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PTERYGIUM
Examiner :
Observer :
NIM : 1261050282
I. PATIENT IDENTITY
Name : Mr. E
Sex : Male
Religion : Islam
Occupation : Entrepreneur
Status : Married
II. ANAMNESIS
Additonal complaint :
Chronology of disease :
A 41 years old male came to the Department of Eye Disease at UKI Hospital
with the main complaint about something like a fat grew on both eyes since 5 months
ago. Patient actually felt this fat even more spreading to the center of his eyes recently.
Patient also complained of redness appearance and itchy eyes sometimes. Patient
admitted, his sight is still good and there is no vision problems at all.
Previous disease :
The patient never felt the same symptoms before. Patients never wore contact
lenses or eyeglasses. Patients denied the presence of a high blood pressure, allergy and
diabetes mellitus.
A. General examination
Parameter OD OS
Periocular Appearance Quiet Quiet
General Condition of The eye Mild Mild
Eyeball position Simetric Simetric
Eyeball movement All direction All direction
Visual field Wide Wide
A.
A Sistematic Examination
Parameter OD OS
Visual Acuity 1,0 1,0
Supersilia Grow evenly Grow evenly
Silia Grow evenly, good Grow evenly, good
position position
Palpebra Normal Normal
Superior/inferior
Color matches the color of Color matches the color of
the skin the skin
A 41 years old male came to the Department of Eye Disease at UKI Hospital
with the main complaint about something like a fat grew on both eyes since 5 months
ago. Patient actually felt this fat even more spreading to the center of his eyes recently.
Patient also complained of redness appearance and itchy eyes sometimes. Patient
admitted, his sight is still good and there is no vision problems at all.
GENERAL STATUS
Parameter OD OS
Visual Acuity 1,0 1,0 (Add +1.00)
Cornea
Clarity Fibrovascular (+) Fibrovascular (+)
OD : Pterygium grade II
OS : Pterygium grade I
V. DIFFERENTIAL DIAGNOSE
- Pinguecula
- Pseudopterygium
I MEDICAL TREATMENT
- Non medicamentosa : Use sunglasses to protect the eyes from ultraviolet rays
- Medicamentosa :-
I RECOMMENDED EXAMINATION
- Funduscopy
I PROGNOSE
OD OS
- Recurrent pterygium
- Diplopia