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CASE REPORTAstrid Feliasari
I 11107063
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cases
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Patient Identity
Name : An. Rea
Se! : "ale
A#e : 6 m$nt%
Address: &'ala II RT.00()00* +',' raya
Et%nic : melay'
-$, :
Reli#i$n : Islam
Patient as e!amined $n -'ne 1/ 01
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Anamnesis
Main complaint :T%e le2t eye l$$+s et $r tears may sill
$4er $nt$ t%e c%ee+.
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Anamnesis
History of disease : Patient and %is arents c$me t$ Ot%alm$l$#ist
it% may$r c$mlain. Patient is t%e t%ird c%ild
in %is 2amily. T%is symt$m is ,e#in since %eas ,$rn. Since %e as ,$rn ,$t% $2 t%e eyesare l$$+s et $r tears may sill $4er $nt$ t%ec%ee+.In t%e a#e $2 2$'r m$nt%s t%e ri#%t eye
didnt s%$ t%at symt$ms anym$re ,'t int%e le2t eyes still sill.
5is arents claim t%at t%e tears didnt st$ t$
sill.
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Past clinical history
5is arents said t%at t%ere is n$ clinical%ist$ry
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Family history
5is ,r$t%er 'sed t$ ,e li+e t%is since %eas ,$rn 'ntil t%e a#e $2 2$'r m$nt%.
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General PhysicalAssestment eneral c$nditi$n : #$$d
Aareness : c$m$s mentis
ital si#n : 8l$$d Press're : 9 mm5#
RR : 0 !)min'te
Temerat're : 37 C
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OD OS
normal Eye ,all$siti$n
n$rmal
Eye "$4ement
Movement (+)
pse!doptosis (")
la#oftalmos (") oedem(")
redness (")
mass (") e$tropion (")
enteropion (")
Pale,ra "$4emen ;
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clear Anterior
'ham&er
'lear
ris colo!r : &ron
sine$ia (")'irc!lar p!pil isochore
Iris)'il Iris c$l$'r : ,r$n sine+ia
9ense clear
'annot &e descri&ed itre$'s Cann$t ,e descri,ed
'annot &e descri&ed F'nd's cann$t ,e descri,ed
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*es!me
Patient and %is arents c$me t$ Ot%alm$l$#istit% T%e le2t eye l$$+s et $r tears may sill $4er$nt$ t%e c%ee+. Patient is t%e t%ird c%ild in %is2amily. T%is symt$m is ,e#in since %e as ,$rn.Since %e as ,$rn ,$t% $2 t%e eyes are l$$+s et$r tears may sill $4er $nt$ t%e c%ee+.In t%e a#e$2 2$'r m$nt%s t%e ri#%t eye didnt s%$ t%atsymt$ms anym$re ,'t in t%e le2t eyes still sill.5is arents claim t%at t%e tears didnt st$ t$ sill.In t%e 2amily %ist$ry %is ,r$t%er 'sed t$ ,e li+e
t%is since %e as ,$rn 'ntil t%e a#e $2 2$'r m$nt%. In t%e insecti$nt%e tears l$$+ sill %is c%ee+ 2r$mt%e le2t eye. T%ere is n$ red eye $r e!'date2$ll$in# it.
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Dia#nose
?$r+in# @ia#n$se:
O,str'cti$n nas$lacrimal d'ct
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Plan for eamination
@ye dissaerarance test @@TOC&E@ TEAR @BCT
A ,l$c+ed tear d'ct is a 2airly c$mm$nand 's'ally tem$rary r$,lem t%at$cc'rs in in2ants %en t%e nas$lacrimal
d'ctt%e assa#e t%at lets tears drain2r$m t%e eye int$ t%e nasal ca4ity,ec$mes $,str'cted $r is cl$sed $D.
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8l$c+ed tear d'cts $cc'r in ' t$ 0ercent $2 ne,$rns. T%e c$nditi$ncalled dacry$sten$sis can aDect ='st $ne
eye $r ,$t%. F$r s$me ,a,ies ,l$c+ed tear d'cts
arent immediately e4ident at ,irt% andmay n$t ,e n$ticed 'ntil t%e ,a,y is am$nt% $ld.
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S"PTO"S
?%en an in2ant %as a ,l$c+ed tear d'ctt%e eye l$$+s et $r tears may sill $4er$nt$ t%e c%ee+ e4en %en %e $r s%e is
n$t cryin#.
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CABSES 1
N$rmally tears are r$d'ced ,y t%e lacrimal#land and t%en m$4e acr$ss t%e eyes it% t%e%el $2 t%e eyelids t$ +ee eyes l',ricated andclean.
?%en a ers$n ,lin+s t%e tears are sG'eeedint$ t%e d'cts in t%e inner c$rner $2 t%e eye.
T%ey t%en drain $'t $2 t%e eyes d$n smallt',esnas$lacrimal d'ctsint$ t%e ,ac+ $2 t%en$se. S$metimes t%e d'cts %a4e n$t 2'lly$ened ,y ,irt% s$ tears cann$t r$erly drain
$'t $2 t%e eye.
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CABSES
F$r m$st c%ildren ,$rn it% a ,l$c+edtear d'ct t%ere is $nly a smallmem,rane ,l$c+in# t%e $enin# %ic%
$ens s$ntane$'sly as t%e in2ant#r$s. Bs'ally t%e mem,rane $ens ,y10 t$ 1 m$nt%s $2 a#e
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@IANOSIS
@ye dissaearance test @@T