canalis lacrimalis rupture + susp blowout fracture + rupture bulbi

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  • Duty ReportFriday 22 April 2016Jaga III: dr. Dina Novita, Sp.MJaga II : dr. GilangJaga I : dr. Monik

  • identityName : Sdr. MAge : 26 tahunWork : worker

  • Chief Complaint : the right inferior eyelid rippedRecent History :

    8 hours before go to hospital, patient got traffic accident. The right inferior eyelid was ripped. His right eye suddenly blurred, pain, swell, hemorrhage, no excrete fluids like jelly. It was difficult to open his right eye. Than he went to regional hospital and referred to kariadi hospital. No history of using spectacless

  • Ophthalmology status

    ODOSVisual acuityLP bad LP>3/60Eye movemenet -3 -3 -3 -2 - 3 -2 -2 -3freeEye lidedema (+), fullthickness laceration eyelid sup+inf+ canalis lacrimalis ruptureedema (-) spasm (-)conjunctivaSKB (+), khemosis (+)Innormal limitCornea Edema(+), iris prolaps (-)Jernih (+)Others Difficult to accessIn normal imit

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  • OD Canalis Lacrimalis Rupture+susp blowout fracture+rupture bulbi

  • Ceftriaxon inj 1gr/12 jamKetorolac inj 30 mg/8 jamMetilprednisolone inj 862,5 mg/12 jamRanitidin inj 150 mg/12 hoursVigamox e.d/jam ODPro CT-Scan Orbita

    Treatment

  • CT-Scan resultIntracerebral Haemorrhage with pneumocephal in frontal lobus dx sinRight oculi bulbi rupture with intraconal haemorrhageComplete fracture in right medial wall maxillari sinus, right sup rim orbita, right papiracea lamina, right ethmoid, right zygomaticus .Right Hematosinus maxillari, ethmoid and frontalSoft tissue swelling with emphysema subcutisNo increase intracranial pressure.

  • Ophthalmology status 3rd day

    ODOSVisual acuityNLP>3/60Eye lidDecrease edema (+), fullthickness laceration eyelid sup+inf+ canalis lacrimalis ruptureedema (-) spasm (-)conjunctivaSKB (+), khemosis (+)Innormal limitCornea Edema(+), iris prolaps (+)clearOthers Difficult to accessIn normal limit

  • Ceftriaxon inj 1gr/12 jamKetorolac inj 30 mg/8 jamMetilprednisolone inj 862,5 mg/12 jamRanitidin inj 150 mg/12 hoursVigamox e.d/jam ODEnucleasi + recanalisasi + palp. reconstruction

    Treatment

  • terimakasihMohon bimbingan dan saran

  • OTS

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