Canalis lacrimalis rupture + susp blowout fracture + rupture bulbi
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A 26-year-old male patient was referred to the hospital after a traffic accident where his right eyelid was ripped. On examination, his right eye had blurred vision, pain, swelling, hemorrhage and difficulty opening. A CT scan showed a right eye bulb rupture with hemorrhage, fractures to the right medial wall and orbit, and hematomas. The treatment plan included antibiotics, steroids, and eventually enucleation of the right eye with reconstruction due to the extent of the injuries. The doctor requested guidance and suggestions on the case.
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REGULATION FOR COMBINATION PRODUCTS AND MEDICAL DEVICES.pptx
Canalis lacrimalis rupture + susp blowout fracture + rupture bulbi
- 1. Duty Report Friday 22 April 2016 Jaga III : dr. Dina Novita, Sp.M Jaga II : dr. Gilang Jaga I : dr. Monik
- 2. identity • Name : Sdr. M • Age : 26 tahun • Work : worker
- 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
- 5. OD Canalis Lacrimalis Rupture+susp blowout fracture+rupture bulbi
- 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
- 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
- 13. terimakasih Mohon bimbingan dan saran
- 14. OTS