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1. GRAND WARD ROUND
03/08/2022
PREMAALOSHINEE THANABAL

2. Baby Y , 10 days ,male , born via SVD ( 38 weeks and 2 days )
presented with right eye lid swelling since 21/7/2021
associated with yellowish discharge
no eye redness
no fever
no vomiting
feeding as usual
Patient was brought to klinik kesihatan on 21/7/22 , for jaundince
check. Noted patient had two episodes of hypotermia at klinik
kesihatan , hence referred to paeds team to rule out sepsis and to
ophthal team for neonatrum ophthalmia

3. • ANC:
- 1. PROM <18 H
UFEME(13/7/2022) : NO UTI PICTURE
HVS( 13/7/2022): NO GROWTH
-2.RESOLVED ANEMIA IN PREGNANCY

4. OCULAR Examination 22/07/2022
RE LE
unable to visual acquity VA unable to do visual acquity
swelling , erythematous ,
yellowish purulent discharge ++,
everted minimal
pseudomembrane
Lid EVERTED LID NO PSM ,
MINIMAL YELLOWISH
DISCHARGE, NOT SWOLLEN
Round/Negative Pupil/RAPD Round/Negative
White Conjunctiva WHITE
Clear, no stain uptake Cornea Clear
formed, no obvious hypopyon AC D/Q
Clear LENS Clear,
OD Pink CDR 0.2, Macula
normal, Retina flat
Fundus OD Pink CDR 0.2, Macula
normal, Retina flat

6. DIAGNOSIS
BILATERAL EYE NEONATRUM OPHTHALMIA

7. MANAGEMENT
• G. VIGAMOX 2 HOURLY RIGHT EYE
• G. VIGAMOX 4 HOURLY LEFT EYE
• BILATERAL EYE LID HYGIENE TDS
• TRACE SWAB C& S ONCE AVAILABLE
• IV CEFOTAXIME 145MG 6 HOURLY ( STARTED BY PAEDS TEAM TO
COVER FOR SEPSIS )

8. OCULAR Examination 23/07/2022
RE LE
unable to visual acquity VA unable to do visual acquity
swelling , erythematous ,
yellowish purulent discharge ++,
everted minimal
pseudomembrane
Lid EVERTED LID NO PSM ,
MINIMAL YELLOWISH
DISCHARGE, NOT SWOLLEN
Round/Negative Pupil/RAPD Round/Negative
White Conjunctiva WHITE
Clear, no stain uptake Cornea Clear
formed, no obvious hypopyon AC D/Q
Clear LENS Clear
OD Pink CDR 0.2, Macula
normal, Retina flat
Fundus OD Pink CDR 0.2, Macula
normal, Retina flat

9. OCULAR Examination 22/07/2022
RE LE
unable to visual acquity VA unable to do visual acquity
swelling , erythematous ,
yellowish purulent discharge ++,
everted minimal
pseudomembrane
Lid EVERTED LID NO PSM ,
MINIMAL YELLOWISH
DISCHARGE, NOT SWOLLEN
Round/Negative Pupil/RAPD Round/Negative
White Conjunctiva WHITE
Clear, no stain uptake Cornea Clear
formed, no obvious hypopyon AC D/Q
Clear LENS Clear,
OD Pink CDR 0.2, Macula
normal, Retina flat
Fundus OD Pink CDR 0.2, Macula
normal, Retina flat

10. OCULAR Examination 22/07/2022
RE LE
unable to visual acquity VA unable to do visual acquity
swelling , erythematous ,
yellowish purulent discharge ++,
everted minimal
pseudomembrane
Lid EVERTED LID NO PSM ,
MINIMAL YELLOWISH
DISCHARGE, NOT SWOLLEN
Round/Negative Pupil/RAPD Round/Negative
White Conjunctiva WHITE
Clear, no stain uptake Cornea Clear
formed, no obvious hypopyon AC D/Q
Clear LENS Clear,
OD Pink CDR 0.2, Macula
normal, Retina flat
Fundus OD Pink CDR 0.2, Macula
normal, Retina flat

11. OCULAR Examination 22/07/2022
RE LE
unable to visual acquity VA unable to do visual acquity
swelling , erythematous ,
yellowish purulent discharge ++,
everted minimal
pseudomembrane
Lid EVERTED LID NO PSM ,
MINIMAL YELLOWISH
DISCHARGE, NOT SWOLLEN
Round/Negative Pupil/RAPD Round/Negative
White Conjunctiva WHITE
Clear, no stain uptake Cornea Clear
formed, no obvious hypopyon AC D/Q
Clear LENS Clear,
OD Pink CDR 0.2, Macula
normal, Retina flat
Fundus OD Pink CDR 0.2, Macula
normal, Retina flat