrease of blood flow

Primary Congenital Glaucoma

Primary congenital glaucoma present at birth; however, but its manifestations may not be

recognized until infancy or early childhood. The pathophysiology of primary congenital glaucoma

is restricted to a developmental abnormality that affects the trabecular meshwork. Primarycongenital glaucoma estimated to affect fewer than 0.05% of ophthalmic patients. The disease is

bilateral in approximately 75% of cases.

Primary congenital glaucoma usually is diagnosed at birth or shortly thereafter, and most cases are

diagnosed in the first year of life. Most cases are sporadic in occurrence and may be transmitted

through an autosomal recessive pattern. Male patients are found to have a higher incidence of the

disease, comprising approximately 65% of cases.

The triad of manifestations of primary congenital glaucoma are epiphora,photophobia , and

blepharospasm. Blepharospasm is a spasm and closure of the eyelids.

Physically of congenital glaucoma there was:

Changes within the cornea, especially within the first few years of life, provide strongadditional support for the diagnosis.

Enlargement of the cornea The early presence of glaucoma may deepen the anterior chamber. Because of the

frequent occurrence of iris abnormalities in many types of both primary and

secondary childhood glaucomas, the iris and angles always should be studied

carefully and with thorough gonioscopy.


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The optic nerve head is usually abnormal. Variable cupping is present, usuallyannular in form, with nasalization of vessels and preservation of the well-vascularized

rim. Pallor is first seen temporally when present at an advanced stage.

The Treatment of Congenital Glaucoma

Unlike adult glaucoma, the initial treatment for congenital glaucoma is often surgical. A

drainageangle surgery is often recommended for congenital glaucoma.

Secondary Glaucoma

Glaucoma can occur as the result of an eye injury, inflammation, tumor or in advanced cases of

cataract or diabetes. It can also be caused by certain drugs such as steroids. This form of

glaucoma may be mild or severe.The type of treatment will depend on whether it is open-angle orangle-closure glaucoma.

Pseudoexfoliative Glaucoma

This form of secondary open-angle glaucoma occurs when a flaky, dandruff-like material peels

off the outer layer of the lens within the eye. The material collects in the angle between the cornea

and iris and can clog the drainage system of the eye, causing eye pressure to rise.

Pseudoexfoliative Glaucoma is common in those of Scandinavian descent. Treatment usuallyincludes medications or surgery.

Pigmentary Glaucoma

A form of secondary open-angle glaucoma, this occurs when the pigment granules in the back of

the iris (the colored part of the eye) break into the clear fluid produced inside the eye. These tiny

pigment granules flow toward the drainage canals in the eye and slowly clog them, causing eye

pressure to rise. Treatment usually includes medications or surgery.

Traumatic Glaucoma

Injury to the eye may cause secondary open-angle glaucoma. This type of glaucoma can occur

immediately after the injury or years later.

It can be caused by blunt injuries that bruise the eye (called blunt trauma) or by injuries that

penetrate the eye.


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In addition, conditions such as severe nearsightedness, previous injury, infection, or prior surgery

may make the eye more vulnerable to a serious eye injury.

Neovascular Glaucoma

The abnormal formation of new blood vessels on the iris and over the eyes drainage channels can

cause a form of secondary open-angle glaucoma.

Neovascular glaucoma is always associated with other abnormalities, most often diabetes. It never

occurs on its own. The new blood vessels block the eyes fluid from exiting through the trabecular

meshwork (the eyes drainage canals), causing an increase in eye pressure. This type of glaucoma

is very difficult to treat.

Irido Corneal Endothelial Syndrome (ICE)

This rare form of glaucoma usually appears in only one eye, rather than both. Cells on the back

surface of the cornea spread over the eyes dra inage tissue and across the surface of the iris,

increasing eye pressure and damaging the optic nerve. These corneal cells also form adhesions

that bind the iris to the cornea, further blocking the drainage channels.

Irido Corneal Endothelial Syndrome occurs more frequently in light-skinned females. Symptoms

can include hazy vision upon awakening and the appearance of halos around lights. Treatment can

include medications and filtering surgery. Laser therapy is not effective in these cases.

Absolute Glaucoma

Absolute glaucoma is the end stage of glaucoma (open angle/angle closure glaucoma). The

clinical sign patien have total blindness. In absolute glaucoma, the cornea looks not clear, shallow

of the chamber, athrofi of papil with excavation of glaucomatous, the eye become harder like a

stone dan also painfull.

The treatment of absolute glaucoma can by given beta light into ciliary body for compres the

function of ciliarybody or doing the nucleation because the eye doesnt have function anymore so

the eye cant painfull anymore.


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CHAPTER III

CASE REPORT

1. Patient identityName : Mrs. S

Sex : female

Age : 84 years old

Address : Kuala Secapah

Job : housewife

Religion : Moslem

Patient was examined on January 21st, 2014

2. Anamnesis Main complaint :

Red eye, watery, blindness. History of desease :

Patient complains blurry vision is affected in right eye. Blurry vision of the

right eye since a few months ago, that become worse especially during this

two weeks. Then, she told that her eye became redness until now. Not only

red, but also pain and watery. Now, patient have cloudy in her eye (right eye),

so patient really cant see anything from right eye. She also complaining the

blurry vision at the left eye. Sometimes she had a headache. The

manifestation of clinical from this patient : Headache (+), pain in the eyes (+),

redness in the eye (+ right eye), itch feeling in the eyes (-), and traumatic

history (-).

Past clinical history :

Hypertension (-) Diabetes Mellitus (denied) because patient never did clinical check. Glasses wearing (-) Traumatic history (-)

Family history Hypertension (-) Diabetes Mellitus (-) Glasses wearing (-)


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3. General Physical assestmentGeneral condition : Moderate

Awareness : Compos mentis

Vital sign :

a. Blood Pressure : 130/90 mmHgb. RR : 18/minutec. Temperture : 36,5C

4. Ophthalmological statusVisual acuity :

a. OD : 0b. OS : 6/12c. Last glasses : the patient never use glasses

OD OS

Ortho Eye ball position Ortho

Eye Movement

Movement(+), ptosis (-),

lagoftalmos (-)

Palpebra Movement (+), ptosis (-),

lagoftalmos (-)

redness (+), discharge (-),

degeneration plaque (-), foreign

body (-), injection (-)

conjungtiva redness (-), discharge (-),

degeneration plaque (-), foreign

body (-), injection (-)

ulcer (-)

arcus senilis (+)

Cornea ulcer (-)

arcus senilis (+)


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Not clear Anterior chamber clear, deep impression

Iris colour : brown, sinekia (-)

Circular pupil, isochore

Iris/pupil Iris colour : brown, sinekia (-)

Circular pupil, isochore

Milky Lense Cloudy

- Shadow test +

- Fundus -

Shadow test : negatif (- right eye) , positive (+ left eye) Intra Ocular pressure (tonometry) : OD 26 mmHg, OS 15 mm Hg Funduscopy : - Visual field test: OD cannot be done, OS normal

5. ResumeA woman, 84 years old, came to ophthalmologist with the complain of blurry

vision in right eye since a few months ago, and become worse during this two weeks.

She told that her eye became redness until now. Not only red, but also pain and

watery. Now, patient have cloudy in her eye (right eye), so patient really cant see

anything from right eye. She also complaining the blurry vision at the left eye.

Sometimes she had a headache. The manifestation of clinical from this patient

Headache (+), pain in the eyes (+), redness in the eye (+ right eye), watery (+), itch

feeling in the eyes (-), and traumatic history (-).

Visual acuity is 0 for OD, 6/12 for OS. Right lense seems milky. Left lense

seems cloudy. Intraocular presure for OD 26mmHg, for OS 15 mmHg. Funduscopy

cannot be done because of the lense opacity. Shadow test for left eye is positive.

Confrontation test just be done at the left eye and the result is normal.

6. DiagnosisDiagnose :

a. OD : mature cataract with secondary glaucoma (absolute glaucoma)b. OS : immature cataract (senilis)


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DDx :

OD : hipermature cataract with absolute galucoma OS : -

7. Plan for examinationa. Slit lamp

b. Perimetric. Whole blood test and blood glucosed. Eyes USG

8. Treatmenta. OD

i. Pharmacological:1. Timolol2. Asetazolamide

ii. Surgery : Extra Capsular Cataract Extraction

b. OSi. Non-pharmacological

1. Using eye protection

ii. Surgery : Pachoemulsification + IOL9. Prognosis

a. OD:i. Ad vitam : bonam

ii. Ad functionam : malamiii. Ad sanactionam : dubia ad malam

b. OS :i. Ad vitam : bonam

ii. Ad functionam : dubia ad bonamiii. Ad sanactionam : dubia ad bonam


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CHAPTER IV

DISCUSSION

A woman, 84 years old complained blurry vision clinic with complain redness,

painfull, watery, even blindness in the right eye since a few months ago. The history before

the eye became redness, patient had migrain at right part of head. The pain felt into her right

eye. Then, she told that her eye became redness until now. Not only red, but also pain and

watery. Now, patient have cloudy in her eye (right eye) , so patient really cant see anything

from her right eye. There were no history of eye trauma.

Visual acuity is 0 for OD, 6/12 for OS. Palpebra, conjunctiva, cornea and anterior

chamber is inspected normally, while the right lens seems milky and the left eye seems

blurry. No foreign body was found. Intra ocular pressure is 26 mmHg for OD, 15 mmHg for

OS. Funduscopy cannot be done because of the lense opacity. Confrontation test for OD

cannot be described, and for OS is normal, shadow test negative for right eye and positive for

left eye.

The abnormality found in physical examination is the opacity of the lens. We can get

rid of inherited disorders because the patient is geriatric, and new phenomena arising in

recent years. In addition, the symptoms that arise in these patients as well as typicalsymptoms of cataract, like the the visual loss is slowly, and there is a cloud on the view that

closes the view. Beside the opacity of left lense, the shadow test results is positive.

In lens assesment found that at the right eye the lens is totally opaque, milky

appearance, funduscopy cant be done cause the light cant passes through the lens and it

indicated that is mature cataract at the right eye and for the left eye the lens looks cloudy and

shadow test is positive (+), show that it is an immature cataract at the left eye.

These are some discussion about the clinical finding from the anamnesis and

examination to the patient :

Blurred vision is caused by the opacity of the lense, that can cause disrupting therefraction media and finally, it can hampered the light to retinal

Vision slowly burred because of the progression of opacity in the lense (thickness ofopacity influence the degree of vision lost)

VA : 0 for OD with good projection, 6/12 for OS opacity of OD is thicker thanOSso OD must be treated firstly


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Based on the examination, known that the visual acuity for right eye is 0. The

patient cant see at all, even with light perception.

There are some specific symptoms that can lead to diagnose the condition of the

right eye. The IOP level for right eye is measure 26 mmHg. It indicated the raised of

IOP greater than normal range. Raised IPO is determine by the balance between

aqueous production inside the eye and aqueous drainage of the eye through the

trabecular meshwork. The resistance to outflow through the trabecular meshwork

gradually increase, causing the damage to the nerve. Pressure on the nerve fibres and

chronic ischaemia at the optic nerve head cause damage to the retinal nerve fibres that

leads to rapid loss of vision. Once optic nerve damage is occured, it cannot be

repaired. It indicated that is absolute glaucoma at the right eye.

In mature cataract, there is degenerative lens capsule that cause the material out

from the lens and enter the anterior chamber,stuck at the trabecular meshwork, block

the drainage angle and cause the problem in excretion of aqueous humor. Type of

glaucoma of this patient is absolute glaucoma indicated by the high level of IOP,

visual acuity is 0, and the pain sensation inside the eye. So, the diagnosis of the right

eye is absolute glaucoma e.c mature cataract

Treatment to this patient is to lower the IOP. Common medical therapy that

used in this condition are combination of beta-blocker and carbonic anhidrase

inhibitor, such as timolol 0,5 % and asetazolamide. Both of them action on the

secretion system, that result the decrease in producing aqueous from ciliary body.

Definitive therapy for both eye is surgery. For the right eye should be treated by lens

extraction. Medication that given to lower the IOP is aimed to controls the IPO and

can minimize the symptoms. For the left eye with immature cataract the

phacoemulsification is choosen as the therapy.


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CHAPTER V

CONCLUSION

The diagnosis of this patient is Mature Cataract with Secondary right eye. And for

the right eye is immature cataract. The therapy for OD is doing the treatment of glaucoma

and surgery for the lens extraction.


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BIBLIOGRAPHY

1. Cynthia AB, basic ophthalmology For Medical Studens and Primary Care Residents,Seventh Edition, electronic book. American Academy Of ophthalmology, 1999.

2. Ilyas, S.Ilmu Penyakit Mata. Edisi 3. Jakarta. Balai Penerbit FKUI. 20073. Galloway NR, Amoaku WMK, Galloway PH, Browing AC. Common Eye diseases and

Their Management, electronic book.Springer-Verlag London, 2010

4. Gnter K. Krieglstein, MD and friends.Glaucoma. Springer-Verlag Berlin Heidelberg.Germany.2008

5. Olver, J. and Cassidy, L., 2005. Ophthalmology at a Glance. Australia: BlackwellPublishing Company

6. Vaughan D. G, Asbury, T. Eva, P.R. Oftalmologi umum. EGC. Jakarta. 2000

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