OPHTALMOLOGY RECORD

CHALAZION

Examiner :

DR. dr. Gilbert. W. Simanjuntak, SpM (K)

Observer :

Yoga Rahmat Witular

(1161050136)

DEPARTMENT OF EYE DISEASE

PERIOD OF FEBRUARY 27rd APRIL 1th , 2017
MEDICAL FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
JAKARTA
2017
 OPHTALMOLOGY RECORD

Examiner : Yoga Rahmat Witular

NIM : 1161050136

Tutor : Dr. dr. Gilbert. W. Simanjuntak, SpM (K)

I. PATIENT IDENTITY

Name : Mr. S

Age : 55 years old

Sex : Male

Religion : Islam

Address : Kampung Rawa Bugel, RT. 01 RW. 010, Bekasi

Occupation : PNS

Status : Married
II. ANAMNESIS

Anamnesis done at March 25th, 2017

Main complaint : Patients present with a lump in the right eyelid.

Additonal complaint : Cause feel prop in the right eyes

Chronology of disease :

A 55 years old male come to eyes Polis UKI Hospital with

complaints of a lump in the lower lids right eye since 7 days ago. Initially
a small-sized lumps, but slowly growing lump is felt. Currently lump like as
green beans. Lump causes a lump in the right eye patient's, but the lump
does not feel pain, itching, and heat. Patients already compress with ice
cubes to reduce complaints. Bumps do not produce the pus. No red eye
before. Patient admitted, his sight is still good and there is no vision
problems at all.

There are no white spots like dandruff or dry wound along the edge
of the eyelid. Complaints blurred vision, double vision denied. Patients are
often exposed to dust. Diabetes and history taking regular drug treatment
since 3 months ago. History of hypertension denied. Surgical history
denied. History of wearing glasses positive.
 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 positive diabetes mellitus.

History of family disease :

In families of patient has never suffered like him.

III. GENERAL STATUS

General condition : Mild illness appearance

Conciousness : Composmentis

IV. STATUS OFTALMOLOGI

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
 B. Sistematic Examination

Parameter OD OS
Visual Acuity 6/9 6/15
Supersilia Grow evenly Grow evenly
Silia Grow evenly, good Grow evenly, good
position position
Palpebra Color not matches the Normal
Superior/inferior color of the skin
Color matches the color of
Edema inferior (+) the skin

Measuring edema (-)

0.5 x 0.5 x 0.3 cm tumor (-)

Consistency soft, flat

surface, tumor (-)
Tarsal conjungtiva Hyperemic (+) Hyperemic (-)
Superior/inferior
Cicatrical (-) Cicatrical (-)

Edema (+) Edema (-)

Forniks conjungtiva Hyperemic (-) Hyperemic (-)

Superior/inferior
 Bulbi conjungtiva Hyperemic (-) Hyperemic (-)

Injection conjungtiva (-) Injection conjungtiva (-)

Injection ciliar (-) Injection ciliar (-)

Fibrovascular in triangular Fibrovascular in triangular

shape (-) shape (-)

Cornea
Clarity Fibrovascular (-) Fibrovascular (-)
Infiltrate (-) (-)

Ulcus (-) (-)

Erosion (-) (-)

(-) (-)
Cicatrix
Sclera White White
Cicatrix (-) Cicatrix (-)
Anterior Chamber Medium in depth Medium in depth
Hypopyon (-) Hypopyon (-)
Hyphema (-) Hyphema (-)
Iris Radier Radier
Brown Brown
Synechia (-) Synechia (-)
 Pupil Round, isokor, diameter 3 Round, isokor, diameter 3
mm, Direct light refleks mm, Direct light refleks
(+), Indirect light refleks (+), Indirect light refleks
(+) (+)

Lens Clear Clear

V. RESUME

A 55 years old male come to eyes Polis UKI Hospital with

complaints of a lump in the lower lids right eye since 7 days ago. Initially
a small-sized lumps, but slowly growing lump is felt. Currently lump like as
green beans. Lump causes a lump in the right eye patient's. On examination
found edema of the eyelids are right outside and inside and reddish. Lump
size of 0.5 x 0.5 x 0.3 cm with a soft consistency and a flat surface.
Patients already compress with ice cubes to reduce complaints. Bumps do
not produce the pus. No pain, itching, heat and red eye before. Patient
admitted, his sight is still good and there is no vision problems at all.
Patients are often exposed to dust. Positive diabetes and history taking
regular drug treatment since 3 months ago. History wear glasses positive.

GENERAL STATUS

General condition : Mild illness appearance

Conciousness : Composmentis
 From the ophtalmologic examination on both eyes founded

Parameter OD OS
Visual Acuity 6/9 6/15
Palpebra Color not matches the Normal
Superior/inferior color of the skin
Color matches the color of
Edema inferior (+) the skin

Measuring edema (-)

0.5x0.5x0.3 cm tumor (-)

Consistency soft, flat

surface.tumor (-)
Tarsal conjungtiva Hyperemic (+) Hyperemic (-)
Superior/inferior
Cicatrical (-) Cicatrical (-)

Edema (+) Edema (-)

Pupil Round, isokor, diameter 3 Round, isokor, diameter 3

mm, Direct light mm, Direct light
refleks(+), Indirect light refleks(+), Indirect light
refleks (+) refleks (+)

Lens Clear Clear

VI. CLINICAL DIAGNOSE

 OD : Chalazion

V. DIFFERENTIAL DIAGNOSE

- Hordeolum

- Karsinoma sel basal

VIII. MEDICAL TREATMENT

1. Non Medikamentosa:

- Education about kalazion disease.

- Sometimes kalazion recovered or lost by itself due to absorbed (absorbed) after a

few months or a few years.

- In these patients, therapy done is ekskokleasi kalazion.

Kalazion ekskokleasi procedure:

- Eye pain pantokain drop with topical anesthesia.

- Do infiltrative anesthesia (with lidocaine) is injected under the skin on the right
sight kalazion.

- Kalazion clamped and then reversed so that the clamps and kalazion tarsal
conjunctiva visible.

- Do incision perpendicular border of the eyelid.

- Fill kalazion curette until clean.

- Clamps kalazion removed.

2. Medical:

- Provision of chloramphenicol eye ointment 1%, applied 3 times a day at OD

post ekskokleasi kalazion.

IX. RECOMMENDED EXAMINATION

A biopsy is indicated in recurrent kalazion

X. PROGNOSE

OD OS
Ad Vitam Bonam Bonam

Ad Sanasionum Bonam Bonam

Ad Fungsionum Bonam Bonam

XI. COMPLICATION

- Recurrent kalazion