3. • Chief Complaint : the right inferior eyelid ripped
• Recent 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
4. OD OS
Visual acuity LP bad LP >3/60
Eye
movemenet
-3
-3 -3
-2 - 3
-2 -2
-3
free
Eye lid edema (+), fullthickness
laceration eyelid sup+inf+
canalis lacrimalis rupture
edema (-) spasm (-)
conjunctiva SKB (+), khemosis (+) Innormal limit
Cornea Edema(+), iris prolaps (-) Jernih (+)
Others Difficult to access In normal imit
Ophthalmology statusOphthalmology status
6. • Ceftriaxon inj 1gr/12 jam
• Ketorolac inj 30 mg/8 jam
• Metilprednisolone inj 862,5 mg/12 jam
• Ranitidin inj 150 mg/12 hours
• Vigamox e.d/jam OD
• Pro CT-Scan Orbita
Treatment
7.
8.
9.
10. CT-Scan result
• Intracerebral Haemorrhage with pneumocephal in
frontal lobus dx sin
• Right oculi bulbi rupture with intraconal
haemorrhage
• Complete fracture in right medial wall maxillari
sinus, right sup rim orbita, right papiracea lamina,
right ethmoid, right zygomaticus .
• Right Hematosinus maxillari, ethmoid and frontal
• Soft tissue swelling with emphysema subcutis
• No increase intracranial pressure.
11. OD OS
Visual acuity NLP >3/60
Eye lid Decrease edema (+),
fullthickness laceration
eyelid sup+inf+ canalis
lacrimalis rupture
edema (-) spasm (-)
conjunctiva SKB (+), khemosis (+) Innormal limit
Cornea Edema(+), iris prolaps (+) clear
Others Difficult to access In normal limit
Ophthalmology status 3rd dayOphthalmology status 3rd day
12. • Ceftriaxon inj 1gr/12 jam
• Ketorolac inj 30 mg/8 jam
• Metilprednisolone inj 862,5 mg/12 jam
• Ranitidin inj 150 mg/12 hours
• Vigamox e.d/jam OD
• Enucleasi + recanalisasi + palp. reconstruction
Treatment
