Cataract Senilis Matur Od: Intania Rosati H1A013031 Supervisor: Dr. Siti Farida, SP.M (K)

Intania Rosati
H1A013031
CATARACT SENILIS MATUR OD Supervisor :
Dr. Siti Farida, Sp.M (K)
INTRODUCTION
Cataracts are a condition of turbidity in the lens caused by a disturbed metabolism of the lens so that
there are protein aggregates that scatter the beam of light and reduce transparency.
Cataracts can occur due to aging, physical trauma, radiation, the influence of chemicals, intraocular
diseases, systemic diseases or congenital.
Senile cataracts are still the main cause of blindness throughout the world.
Based on 2007 Basic Health Research, the national prevalence of blindness in Indonesia is 0,9% of
the main causes are cataracts, followed by glaucoma, refractive disorders, degenerative eye diseases,
and other eye diseases.
With increasing life expectancy and the elderly population, it is estimated that the incidence of
cataract cases will continue to increase.
CASE REPORT
PATIENT IDENTITY
Name : Mrs. J
Age : 57 years old
Gender : Female
Address : Tanjung, KLU
Religion : Islam
Job : Housewife
Education : High School
Date of Examination : 24 January 2019
MAIN COMPLAIN
Blurry vision
PRESENT DISEASE’S HISTORY

Patient were referred from KLU General Hospital with complaints of blurred vision in the right eye, and then patient
were then referred to the Provincial Hospital of NTB with mature senile cataract OD.
The patient complained blurry vision in the right eye since about 1 year ago. The blurry vision decribed as cloudy by
the patient.
Patient cannot see near or far.
The patient can only see light with his right eye.
Patients deny the presence of red eyes (-), pain (-), itchy eyes (-), watery eyes (-), headache (-) and dizziness (-),
throbbing pain (-), seeing a light around around objects (-)
PAST MEDICAL HISTORY
Patients have a history of hypertension since about 5 years ago and patients routinely take medication
from the Puskesmas. The patient's last blood pressure was 160/90 mmHg. the patient has a history of
cataract surgery in the left eye. The patient has no history of using glasses (-), no history of trauma to
the eye (-), asthma (-), heart disease (-).
FAMILY MEDICAL HISTORY

Similar complaints to the patient's family are denied.
TREATMENT HISTORY
Patients controlled their hypertension with captopril 10 mg / day. the patient also had cataract surgery in the left eye.
ALLERGIC HISTORY
The patient does not have allergies to drugs or food
STATUS GENERALIS
General condition : Normal
Awareness : Compos mentis
Vital signs:
- Blood pressure : 160/90 mmHg
- Frequency of breath: 20x/minute
- Pulse rate : 80x/minute
- Temperature : 36.5 ° C
STATUS OPHTALMOLOGIS
No Pemeriksaan OD OS
1. Visus
- Natural visions LP + 6/7
- Ph No improvement 6/6
2. Eyeball position Ortoforia Ortoforia
3. Eyeball movement Good in all directions Good in all directions

4 Field of view
+ +
+ + + +
+ +
5. Palpebra Edema (-) (-)

Superior Hiperemi (-) (-)
Pseudoptosis (-) (-)
Entropion (-) (-)
Ektropion (-) (-)
6. Palpebra Edema (-) (-)

Inferior Hiperemi (-) (-)
Entropion (-) (-)
Ektropion (-) (-)
7. Konjungtiv Hiperemi (-) (-)
a Palpebra Cobble stone (-) (-)
Superior Cicatrics (-) (-)
Foreign body (-) (-)
Konjungtiva Palbebra Hiperemi (-) (-)
Inferior Cobble stone (-) (-)
Cicatrics (-) (-)
Foreign Body (-) (-)
Konjungtiva Bulbi Injection Conjungtiva and Siliar (-) (-)
Bleeding (-) (-)
Mass (-) (-)
Edema (-) (-)
Kornea Shape concave concave
Transparant clear clear
Surface smooth Smooth
Cicatrics (-) (-)
Foreign body (-) (-)
Massa (-) (-)

COA Depth Deep Deep
Hifema (-) (-)
Hipopion (-) (-)
Iris colour Chocolate Chocolate
Iris pattern Reguler Reguler
Pupil Shape Round, 3 mm Round, 3 mm
Direct Light Reflex (+) (+)
Indirect Light Reflex (+) (+)
Lens Transparancy cloudy pseudofakia
Intraocular pressure Perpalpasi normal normal
Funduskopi Reflex Negative Positive
Cannot be evaluated Artery and vein normal, orange

background, nervus opticus is oval
and well defined
PHOTO OF PATIENT EYES
IDENTIFIKASI MASALAH
SUBJECTIVE OBJECTIVE
 Natural LP + OD view (fixed pinhole), visual OS
a. Complaints of blurred vision in the 6/7 (pinhole 6/6)
right eye and does not improve with  The right eye lens is found to be evenly cloudy
pinhole
b. Complaints have occurred since 1 year
ago and increasingly burdensome.
ANALISIS KASUS
•Patients with complaints of blurred vision can be caused due to abnormalities or
disorders of the refractive media cornea to the retina.
•Patients complained of blurred vision that happened slowly since about 1 year ago.
•The natural vision were OD LP + and OS 6/7 and OD were corrected with pinhole and
there is no improvement and OS vision by pinhole became 6/6.
•On the anterior segment examination, the right eye lens is evenly cloudy.
•From the results of a visual examination it can be concluded that the patient has
cataracts in the right eye and has no problem with refractive in his right eye, the blurred
vision is caused by the clouding of the lens so that it blocks light from reaching the
retina.
•Cataracts are a condition of lens opacification.
•Aging is the most common cause of cataracts, but several other factors can be
involved, including trauma, toxins, systemic diseases (diabetes mellitus), smoking, and
offspring.
•Cataracts can occur due to hydration (addition of fluids) to the lens, denaturation of
lens proteins due to both.
•Most cases are bilateral, although the speed of development is rarely the same.
•The cloudiness of the lens can cause the lens to become transparent so that the pupil
will be white or gray. This turbidity can be found in various localizations in the lens
such as the cortex, nucleus, subcapsular.
•Examinations performed in cataract patients include sharp vision, slit lamp,
funduscopy, and tonometry if possible.
ASSESMENT
Working Diagnosis :
Cataract Senilis Matur OD
PLANNING DIAGNOSIS
- Slitlamp
Slitlamp examination is done to determine the condition of the front of the eye until
the lens is needed to support the results of other examinations.
TREATMENT
Surgery :
•Extracapsular Cataract Extraction
•Intracapsular Cataract Extraction
•Small Incision Cataract Surgery
•Phacoemulsification
KIE
1. Explain to the patient that the view on the blurred eye is caused by cataracts on
the lens of the eye,
2. Explain to patients that cataracts cannot be treated with drugs but can be cured by
surgery and giving a lens to the eye,
3. Explain to patients about the importance of cataract extraction surgery, types of
actions and preparation
4. Explain about complications that will occur if not operated on, the possibility of
the lens will melt, the contents of the lens will come out, causing an inflammatory
reaction and increased pressure on the eyeball
5. Explain the complications that may arise during surgery and postoperatively.
PROGNOSIS
Ad vitam : Bonam
Ad functionam : Dubia ad bonam
Ad sanationam : Dubia ad bonam
REFERENCES
Vaughan Daniel G., Asbury T. 2015. Oftalmologi Umum, Edisi 17 (Alih Bahasa: Waliban dan Bondan Hariono); Widya Medika:
Jakarta.
Ilyas, S, Yulianti, SR. 2015. Ilmu Penyakit Mata. Edisi 5. Badan Penerbit FK UI : Jakarta.
Kementerian Kesehatan RI, 2014. Situasi Gangguan Penglihatan dan Kebutaan. [pdf] Available at :
http://www.depkes.go.id/download.php?file=download/pusdatin/infodatin/infodatin-penglihatan.pdf [Accessed 5 Jan 2019].
Ilyas, S. Mailangkay, Taim H., Saman RR., Simartama, M., Widodo PS., 2002. Ilmu Penyakit Mata Ed.2 Perhimpunan Dokter Spesialis
Mata Indonesia. Sagung Seto: Jakarta
Budiono, S, et al. Buku Ajar Ilmu Kesehatan Mata. Surabaya: Airlangga University Press; 2013.
Salvi, S.M., Akhtar,S., & Currie, Z., 2006. Ageing Changes in The Eye. Postgrad Med, vol. 86, pp. 581-587. [pdf] Available at: <
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2585730/pdf/581.pdf> [Accessed 5 Jan 2019].
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Intania Rosati

PRESENT DISEASE’S HISTORY

FAMILY MEDICAL HISTORY

2. Eyeball position Ortoforia Ortoforia

3. Eyeball movement Good in all directions Good in all directions

5. Palpebra Edema (-) (-)

6. Palpebra Edema (-) (-)

Cicatrics (-) (-)

Foreign Body (-) (-)

Konjungtiva Bulbi Injection Conjungtiva and Siliar (-) (-)

Bleeding (-) (-)

Mass (-) (-)

Edema (-) (-)

Kornea Shape concave concave

Transparant clear clear

Surface smooth Smooth

Cicatrics (-) (-)

Foreign body (-) (-)

Massa (-) (-)

Hifema (-) (-)

Hipopion (-) (-)

Iris colour Chocolate Chocolate

Iris pattern Reguler Reguler

Pupil Shape Round, 3 mm Round, 3 mm

Direct Light Reflex (+) (+)

Indirect Light Reflex (+) (+)

Lens Transparancy cloudy pseudofakia

Intraocular pressure Perpalpasi normal normal

Funduskopi Reflex Negative Positive

Cannot be evaluated Artery and vein normal, orange

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