1) This is a weekly report from the glaucoma division summarizing Mrs. M's admission and treatment. 2) Mrs. M, a 54-year-old female, presented with blurred vision in both eyes and was found to have primary angle closure glaucoma in the left eye and a history of glaucoma and prior trabeculectomy in the right eye. 3) She underwent a left eye trabeculectomy surgery on August 15th, and follow up notes on her postoperative recovery are included.

1. WEEKLY REPORT
GLAUCOMA DIVISION
GEA/YOG/WTA/AZA/DAM/FIK

2. MRS. M/ 54 Y.O.
ADMISSION: AUGUST 14TH 2023
Subjective
Chief Complaint : Blurred vision of her both eyes
Patient complaints blurred vision of her eyes since 2 years ago. The Left eye progressively getting worse
and since 6 months ago the patients can’t see at all. Patient also complaints the Left eye is pain (+),
redness (+), halo (-) tunnel vision (-)
History of past ocular illness: RLE Glaucoma , 2 years ago
History of spectacle: (-)
History of trauma: (-)
History of surgery: RE Trabeculectomy (June, 15, 2023)
History of systemic disease: HT (-), DM (-)
History of similar condition in the family: (-)
History of treatment : Timol 2x1 RLE

3. MRS. M/ 54 Y.O. (AUGUST 14TH
,2023)

4. Right Eye Left Eye
3/60 VA 1/300
Edema (-), spasm (-) Eyelid Edema (-), spasm (-)
CI (-), PCI (-), bleb slightly elevated (+),
suture TGA 2, @11 and 1 o’clock
Conjuctiva CI (-), PCI (-)
Clear Cornea Clear
VH II COA VH II
Radline, coloboma (+) @ 1 o’clock Iris Radline
Round, 4 mm, RP (+) Pupil Round, 3 mm, RP (+) RAPD (-)
Non Homogenous Opacity Lens Non Homogenous Opacity
18 mmHg IOP 28 mmHg
FR (+), C/D ratio 0.4, nas (-), bay (-), LC (-),
chrioretinal atrophy (+), traction (+)
Funduscopy
FR (+), C/D ratio 1,0, nas (+), bay (dte), LC (dte),
chrioretinal atrophy (+), traction (dte)
DAY 1 PRE-OPERATIVE
AUGUST 14TH 2023

5. OCT

6. PERIMETRI

7. LABORATORY EXAMINATION (9-8-2023)
RSSA
Hb : 13.20
RBC : 4.29 x 106
WBC : 6,48
Hct : 39,70 %
PLT : 250.000
PPT : 10.60
APTT : 31.30
OT/PT : 17/10
Na/K/Cl : 139/4.07/105
Ur/Cr : 26.6/0.61
eGFR : 102,776
CRP : 0.04
Antibodi anti SARS CoV-2 : Non reactive
GDS : 112 mg/dL

8. RADIOLOGY EXAMINATION
Cor and pulmo within normal limit

9. ASSESSMENT
Left Eye Primary Angle Closure Glaucoma + Imature
Cataract
Right Eye Primary Angle Closure Glaucoma Post
Trabeculectomy + Imature Cataract + PDR Advance

10. PLANNING
Educate about the disease, planning therapy, and prognosis
Glauseta 2x250mg
KSR 1x1
Timolol 0,5% 2x1 RLE
Glaupac ED 3x1 LE
Lyteers 6x1 RLE
Pro OS Trabeculectomy /LA  Tuesday, August 15th 2023
Pro Consultation to Vitreoretina Division after surgery

11. CONSULTATION
Interna Department Cardiology Department
Assessment:
LE PACG pro Trabeculectomy
Assessment:
LE PACG Pro Trabeculectomy
HT St 1
Status cardio: ESC low risk, RCRI class I
risk
Planning:
• There was no specific
management in Interna
Department
• Other plannings are according to
Ophthalmology Department
Planning:
• Ramipril 0-0-10 mg

12. RE Trabeculectomy / LA
Performed on : August 15th , 2023
 Operator : dr. Fika / dr. Aulia Abdul Hamid, Sp.M(K)
 Ass : Ns. Maulidia / Ns. Djayadi
 Difficulty : (-)
 Complication : (-)

13. Post Op Treatment :
• Ciprofloxacin 2x500 mg
• Mefenamic acid 3x500 mg
• Levocin 6x1 gtt LE
• Vosama 6x1 gtt LE
• Timol 0,5% 2x1 gtt RE

14. POST SURGERY August 16th 2023

15. DAY 1 POST OPERATIVE - AUGUST 16TH 2023
Right Eye Left Eye
3/60 VA
Edema (-), spasm (-) Eyelid Edema (-), spasm (-)
CI (-), PCI (-), bleb slightly elevated (+), suture
TGA 2, @11 and 1 o’clock
Conjuctiva CI (-), PCI (-)
Clear Cornea Clear
VH II COA
Radline, coloboma (+) @ 1 o’clock Iris Radline
Round, 4 mm, RP (+) Pupil
Non Homogenous Opacity Lens Non Homogenous Opacity
18 mmHg IOP mmHg
FR (+), C/D ratio 0.4, nas (-), bay (-), LC (-),
chrioretinal atrophy (+), traction (+)
Fundus
FR (+), media opacity grade I, c/d ratio 0,5, nas (+),
bay (+), LC (+)
S: Left eye felt uncomfortable

16. ASSESSMENT
Left eye Primary Angle Closure Glaucoma post
trabeculectomy day 1 + Imature Cataract
Right Eye Primary Angle Closure Glaucoma
Post Trabeculectomy + Imature Cataract + PDR
Advance

17. PLANNING
- Educate the patient regarding diagnosis, treatment,
and prognosis
• Ciprofloxacin 2x500 mg
• Mefenamic acid 3x500 mg
• Levocin 6x1 gtt LE
• Vosama 6x1 gtt LE
• Timol 0,5% 2x1 gtt RE

18. BEFORE
AFTER