Mata.pdf

ANAMNESIS MATA MERAH VISUS NORMAL

MATA MERAH VISUS TURUN

Mengenai struktur yang bervaskular Media refrakta intak

mengenai media refrakta (kornea, (kornea, aquous humor humor,, lensa, vitreous body) body)

PALPEBRA: blepharitis, hordeolum, kalazion,, tumor, kalazion trauma KONJUNGTIVA: konjungtivitis, pterygium,, pterygium flikten, tumor, tumor, trauma SCLERA: skleritis,

MAT MATA TENANG TENA NG VISUS TURUN MENDADAK

LENSA: luksasi, subluksasi VITROUS: pendarahan KORNEA: keratitis, (DM, HT, ulkus leukemia, dll) COA: uveitis RETINA: ablasio, anterior, glaukoma oklusi a/v akut N.OPTICUS: VITREOUS: neuritis optik endoftalmitis, toksik panoftalmitis Tumor intra dan (methanol, retrobulbar ethambutol) trauma2 OTAK: stroke ©Bimbel UKDI MANTAP occipitalis

MAT MATA TENANG TENA NG VISUS TURUN PERLAHAN KORNEA: kelainan kontur COA: glaukoma sudut terbuka primer LENSA: gang refraksi, katarak Uveitis posterior RETINA: retinopati DM, HT, retinitis pigmentosa,pe nyakit makula

ANAMNESIS MATA MERAH VISUS NORMAL


Mengenai struktur yang bervaskular Media refrakta intak

mengenai media refrakta (kornea, (kornea, aquous humor humor,, lensa, vitreous body) body)

PALPEBRA: blepharitis, hordeolum, kalazion,, tumor, kalazion trauma KONJUNGTIVA: konjungtivitis, pterygium,, pterygium flikten, tumor, tumor, trauma SCLERA: skleritis,

MAT MATA TENANG TENA NG VISUS TURUN MENDADAK

LENSA: luksasi, subluksasi VITROUS: pendarahan KORNEA: keratitis, (DM, HT, ulkus leukemia, dll) COA: uveitis RETINA: ablasio, anterior, glaukoma oklusi a/v akut N.OPTICUS: VITREOUS: neuritis optik endoftalmitis, toksik panoftalmitis Tumor intra dan (methanol, retrobulbar ethambutol) trauma2 OTAK: stroke ©Bimbel UKDI MANTAP occipitalis

MAT MATA TENANG TENA NG VISUS TURUN PERLAHAN KORNEA: kelainan kontur COA: glaukoma sudut terbuka primer LENSA: gang refraksi, katarak Uveitis posterior RETINA: retinopati DM, HT, retinitis pigmentosa,pe nyakit makula

Eye Lid Disorder BLEFARITIS MAT MATA MERAH MER AH VISUS VISU S NORMAL NO RMAL Radang pada kelopak Etiologi Alergi akibat debu, asap, iritan atau infeksi kuman dapat oleh streptococcus alfa/beta, pneumococcus, pseudomonas, staphylococcus Gejala Kelopak mata merah, edema, nyeri, eksudat lengket, epiforia, dapat disertai konjungtivitis dan keratitis Pengobatan Dibersihkan dengan garam fisiologik hangat, diberi antibiotik lokal yang sesuai, dan antibiotik sistemik bila infeksi berat, dan kompres hangat Penyulit Konjungtivitis, keratitis, hordeolum, kalazion, madarosis Tipe Blepharitis typically comes in two forms, anterior (Staphylococcal or Seborrheic) and posterior (Meibomian Gland Dysfunction). These are both common, and an individual can develop both of these at one time. ©Bimbel UKDI MANTAP

KLASIFIKASI BLEFARITIS ANTERIOR SEBOROIK

STAFILOKOKAL/ULSERATIVA

Penyebab

Gangguan pd gld. Zeis dan Moll (seboroik anterior) atau gld Meibom (seboroik posterior) yg berkaitan dg dermatitis seboroik (kulit kepala, nasolabial folds, preauricula, sternum)

Infeksi kronik stafilokokus, biasanya pd anak-anak.

Patofisiologi

Overproduksi Corynebacterium acnes lemak yg iritatif

Infeksi kronik pd dasar bulu mata abses intrafolikular ulserasi dermis dan epidermis

jd asam

Manifestasi

Sisik putih, halus, biasanya pd ujung bulu mata, penebalan palpebra, madarosis, dasar hiperemis, ulkus -

Sisik2 pd dasar bulu mata, bila diusap biasanya meninggalkan keropeng berdarah, sisik lbh lengket. Komplikasinya bs menyebabkan trichiasis, madarosis, poliosis.

Terapi

-Higien sisik dgn salep salisil 1% dan -Higien sisik 2x1 dgn 25% sampo bayi, merkuri amoniak (tdk boleh masuk usap dgn cottonbud. mata. -Salep antibiotik (basitrasin atau eritromisin) stlh sisik dibersihkan. ©Bimbel UKDI MANTAP bakteri: tetrasiklin 2x250 mg 1 bulan; -Steroid topikal lemah (fluorometolon

KLASIFIKASI BLEFARITIS ANTERIOR Blefaritis seboroik

Blefaritis ulseratif

©Bimbel UKDI MANTAP

Terapi Blefaritis Treatment depends on the specific type of blepharitis. The key to treating most types of blepharitis is keeping the lids clean and free of crusts. Warm compresses can be applied to loosen the crusts, followed by gentle scrubbing of the eyes with a mixture of water and baby shampoo or an over-thecounter lid cleansing product. In cases involving bacterial infection, an antibiotic may also be prescribed. If the glands in the eyelids are blocked, the eyelids may need to be massaged to clean out oil accumulated in the eyelid glands. Artificial tear solutions or lubricating ointments may be prescribed in some cases. Use of an anti-dandruff shampoo on the scalp can help. Limiting or stopping the use of eye makeup is often recommended, as its use will make lid hygiene more difficult. If you wear contact lenses, you may have to temporarily discontinue wearing them during treatment. Some cases of blepharitis may require more complex treatment plans. Blepharitis seldom disappears completely. Even with successful treatment, relapses may occur. ©Bimbel UKDI MANTAP

MATA MERAH VISUS NORMAL

Hodeolum vs Khalazion HORDEOLUM

KHALAZION

Definisi

Peradangan pada kelenjar Zeiss, Moll, dan Meibom karena infeksi bakteri

Inflamasi kronik pada kelenjar Meibom.

Lokasi defek

-Gld. Sebasea (Zeiss), Gld. Siliaris (folikel rambut bulu mata/Moll): H. EXTERNUM -Gld. Tarsalis (Meibom): H. INTERNUM

Gld. Tarsalis (Meibom). Biasanya pada palpebra superior.

Etiologi dan PA

Infeksi bakteri. Sekumpulam sel-sel PMN dan jaringan nekrotik.

Reaksi granulomatosa, biasanya idiopatik.

Manifestasi

Nyeri, hangat, bengkak.

Nodul tak nyeri.

Terapi

-Kompres hangat 4x10 menit -Antibiotik topikal (salep eritromisin atau basitrasin 2x1). Pikirkan utk tx sistemik dg doksisiklin 2x100 mg utk efek antibakteri dan antiinflamasinya. -Bila memburuk, pikirkan insisi drainase

Apabila gagal diobati dgn tx obat selama 3-4 minggu dan pasien menghendaki removal, maka dpt dilakukan insisi dan kuretase menggunakan inj. Steroid (0,2-1 ml triamsinolon 40 mg/ml) dan lidocaine 2% (1:1)



Internal Hordeolum Treatment The infection is deep within the lid tissue antibiotics topical usually ineffective Apply hot compresses for five to 10 minutes, two to four times a day, in order to liquefy the stagnant secretions and facilitate drainage through the meibomian orifice Lidscrubs with a mild shampoo also helps to remove any debris, which may have accumulated on the eyelid margin surface, and in those patients with blepharitis Staphylococcus species primary medical therapy should consist of a penicillinaseresistant penicillin such as dicloxacillin. Dosages of 125mg to 250mg every six hours, usually result in prompt resolution of the infection Patients who are allergic to penicillin can try oral erythromycin, chloramphenicol or the aminoglycosides Finally, in cases which resist medical therapy, incision and drainage using a sterile needle or blade may be necessary

External Hordeolum Treatment Hot compresses several times a day accelerate the pointing of the lesion and its spontaneous drainage If an eyelash is seen to extend from the involved lesion, then epilation of the lash can initiate drainage of the lesion by creating an effective drainage channel Bacitracin or erythromycin antibiotic ointment, applied four times a day during the acute phase and continued twice daily for one week thereafter, may prove helpful, especially in preventing the infection spreading to the surrounding lash follicles Systemic antibiotics such as oral erythromycin or dicloxacillin may be necessary if there is severe preseptal cellulitis Finally, for resistant lesions, an incision can be made with a sterile needle or blade into the area of pointing, which allows the abscess cavity to drain.


Chalazion Treatment Topically /systemically administered antibiotics are ineffective because the lesion is not infectious in origin Hot compresses followed by gentle massage evacuate stagnant secretions. This prevents further chalazion formation and encourages drainage along the duct of the involved gland which may be of benefit if the lesion is small . Vigorous massage can cause further extravasation of the meibomian secretions into the surrounding tissue, spreading the granulomatous inflammation. Intralesional injection of steroid. Since the chalazion is encapsulated by connective tissue, there is little room for space-occupying steroid medication. Therefore, a steroid of increased concentration such as triamcinolone acetomide (Kenalog-40), a 40mg/ml concentration works well since only a 0.10-0.20cc dose needs to be injected The most reliable therapy involves surgical excision of the affected meibomian gland. The eye is treated with antibiotic ointment, which the patient should continue to use two times a day for five to seven days. On rare occasions, the chalazion may recur if the surgical excision was incomplete ©Bimbel UKDI MANTAP

Pterygium Definisi Pertumbuhan jaringan fibrovaskular subepitelial berbentuk segitiga pada jaringan konjungtiva bulbar meliputi limbus hingga kornea. Mekanisme Respon terhadap kekeringan kronik dan pajanan ultraviolet DD Pinguecula (yellow-white deposit pd konjungtiva bulbi di nasal/temporal limbus krn degenerasi kolagen pd stroma konjungtiva, penipisan epitel, dan kalsifikasi. Eksisi jarang diperlukan Tanda dan gejala Mata iritatif, merah, 90% di nasal, dapat terjadi astigmat Terapi Hindari asap, debu, dan sinar UV; lubrikan topikal; vasokonstriktor dan kortikosteroid topikal . Operasi bila terjadi gangguan penglihatan



Derajat Pterigium (Youngson) Derajat 1 Jika pterigium hanya terbatas pada limbus kornea

Derajat 2 Jika pterigium sudah melewati limbus kornea tetapi tidak lebih dari 2 mm melewati kornea

Derajat 3 Jika pterigium sudah melebihi derajat dua tetapi tidak melebihi pinggiran pupil mata dalam keadaan cahaya normal (diameter pupil sekitar 3-4 mm)

Derajat 4 Jika pertumbuhan pterigium sudah melewati pupil sehingga mengganggu penglihatan ©Bimbel UKDI MANTAP

Pterygium vs Pseudopterygium Tes Sonde

Sonde (+): dapat menembus bagian bawah jaringan pseudopterygium Sonde (-): tidak dapat menembus bagian bawah jaringan pterygium

Pulau-pulau fusch pada kornea

Pulau-pulau fusch pada kornea di puncak pterygium (+) pterygium Pulau-pulau fusch pada kornea (-) pseudopterygium

Riwayat kerusakan permukaan kornea

Riwayat kerusakan permukaan kornea (+) pseudopterygium Riwayat kerusakan permukaan kornea (-) pterygium

Pembuluh darah

Pembuluh darah lebih menonjol pterygium ©Bimbel UKDI MANTAP


KONJUNGTIVITIS konjungtivitis adalah inflamasi pada konjungtiva, bisa terjadi pada konjungtiva bulbi, konjungtiva forniks, ataupun konjungtiva palpebra.

Evaluasi REAKSI- REAKSI INFLAMASI KONJUNGTIVAL jenis sekret WATERY: eksudat serosa+air mata, ec viral inflamasi toksik MUKOID: vernal, keratokonjungtivitis sicca PURULEN: bakteri akut berat MUKOPURULEN: bakteri ringan, klamidia jenis reaksi konjungtiva FOLIKULAR: hiperplasi jar limfoid, bentuk kyak butir2 PAPILAR: hiperplasi epitel konjungtiva, bentuk poligonal, ec blefaritis kronis, vernal, infeksi bakterial, lensa kontak, SLK ada tidaknya pseudomembran atau membran PSEUDOMEMBRAN: koagulasi eksudat, ec adenovirus berat, konjungtivitis ligneus, konjungtivitis gonorea, dan konjungtivitis autoimun MEMBRAN: penetrasi eksudat ke epitel konjungtiva, ec Streptococcus beta hemolyticus dan difteri ada tidaknya limfadenopati preaurikular atau submandibular, ec viral, klamidia, gonokokus berat


Konjungtivitis akut FOLIKEL

lnn preaurikular +

tanda herpetik + HSV

lnn preaurikular -

toxic, molluscum, pediculosis

PAPILLA

purulen berat: GO

purulen ringan: bakteri selain GO

watery: alergi, atopi

tanda hepretik adenovirus, klamidia

Pathology

Etiology

Viral (akut)

Adenovirus herpes simplex virus or varicellazoster virus, coxackie virus,

Feature

Treatment

Mata merah, gatal, panas, discar berair, mengganjal.pre-auricular lymphadenopathy, reaksi folikular pseudomembrane (+/-)

4-7 hari berat 2-3 minggu membaik Higiene, krn sgt menular Artificial tears relieve dryness and inflammation (swelling) Kompres dingin Antiviral herpes simplex


Pathology

Feature

Treatment

Mata merah, sensasi benda asing, discar mukopurulen/purulen, fotofobia dijumpai apabila kornea terlibat, papila konjungtiva, kemosis, limfadenopati preaurikular jarang tapi sering muncul pada konjungtivitis gonokokal.

topical antibiotics trimetoprim/polimiksin B atau fluorokuinolon tetes qid Artificial tears

Gonokokal N.gonorrheae (hiperakut)

Discar purulen berat, hiperakut (dalam 12-24 jam), papila konjungtiva, kemosis berat, lnn preaurikular, edema palpebra, pseudomembran. Dapat terjadi keratitis akibat penumpukan sel-

Seftriakson 1 gr i.m single dose. Irigasi untuk membersihkan sekret. Siprofloksasin topikal ointment qid atau tetes q2h. Tx partner seksual

Klamidial (kronis)

riwayat vaginitis, servisitis, atau uretritis. Folikel konjungtival pada tarsal atau bulbar, pannus, teraba lnn.preaurikular. Biasanya terjadi unilateral,©Bimbel kronis,UKDI sekret MANTAP

Azitromisin 1 gr p.o single dose. Eritomisin topikal atau tetrasiklin ointment bid-tid selama 2-3 minggu.

Bakterial non gonokokal (akut)

Etiology S.aureus S.epidermidis, H.influenzae, Streptococcus pneumoniae, M.catarrhalis

Chlamydia trachomatis serotipe D-K


Pathology

Etiology

Feature

Treatment

Alergika

Allergy

Gatal biasanya bilateral namun dapat asimetrik, discar tebal, umumnya pada laki-laki. Rekurensi musiman, riwayat atopi, usia muda. papila konjungtiva besar, terlihat di balik palpebra superior atau sepanjang limbus (limbal vernal). superior corneal shield ulcer Horner-Trantas dots

Removal allergen Topical antihistamine Vasoconstrictors

Trachoma

Chlamydia trachomatis serotipe A, B, Ba, dan C

TF (trachomatous inflammation: folikular): >5 folikel pada tarsal atas. TI (trachomatous inflammation: intens): inflamasi dengan penebalan vasa tarsal >50%. TS (trachomatous scarring); sikatrik pada konjungtiva tarsal dengan pita fibrosis putih. TT (trachomatous trichiasis): trichiasis pada paling tidak satu bulu mata. CO (corneal opacity ): opasitas paling tidak melibatkan batas pupil.

Azitromisin 20 mg/kg p.o single dose, doksisiklin 100 mg p.o bid, eritromisin 500 mg p.o qid, atau tetrasiklin 250 mg p.o qid 2 minggu. Tetrasiklin, eritromisisn, atau sulfasetamid salep bid-qid selama 3-4 minggu.


http://nurse-practitioners-and-physician-assistants.advanceweb.com/Features/Articles/BacterialConjunctivitis.aspx (Bacterial Conjunctivitis : A review of therapies and approaches, 2012) ©Bimbel UKDI MANTAP

Konjungtivitis Viral Adenoviral Pharyngoconjunctival fever (PCF): tipe 3 dan 7, ISPA +, 30% ada keratitis Epidemic keratoconjuntivitis: tipe 8 dan 19, sistemik -, keratitis 80% Enterovirus 70 (Acute hemorrhagic conjunctivitis) Sering di daerah kumuh padat, self-limiting, pendarahan sc, folikel+ Pox virus Molluscum contagiosum Ciri: molluscum lid lesion, folikular kronik, limfadenopati-. Bisa ada keratitis. Tx: eksisi lesi ©Bimbel UKDI MANTAP

Konjungtivitis Alergika 1. Konjungtivitis Musiman/hay fever Trigger: pollen, bulu, dll. Hipersensitivitas tipe 1 olh IgE di subs propria konj. Gatal, akut, nyrocos, merah, papilar. Tx: mastcell stabilizer (2% Na kromoglikat tts, lodoksamid 0.1% tts)

2. Konjungtivitis Alergika akut Trigger: dust mite, bulu hewan, dll dlm jumlah besar masuk masuk ke ke saccus konjungtiva. SS: Kemosis berat akut, blefaritis. Cepat sembuh dlm hitungan jam. Tx Tx

3. Konjungtivitis Atopik Laki2 muda, dermatitis atopik, area kulit pd leher, fossa poplitea, antecubiti, asma, dll. Palpebra menebal, berkrusta, fisur. Tx: steroid topikal short term, MCS, antihistamin po

4. Konjungtivitis Vernal Spring catarrh, jarang, bilateral, anak, remaja, laki2>, reaksi alergi oleh IgE, atopi. RPD asma, berkaitan dgn RPD/K atopi. eksema. Eosinofil +. Bisa kena kornea: epiteliopati punctata, makroerosi dan ulkus, plak, parut subepitel, pseudogerontokson (seperti arcus senilis). Ocular signs of VKC commonly are seen in the cornea and conjunctiva. In contrast to atopic keratoconjunctivitis (AKC), the eyelid skin usually is not tipe: involved. 3 tipe: palpebral: kemosis, cobble stone papillae, Limbal: konj edem, hiperemik, tebal; Mixed

5. Konjungtivitis Giant-Papilar korpal (lensa kontak, prothesa, ec korpal (lensa jahitan)


Konjungtivitis Alergika Konj. atopik

Konj. vernal


SUMMARY KONJUNGTIVITIS Evaluasi REAKSI- REAKSI INFLAMASI KONJUNGTIVAL jenis sekret (serosa: alergika, viraL; purulenta: bakteri, mukoid: vernal; mukopurulen: bakteri ringan, klamidia) jenis reaksi konjungtiva (folikular,papilar) ada tidaknya pseudomembran (adenovirus berat, konjungtivitis ligeneus, konjungtivitis gonorea, dan konjungtivitis autoimun) atau membran (Streptococcus beta hemolyticus dan difterii). ada tidaknya limfadenopati preaurikular

Tabel 1. Gambaran beberapa jenis konjungtivitis

Klinis

Virus

Bakteri

Klamidia

Alergi

Gatal

Min

Min

Min

+++

Generalisat

Generalisat

Generalisat

a

a

a

a

Lakrimasi

+++

++

++

++

Eksudasi

Min

+++

+++

Min

Lnn

Lazim

Tak lazim

Pd

Hiperemia Generalisat

konj.

-

Inklusi

Sel

Monosit

Bakteri,

PMN,

PMN

badan inklusi

Eosinofil

sel

plasma Faringitis,

demam ©Bimbel UKDI MANTAP

Kadang

Kadang

Tidak

Tidak

pernah

pernah

Aminoglycosides Bactericidal & effective against gram-negative organisms, incomplete coverage against gram-positive bacteria The emergence of resistant bacterial strains has decreased the usefulness of aminoglycosides for conjunctivitis

Polymyxin B Combination Therapies Bactericidal for gram-negative organisms, no coverage for gram-positive organisms. Combined with other antimicrobial agents to expand effectiveness against a wider range of pathogens. Polymyxin B combinations penetrate tissue poorly and are not reliably bactericidal.

Macrolides Bacteriostatic and inhibit protein synthesis but do not affect nucleic acid synthesis.

Fluoroquinolones Potent, broad-spectrum, bactericidal antibiotics with a dual mechanism of action that inhibits the bacterial enzymes DNA gyrase (topoisomerase II) and/or topoisomerase IV, enzymes that are essential in the synthesis and replication of DNA. The fluoroquinolones are active against gram-positive and gram-negative bacteria and have been well tolerated in clinical trials.They are frequently prescribed as firstline therapy because of their greater efficacy compared with other classes of ocular antibacterial agents

The fluoroquinolones are currently the most effective & potent agents against most bacterial pathogens (broad spectrum of activity, demonstrate rapid bactericidal activity, achieve high concentrations in the eye, have a long ©Bimbel UKDI MANTAP residence time at the infection site, and are well tolerated)

Subconjunctival Hemorrhage




Subconjunctival Subconjunctiv al hemorrhage (cont.) Characterized by red, flat discoloration due to bleeding from the small blood vessels that run through the conjunctiva The most common cause for spontaneous subconjunctival hemorrhage is idiopathic in nature The condition is painless, clearing itself within 7 to 14 days In a few cases, the redness may be associated with bleeding disorders, the use of anticoagulants, conjunctivitis, scleritis, or trauma to the eye Warm compresses may be useful in symptomatic relief. Treatment involves the identification and appropriate management of the underlying cause ©Bimbel UKDI MANTAP


Episkleritis vs Skleritis Tipe

Etiologi

Idiopatik EPISKLERITIS (Reaksi radang (mostly), reaksi jaringan ikat hipersensitivitas vaskular di terhadap antara penyakit konjungtiva & sistemik, infeksi: permukaan zooster, zooster, dll sklera, umumnya unilateral)

Manifestasi klinis Mata merah (pelebaran vasa) Nyeri ringan Dewasa muda (perempuan>>) Visus normal Mengganjal Khas : Kemerahan biasanya sektoral sektoral (jarang difus), tonjolan setempat, setempat, batas batas tegas, tegas, dan berwarna merah ungu dibawah konjungtiva yang sakit jika ditekan Pada episkleritis luas, gambaran klinis mirip dengan konjungtivitis. Bedanya adalah pada episkleritis tidak terdapat hiperemi konjungtiva tarsal, tidak ada sekret, serta terasa nyeri saat penekanan ringan bola mata Komplikasi : penyulit yang dapat timbul timbul adalah adalah terjadin terjadinya ya peradangan yang lebih dalam pada sklera yang disebut sebagai ©Bimbel UKDI MANTAP Skleritis

Terapi Pembuluh darah yang melebar akan mengecil bila diberi fenilefrin 2,5% topikal (vasokonstriktor) (vasokonstriktor) Artificial tears Pada keadaan yang berat diberi kortikosteroid tetes mata topikal, sistemik atau salisilat Prognosis : Episkleritis dapat sembuh sempurna/residif Dengan pengobatan adekuat, episkleritis dapat sembuh dalam 1 minggu, atau lebih (episkleritis nodular)


Episkleritis vs Skleritis Tipe

Etiologi

Manifestasi klinis

Terapi

SKLERITIS

50% berkaitan dgn penyakit sistemik: peny. Jar ikat (RA,

Mata merah gradual, nyeri sedangberat menyebar hingga ke kepala, wajah. Rekuren. Inflamasi sklera, episklera, dan konjungtiva. Bluish scleral hue pd px dgn cahaya biasa. Vasa menetap walau diberi fenilefrin 2,5%, nodul sklera Nb. Skleritis posterior: nyeri, proptosis, retinal detach n hem

Tergantung tipe! 1. Nodular difus: NSAID, steroid sistemik, tx imunosupresif k/p. 2. Nekrotikans: steroid sistemik, tx imunosupresif 3. Posterior: kontroversial 4. Infeksius: sesuai sebab

polyarteritis nodosa, AS), sifilis, gout, tb, dll


episkleritis

skleritis



Keratitis Keratitis: peradangan kornea

nyeri, injeksi perikornea, sekret sedikit/-, kekeruhan kornea (infiltrat, edema, ulkus: apabila ada kerusakan stroma). Tipe

Etiologi

Anamnesis

Manifestasi klinis

Bakterial

Stafilokokus, Pseudomonas, Streptokokus, Moraksella, Serratia

Pengguna lensa kontak, riwayat penyakit dan operasi pd kornea, trauma, korpal

Opasitas putih (infiltrat) pada kornea, defek epitel, discar mukopurulen, edema stroma, reaksi pd COA dgn/tanpa hipopion.

Viral

HSV, Herpes zooster

HSV: 6 bln-5 th, self limited Zooster: immunocompromised, usia lbh tua

HSV: dendritik, geografika, vesikel +/- tidak dermatomal Zooster: nyeri dermatomal, vesikel2 di kulit sekitar mata sesuai dermatom unilateral,

Fungal

Aspergillus, Riwayat trauma terkena Fusarium, Candida tanaman ©Bimbel UKDI MANTAP

Infiltrat dengan batas kabur, lesi satelit, hipopion.

Keratitis

Bacterial

Normal corneal layers

Viral

Fungal


Keratitis viral HSV

Zooster



Viral Keratitis tx Zooster

HSV Since most cases of herpes simplex virus (HSV) epithelial keratitis resolve spontaneously within 3 weeks, the rationale for treatment is to minimize stromal damage and scarring. Gentle epithelial débridement may be performed to remove infectious virus and viral antigens that may induce stromal keratitis. Antiviral therapy, topical or oral, is an effective treatment for epithelial herpes infection. Treatment options for primary ocular herpes infection include the following: Ganciclovir ophthalmic gel 0.15% - 5 times daily Trifluridine 1% drops - 9 times daily Vidarabine 3% ointment - 5 times daily Oral acyclovir 400 mg - 5 times daily for 10 days[19] ; oral acyclovir is the preferred treatment in patients unable to tolerate topical medications and with good renal function A cycloplegic agent may be added to any of the above regimens for comfort from ciliary spasm.

Oral acyclovir 800 mg po five times daily for 7 to 10 days is the standard treatment. Alternatively, a provider could use famciclovir 500 mg po tid or valacyclovir 1000mg po tid. If the systemic condition warrants or if the patient is unable to tolerate food by mouth then acyclovir 5-10 mg/kg iv q8 for 5 days may be utilized. Topical steroids (e.g. prednisolone acetate 1%) should be used for interstitial keratitis and uveitis. For episodes of scleritis, retinitis, choroiditis, and optic neuritis, systemic steroids by mouth or intravenous administration should be strongly considered. For increased intraocular pressure commonly found in herpes trabeculitis, topical steroids should be administered as well as aqueous suppressants (e.g. timolol, brimonidine, dorzolamide, acetazolamide).

Pain should be treated with narcotics if warranted. Neuropathic pain responds well to amitriptyline 25 mg po qhs and can decrease the incidence of postherpetic neuralgia. Capsaicin cream applied to ©Bimbel UKDI MANTAP the rash may decrease pain as well. [13]

Keratitis bakterial


Keratitis bakterial tx



Keratitis fungal Tx - Mondok - Nat Natamis amisin in 5% tet tetes es atau amfoterisin amfoterisin B 0.15% (esp utk Candida) q1-2 jam lalu t.o 4-6 minggu - Sikloplegik - Topik pikal steroi eroid d - No! No! - Antifu ifungi sistemik mik (flukonazol 200-400 mg po loading, lalu 200 mg p.o bid) ©Bimbel UKDI MANTAP

AAO, 2014




How to Diagnose Corneal Ulcers? Direct observation under magnified view of slit lamp revealing the ulcer on the cornea The use of fluorescein stain, which is taken up by exposed corneal stroma and appears green, helps in defining the margins of the corneal ulcer, and can reveal additional details of the surrounding epithelium. Rose-Bengal dye is also used for supra-vital staining purposes, but it may be very irritating to the eyes Doing a corneal scraping and examining under the microscope with stains like Gram's and KOH preparation may reveal the bacteria and fungi respectively. Microbiological culture tests may be necessary to isolate the causative organisms for some cases Other tests that may be necessary include a Schirmer's test for keratoconjunctivitis sicca and an analysis of facial nerve function for facial nerve paralysis. ©Bimbel UKDI MANTAP


Uveitis Uveitis: inflamasi pada uvea (iris, badan silier, koroid) Manifestasi: bergantung pd lokasinya. Tipe

Etiologi

Anamnesis

ANTERIOR (iris)

Idiopatik, peny Akut: merah, nyeri, sistemik (AS, fotofobia, RA, IBD, SLE, Behcet), lensinduced, eksaserbasi-remisi. postOP, herpes, sifilis, TB

Manifestasi klinis

Terapi

Injeksi siliar, sel (inflamasi aktif +), flare (protein leakage) / efek tyndall pada COA, keratic precipitates (KP), hipopion, sinekia

Sikloplegik, steroid topikal, bl tdk membaik berikan sistemik.

glaukoma.

INTERMEDI ATE (badan silier)

Idiopatik (>70%), sarkoidosis, MS, Lyme, sifilis, toxocariasis

Sensasi benda apung tidak nyeri, fotofobia dan inflamasi eksterna minimal, bilateral, usia 15-40 th.

Infiltrasi sel ke vitreous (vitritis), tampak snowbanking di inferior vitrous.

Steroid topikal, bl tdk membaik berikan sistemik.

POSTERIOR (koroid)

Toxo, CMV, histoplamosis

benda apung. Umumnya tidak nyeri. Nyeri, merah, fotofobi jk inflamasi COA (+)

Vitreous: sel, hazy; koroiditis, retinitis, vaskulitis

Tx penyebab


Diagram uvea


Uveitis Keratic precipitate

Koeppe nodules (infeksi granulomatosa)

Buasacca nodule (infeksi granulomatosa)


Uveitis posterior


Glaukoma


Definisi: neuropati optik yang disebabkan oleh TIO yg relatif tinggi, ditandai dgn kelainan lapang pandang dan atrofi papil saraf optik. TIO N 8-21 mmHg. Klasifikasi

PENYEBAB: primer (idiopatik), sekunder, kongenital KEADAAN SUDUT: open, closed Mekanisme: gangguan aliran humor akuos akibat kelainan sistem drainase shg

penggaungan/cupping diskus optikus PX: 1.

PAPIL: atrofi (pucat, batas tegas, lamina kribrosa jelas), penggaungan (tepi temporal menipis, D vertikal>horizontal, vasa menggantung di pinggir dan terdorong ke nasal).

2.

TONOMETRI: palpasi, Tonometri Schiotz, aplanasi Goldmann, NCT

3.

GONIOSKOPI: px sudut iridokornea

4.

LAPANG PANDANG: perimetri ©Bimbel UKDI MANTAP

Glaukoma



Glaukoma


Glaukoma


Glaukoma Primer SUDUT

NAMA

ETIOLOGI

MANIFESTASI

TERAPI

OPEN

Primary Open Angle Glaucoma (POAG) Normotension glaucoma

Idiopatik

Kronis, asimptomatik hingga tingkat lanjut, progressive visual field loss, TIO sebagian meningkat, sudut normal, funduskopi: atrofi, penggauangan/cupping.

Menurunkan TIO dgn medikasi (first line) atau trabekuloplasti atau trabekulektomi

CLOSED

Acute Angle Closure Glaucoma

Pupillary block

Nyeri, di skliling cahaya, nyeri kepala berat, mual muntah.

- Tx topikal utk blocker (timolol 0,5% tdk boleh pd COPD atau asma) / alfa2 agonis (brimonidin 0,15%) / Pg analog / carbonic anhydrase inhibitor (dorzolamid). -Steroid topikal -CAI sistemik (asetazolamid 250500 mg iv atau po). -Ulangi ukur TIO dan visus 1 jam kemudian, bila tdk membaik berikan manitol 1-2 gr/kg iv selama 45 menit.

edema kornea, mata merah, injeksi konjungtiva, pupil terfiksasi middilatasi.

Chronic AngleClosed Glaucoma

Prolonged acute angle-closure glaucoma

Asimptomatik, progressive sudut tertutup


iridotomi

Glaukoma


NAMA

Glaukoma Sekunder

ETIOLOGI GLAUKOMA SEKUNDER

MANIFESTASI

Pigmentary glaucoma

open-angle galucoma

Pandangan kabur, nyeri, halo pelangi, dilatasi pupil, dpt asimptomatik. Dewasa muda, laki2, bilateral.

Exfoliative glaucoma

Penyakit sistemik krn adanya material eksffoliasi putih-keabuan yg terdeposit di lensa, iris, eptiel siliar, dan trabecular meshwork.

Asimptomatik pd awal. Tampak material ptih-abu pd tepian pupil.

Phacogenic glaucoma

PHACOLYTIC GLAUCOMA Krn ada material lensa yg keluar dr lensa (katarak hipermatur)

Nyeri unilateral, visus LP atau NLP, fotofobia, nyrocos, katarak matur/hipermatur, edema kornea, cell and flare pd COA.

LENS PARTICLE GLAUCOMA Krn ada material yg mengobstruksi aliran akuos stlh trauma atau operasi mata

Nyeri, visus turun, merah, nyrocos, fotofobia, material putih di COA.

PHACOANAPHYLAXIS Chronic granulomatous uveitis in response to lens material liberated

Idem, riwayat uveitis

trabekula PHACOMORPHIC GLAUCOMA

Idem, sudut tertutup

block

Inflammato ry openangle glaucoma

Uveitis (anterior, intermediate, posterior, panuveitis), keratouveitis, post trauma, intraocular surgery

Nyeri, visus turun, fotofobia, TIO naik, inflamasi pd COA.

Steroidresponse glaucoma

Riwayat penggunaan steroid lama (terutama topikal, periokular,

TIO meningkat, tanda2 POAG


Medikamentosa glaukoma


Terapi Glaukoma Sudut Terbuka (OAG) Primary goal of therapy : Menurunkan TIO sehingga mengurangi progresi penurunan lapang pandang penglihatan Inisiasi terapi : TIO >25 mmHg (most clinicians), sebagian lain >22 mmHg. Alternatif lain, TIO 18mmHg + cupping & field loss harus ditx Modalitas terapi : farmakologik, laser (trabeculoplasty), operasi (trabeculotomy) ©Bimbel UKDI MANTAP

Farmakologik Prostaglandin Prostaglandin topikal lebih dipilih dibanding betabloker topikal sebagai first line tx pada OAG Menurunkan TIO lebih besar dibanding betabloker, lebih efektif, lebih ditoleransi, efek samping sistemik paling kecil Durasi aksi kerja panjang 1x/hari Contoh : Latanoprost (efek samping paling kecil dibanding prostaglandin lainnya), bimatoprost, tafluprost Ocular S.E. : conjunctival hyperemia, eye irritation, bulu mata tambah panjang/banyak, perubahan iris dan pigmentasi bulu mata

Betablocker Dahulu, dianggap sebagai first line tx u/ OAG Menurunkan TIO, durasi aksi kerja panjang 1-2x/hari, efek samping okular sedikit Contoh : timolol, betaxolol Systemic S.E. : Worsening of heart failure, bradycardia, heart block, and increased airway resistance Topikal beta bloker : Kontraindikasi pada pasien dengan cardiac/pulmonary disease ©Bimbel UKDI MANTAP

Alpha adrenergic agonists Efektivitas mirip dgn betabloker dalam menurunkan TIO pada OAG Contoh brimonidine Ocular side effects >> : allergic conjunctivitis, hyperemia, & ocular pruritus. Nonselective agents (epinephrine) arrhythmia, hypertension, and tachycardia

Systemic carbonic anhydrase inhibitors Mulai ditinggalkan, diganti dengan preparat topikal yang lebih baru dan memiliki S.E. lebih kecil Preparat topikalnya tidak lebih baik dibandingkan preparat topikal jenis lain Contoh : Acetazolamide oral

Cholinergic agonists Adverse effects << dibanding betabloker Memiliki ocular side effects >>seperti fixed, small pupils (miotikum), myopia, and increased subjective visual disturbance yang berkaitan dengan katarak koeksis menurunkan popularitas obat ini ©Bimbel UKDI MANTAP Uptodate, 2015 Contoh : Pilokarpin

Terapi Glaukoma Sudut Tertutup (CAG) Dalam 1 jam sebaiknya langsung dirujuk ke Sp.M. Tetapi apabila tidak memungkinkan, mulai dengan tx empiris

For an acute primary angleclosure attack, initial management involves prompt administration of pressure lowering eye drops. A possible regimen would be one drop each, one minute apart

0.5% timolol maleate (Timoptic) 1% apraclonidine (Iopidine), dan 2% pilocarpine (Isopto Carpine) ©Bimbel UKDI MANTAP

Systemic medications (oral or IV acetazolamide, IV mannitol, or oral glycerol or isosorbide) to control the intraocular pressure are often given We suggest giving the patient two 250 mg tablets of acetazolamide in the office The eye pressure should be checked 30 to 60 minutes after giving pressure lowering drops and oral acetazolamide. If medical treatment is successful in reducing intraocular pressure, as is most often the case, corneal edema and eye pain will typically lessen or resolve Once the attack is broken, the treatment of choice is a peripheral iridotomy. If laser peripheral iridotomy fails to remain patent, or the cornea is too cloudy to visualize the iris, surgical peripheral iridectomy may be necessary. Uptodate, 2015



Uptodate, 2015


GOLONGAN

MEKANISME AKSI

CONTOH

Beta-blocker

Berguna utk semua jenis glukoma, first line. SE: bronkospasme, bradikaria, hipotensi

Timolol 0.25% dan 0.5%, Betaxolol 0.5%, Levobunolol 0.5%, dll

Simpatomimetik (Agonis alfa dan beta adrenergik)

First choice utk POAG yg pny kontraindikasi beta-blocker. Pny efek MIDRIATIL shg tdk blh utk yg glaukoma sudut sempit!

Adrenalin 0.5% 1% 2%, Dipivefrin 0.1%

Miotikum (Cholinergic Agonis)

Pd POAG bs memperlancar aliran aquos krn trabekula lbh terekspos saat miosis. Pd PACG bs membuka sudut krn pupil konstriksi

Pilokarpin 1% 2% 3% 4% Carbachol 3%

Carbonic anhydrase inhibitor (CAI)

aquos dgn menginhibisi langsung enzim CA

Asetazolamid tab 250 mg

Agen hiperosmotik

Sikloplegik

Manitol 20%, gliserol darah shg darah di vasa menarik air dr vitreous. Bagus utk penurunan TIO temporer (mau operasi) Kerja m.siliaris diblok, efek parasimpatolitik. Hasilnya akan midriasis ©Bimbel UKDI MANTAP

Atropin Sulfat

Pada Glaukoma Sudut Tertutup Akut Sudut Iridokorneal tertutup/sempit (Muskulus siliaris tidak berkontraksi) Kondisi pupil dilatasi/mid-dilatasi

- Berikan agen yang dapat menyebabkan pupil miosis sehingga sudut iridokorneal terbuka (m. siliaris kontraksi) (c/o : Agonis kolinergik (Pilokarpin)) - Jangan berikan agen yang dapat menyebabkan pupil midriasis, kerja m. siliaris diblok, sehingga sudut iridokorneal tertutup (c/o : Agonis alfa (brimonidine, epinefrin); Sikloplegik (Atropin Sulfat) ©Bimbel UKDI MANTAP

Glaukoma Kongenital

Terjadi karena saluran pembuangan tidak terbentuk dgn baik atau bahkan tidak terbentuk sm skali. Klasifikasi

3. Sekunder: fibrolasia retrolental, tumor (retinoblastoma, juv xantogranuloma), inflamasi, penggunaan steroid. Tx: bedah



Endoftalmitis

Inflamasi bola mata yg melibatkan vitreous dan segmen depan. Tp kenyataannya bs jg melibatkan koroid dan retina hiperemis, kemosis, edem palpebra dan kornea Post OP paling sering OP katarak, kertoplasti tembus, vitrektomi Tx: topikal antibiotik, steroid, antibiotik sistemik. Post OP akut <2 mggu Eksogen

Post trauma

Infeksi Endogen

endoftalmitis Non-infeksi

Post OP kronik >4 mggu

Sisa lensa, trauma ©Bimbel UKDI MANTAP

Filtration belb-related


Endoftalmitis vs Panoftalmitis

Enukleasi melibatkan pengangkatan bola mata dan sebagian nervus optikus anterior, dengan usaha untuk mempertahankan konjungtiva, kapsula Tenon, serta otot ekstraokular.

Eviserasi adalah pengangkatan isi bola mata tapi dengan menyisakan sklera dan, pada beberapa kasus, juga menyisakan kornea.

TRAUMA TUMPUL PADA MATA Kelainan

Definisi

Manifestasi

Khemosis

The swelling (or edema) of the conjunctiva. Due to exudation from abnormally permeable capillaries. A nonspecific sign of eye irritation. Caused by allergies or viral infections, as well as eye rubbing

The conjunctiva becomes swollen and gelatinous in appearance. Often, the eye area swells so much that the eyes become difficult or impossible to close fully.

Iridodialisis

known as a coredialysis, is a localized separation or tearing away of the iris from its attachment to the ciliary body; usually caused by blunt trauma to the eye

may be asymptomatic and require no treatment, but those with larger dialyses may have corectopia (displacement of the pupil from its normal, central position) or polycoria (a pathological condition of the eye characterized by more than one pupillary opening in the iris) and experience monocular diplopia, glare, or photophobia

Hifema

Darah pada COA yg berasal dr pendarahan vasa pd korpus siliari, a.koroidalis, vasa irirs. Hifema primer: segera stlh trauma, hifema sekunder: 3-5 hari stlh trauma

Tx: bed rest kepala elevasi 60 derajat, asam traneksamat, SA utk midriasis, steroid sistemik atau topikal, asetazolamid bl TIO naik. Cegah glaukoma. Bila TiO ttp tinggi atau bl sinekia anterior perifer lakukan OP (parasentesis COA).

Hemoftalmos

Pendarahan pd vitrous body krn robekan pd retina, siklodialisis, iridodialisis, ruptur koroid.

Perlu evaluasi dgn USG. Bila ringan biarkan resorpsi spontan. Bila berat OP vitrektomi

Blow out fracture

Fraktur dasar orbitae

Ekimosis, edem palpebra, diplopia vertikal, keterbatasan gerak vertikal,nyeri ©Bimbel UKDI MANTAP



http://samoke2012.files.wordpress.com/2012/10/trauma-kimia-pada-mata.pdf

TRAUMA KIMIA MATA Merupakan trauma yang mengenai bola mata akibat terpaparnya bahan kimia baik yang bersifat asam atau basa yang dapat merusak struktur bola mata tersebut Keadaan kedaruratan oftalmologi karena dapat menyebabkan cedera pada mata, baik ringan, berat bahkan sampai kehilangan penglihatan Etiologi : 2 macam bahan yaitu yang bersifat asam (pH < 7) dan yang bersifat basa (pH > 7,6) Pemeriksaan Penunjang :

Klasifikasi :

Kertas Lakmus : cek pH berkala Slit lamp : cek bag. Anterior mata dan lokasi luka Tonometri Funduskopi direk dan indirek


Derajat 1: kornea jernih dan tidak ada iskemik limbus (prognosis sangat baik) Derajat 2: kornea berkabut dengan gambaran iris yang masih terlihat dan terdapat kurang dari 1/3 iskemik limbus (prognosis baik) Derajat 3: epitel kornea hilang total, stroma berkabut dengan gambaran iris tidak jelas dan sudah terdapat 1/2 iskemik limbus (prognosis kurang) Derajat 4: kornea opak dan sudah terdapat iskemik lebih dari 1/2 limbus (prognosis sangat buruk)

http://samoke2012.files.wordpress.com/2012/10/trauma-kimia-pada-mata.pdf

Trauma Kimia Trauma Basa :

Trauma Asam : Bahan asam mengenai mata maka akan segera terjadi koagulasi protein epitel kornea yang mengakibatkan kekeruhan pada kornea, sehingga bila konsentrasi tidak tinggi maka tidak akan bersifat destruktif Biasanya kerusakan hanya pada bagian superfisial saja Bahan kimia bersifat asam : asam sulfat, air accu, asam sulfit, asam hidrklorida, zat pemutih, asam asetat, asam nitrat, asam kromat, asam hidroflorida

Bahan kimia basa bersifat koagulasi sel dan terjadi proses safonifikasi, disertai dengan dehidrasi Basa akan menembus kornea, kamera okuli anterior sampai retina dengan cepat, sehingga berakhir dengan kebutaan. Pada trauma basa akan terjadi penghancuran jaringan kolagen kornea. Bahan kimia bersifat basa: NaOH, CaOH, amoniak, Freon/bahan pendingin lemari es, sabun, shampo, kapur gamping, semen, tiner, lem, cairan pembersih dalam rumah tangga, soda kuat.



Trauma Kimia Tatalaksana Emergensi : Irigasi : utk meminimalkan durasi kontak mata dengan bahan kimia dan menormalkan pH mata; dgn larutan normal saline (atau setara) Double eversi kelopak mata : utk memindahkan material Debridemen : pada epitel kornea yang nekrotik

Tatalaksana Medikamentosa : Steroid : mengurangi inflamasi dan infiltrasi neutrofil Siklopegik : mengistirahatkan iris, mencegah iritis (atropine atau scopolamin) dilatasi pupil Antibiotik : mencegah infeksi oleh kuman oportunis

©Bimbel UKDI MANTAP http://samoke2012.files.wordpress.com/2012/10/trauma-kimia-pada-mata.pdf ; Ilmu Penyakit Mata, Sidarta Ilyas

TRAUMA TUMPUL PADA LENSA Dislokasi Lensa : putusnya zonula Zinn lensa terganggu

kedudukan

Subluksasi Lensa : putusnya sebagian zonula Zinn lensa berpindah tempat. Luksasi lensa anterior : seluruh zonula Zinn di sekitar ekuator putus lensa masuk ke dalam bilik mata depan Luksasi lensa posterior : putusnya zonula Zinn di seluruh lingkaran ekuator lensa lensa jatuh ke dalam badan kaca dan tenggelam di dataran bawah polus posterior fundus okuli ©Bimbel UKDI MANTAP

Trauma Lensa-Subluksasi Lensa Dapat karena trauma atau spontan (pada penderita sindrom Marphan zonula Zinn rapuh) Gejala : visus menurun, iridodenesis, lensa menjadi lbh cembung miopik. Penyulit : Glaukoma, uveitis Tatalaksana : kacamata koreksi yang sesuai, bila timbul penyulit operasi (pengeluaran lensa) ©Bimbel UKDI MANTAP

Pendarahan Vitreous bintik2 hitam, berkabut Tanda: refleks fundus hilang, tampak darah pd vitreous, mild RAPD Etiologi: proliferative diabetic retinopathy, posterior vitreous detachment, ablasio retina, BRVO, AMD eksudatif, sickle cell disease, trauma, tumor intraokular, SAH, SDH, Eales disease Tx: sesuai etiologi, vitrectomy ©Bimbel UKDI MANTAP

MATA TENANG VISUS TURUN MENDADAK

Ablasio Retina Lapisan sel kerucut dan sel batang terpisah dari lapisan sel epitel pigmen (RPE). Di antaranya memang tidak terdapat perlengketan (asal embriologi beda) tp ada celah potensial. 3 macam: 1. Ablasio retina eksudatif 2. Ablasio retina traksional 3. Ablasio retina rhegmatogen ©Bimbel UKDI MANTAP


Ablasio Retina Rhegmatogen Robekan pada retina menyebabkan cairan subretinal yg berasal dari synchitic vitreous masuk ke celah potensial dan menyebabkan ablasio dr dalam. Retinal breaks (defek retina sensoris) bertanggung jwb, dsebabkan oleh adanya traksi vitreoretinal dan kelemahan pd retina perifer (RF). Faktor risiko: miopia, afakia,degenerasi anyaman, trauma okular. SS: flashing lights, benda apung, defek lapang pandang tepi lalu jadi sentral, gjala awal adlh bayangan ringan ©Bimbel UKDI MANTAP


Ablasio Retina Rhegmatogen


Ablasio Retina Traksional Disebabkan tarikan retina ke dalam vitrous body. pandang, bs asimptomatik, retina yg detached terlihat konkaf Etiologi: jaringan fibroselular pd vitreous (kr PDR), sickle cell retinopathy, ROP, trauma Tx: vitrektomi, scleral buckle



Ablasio Retina Eksudatif Karena timbunan cairan di celah potensial krn ada kelainan RPE dan koroid misal koroiditis, tanpa didahului robekan. lapang pandang, area yg detached berubah sesuai posisi (gravitasi) ©Bimbel UKDI MANTAP


OKLUSI VASKULAR RETINA (Arteri) NAMA

GEJALA

Central Retinal Artery Occlusion (CRAO)

Unilateral, tdk

Branch Retinal Artery Occlusion (BRAO)

Unilateral, tdk nyeri,

TANDA

Opasitas superfisial pd mendadak polus posterior (counting retina, cherryfinger-LP), riw red spot di amaurosis fugax sentral makula, RAPD


ETIOLOGI

TERAPI

Embolus, trombosis, GCA, SLE, hiperkoagulasi

Kontroversial: masase okular, parasentesis COA, asetazolamid 500 mg iv/po, hiperventilasi pd paper bag spy asidosis

Opasitas Idem superfisial pd distribusi lapang cabang arteri yg pandang, riw defek, edema amaurosis fugax lokal ©Bimbel UKDI MANTAP

idem

OKLUSI VASKULAR RETINA (Arteri) CRAO

BRAO


OKLUSI VASKULAR RETINA (Vena)


NAMA

GEJALA

TANDA

ETIOLOGI

TERAPI

Central Retinal Vein Occlusion (CRvO)

Unilateral, tdk

Pendarahan retina difus di seluruh kuadran, vena dilatasi dan tortuous, cotton wool, edema diskus dan makula, neovaskularisasi

Atherosclerosis , HT, glaukoma, hiperkoagulasi, vaskulitis, obat (kontrasepsi oral, diuretik)

Obati penyakit dasar, laser bl ada neovaskularis asi, aspirin 81325 mg po qd, anti VEGF

Branch Retinal Vein Occlusion (BRVO)

Unilateral, tdk visus atau sebagian lapang pandang dgn blind spot

Pendarahan superfisial pd distribusi cabang vena yg defek, tdk melintas midline, cotton wool, edemavena dilatasi dan tortuous

Peny dinding arteri menekan vena pd titik crossing

Laser bl ada neovaskularis asi, tx penyakit dasar

mendadak


OKLUSI VASKULAR RETINA (Vena) CRVO

BRVO


Optic Neuritis Major symptoms Sudden loss of vision (partial or complete) Sudden blurred or "foggy" vision Pain on movement of the affected eye The vision might also be described as "disturbed/blackened" rather than blurry, as when feeling dizzy Many patients with optic neuritis may lose some of their color vision in the affected eye (especially red), with colors appearing subtly washed out compared to the other eye Remarkable differences between the presentation of adult optic neuritis as compared to pediatric cases include more often unilateral optic neuritis in adults, while children much predominantly present with bilateral involvement Symptoms peak several days to weeks after onset, while symptoms failing to improve after 8 weeks should suggest a diagnosis other than optic neuritis. Medical examination The head of the optic nerve can easily be visualised by a slit lamp with high plus or by using direct ophthalmoscopy However, frequently there is no abnormal appearance of the nerve head in optic neuritis (in cases of retrobulbar optic neuritis), though it may be swollen in some ©Bimbel UKDI MANTAP patients (anterior papillitis or more extensive optic neuritis).


Neuritis Optik Toksik SS: tanda alkoholisme, rokok, nutrisi kurang (B1, B12), riwayat penggunaan obat2an tertentu (kloramfenikol, etambutol, isoniazid, digitalis, streptomisin, klorpropamid, disulfiram, lead, etilklorfinol)

Tx: eliminasi kausa, B1 100 mg po bid, folat 1 mg po bid, in B12 1000 mg im/bln utk anemia pernisiosa.


Gangguan Refraksi (Ametropia)

MATA TENANG VISUS TURUN PERLAHAN

Anomali

Titik fokus

Sebab

Manifestasi

Komplik asi

Koreksi

Miopia

Di depan retina

-AKSIAL: aksis AP >> (makroftalmos, membaca terlalu dekat, wajah lebar) -KURVATURA: keratokonus/globus, keratektasia, lensa tll cembung, katarak imatur -INDEKS BIAS: DM

-Penglihatan dekat baik -Penglihatan jauh jelek -Miop tinggi: bola mata lbh mnnonjol, COA lbh dalam, pupil lebar, fundus trigroid

Ablasio retina, katarak

Lensa sferis negatif terkecil yang memberikan visus 6/6. miop tinggi diberikan pengurangan 2/3 koreksi penuh

Glaukom a sudut sempit

Lensa sferis positif terbesar yg memberi visus terbaik.

-POSISI: lensa tll ke depan

Hipermetropia (Hyperopia)

Di belakang retina

-AKSIAL: aksis AP << (mikroftalmos, edem makula, ablatio retina) -KURVATURA: kornea plana, sklerosis lensa, afakia -INDEKS BIAS: kadar gula

baik) hrs berakomodasi supaya jatuh di retina -Melihat dekat, akomodasi >> shrg astenopia -Hipertrofi otot siliaris, COA dangkal, miosis, papil ©Bimbel UKDI MANTAP -POSISI: lensa tll ke belakang hiperemis


Gangguan Refraksi Anomali

Titik fokus

Sebab

Manifestasi

Komplik asi

Koreksi

Astigmatisme

Berbagai derajat refraksi pada berbagai meridian shg fokus jg bermacam2

Kelainan kornea (90%): perubahan lengkung kornea; kelainan lensa, kekeruhan lensa (ex.katarak insipien, imatur)

- Mata kabur saat melihat jauh dan dekat, obyek membayang, astenopia.

Risiko ambliopi a

Menyatukan kedua fokus utama (dengan lensa silinder), kemudian kedua fokus yang sudah bersatu tsb diletakkan tepat di retina (dengan lensa sferis).

Presbiopia

PP jauh shg pekerjaan dekat sulit

ensa mengeras, tdk kenyal, daya kontraksi otot siliar berkurang

- Penglihatan dekat kurang, astenopia, mata sakit, lakrimasi

-

Sferis positif sesuai umur (40 tahun adisi S+1D, 45 tahun adisi S+1,5D, 50 tahun adisi S+2D, 55 tahun adisi S+2D, 60 tahun adisi S+3D)




Miopia simpleks Jenis paling umum Diameter AP >> atau Indeks Bias >> Umumnya < 6D Miopia Nokturnal Hanya terjadi di cahaya redup/malam Disebabkan karena kurangnya kontras cahaya untuk menstimulus akomodasi yang sesuai, mata tidak bisa melihat dengan jelas untuk benda dengan jarak tak hingga (Akomodasi berlebihan) Psedomyopia Hasil dari bertambahnya kekuatan refraksi okular o/k overstimulasi akomodasi mata atau spasme m.siliaris. Umumnya pada orang dengan near-work secara reguler, belajar terus menerus menjelang ujian Miopi degeneratif Miopi patologis Miopi derajat tinggi dengan perubahan degeneratif pada segmen posterior Dapat menyebabkan perubahan visus/ lapang pandang. Sekuele seperti retinal detachment dan glaukoma umum terjadi Miopia induksi Miopia yang didapat (Acquired) Akibat paparan bermacam-macam agen farmasetik, variasi level kadar gula darah, nuclear sclerosis pada kristalin lensa, dll. UKDI MANTAP Miopi ini bersifat temporer atau©Bimbel reversibel


KOMPONEN HIPERMETROPIA

Tanpa sikloplegik

Dengan sikloplegik

Total hypermetropia is the total amount of refractive error, which is estimated after complete cycloplegia with atropine




Macam-macam astigmatisma


Contoh soal astigmatisma no.1


Contoh soal astigmatisma no.2 Koreksi lensa OD S -0.75 OS S -1.00

CC-



Contoh soal presbiopia Soal

Jawaban

1. Wanita 45 thn, sulit membaca (buku hrs dijauhkan). Riw kacamata -. VOD 6/15 dikoreksi S+2.00 jadi 6/6, VOS 6/9 dikoreksi S+1 jadi 6/6. resep?

1. OD S+2.00 OS

2. Pria 45 thn, OD dikoreksi S1D jd 6/6, OS dgn S-0.5D jd 6/6.

S+3.50

S+1.00 S+2.50

or OD S+2.00 OS S+1.00 adisi S+1.50 ODS 2. OD S-1.00 OS S+0.50

S-0.50 S+1.00

or OD S-1.00 OS S-0.50 adisi S+1.50 ODS


Amblyopia In general, amblyopia is believed to result from disuse from inadequate foveal or peripheral retinal stimulation and/or decrease of vision, either abnormal binocular interaction that causes different visual input from the unilaterally or bilaterally, for foveae.[6] which no cause can be Three critical periods of human visual acuity development have been found by physical determined. [7, 8] During these time examination of the eye. The periods, vision can be affected by the various mechanisms to cause or reverse term functional amblyopia amblyopia. These periods are as follows: - The development of visual acuity from the often is used to describe 20/200 range to 20/20, which occurs from amblyopia, which is birth to age 3-5 years. - The period of the highest risk of deprivation potentially reversible by amblyopia, from a few months to 7 or 8 occlusion therapy. Organic years. - The period during which recovery from amblyopia refers to amblyopia can be obtained, from the time irreversible amblyopia. of deprivation up to the teenage years or ©Bimbel UKDI MANTAP even sometimes the adult years.

Definition a

Amblyopia Ax Elicit any previous history of patching or eye drops as well as past compliance with these therapies. Document previous ocular surgery or disease. In addition to the routine information, obtaining a family history of strabismus or other ocular problems is important because the presence of these ocular problems may predispose a child to

Etiologi Anisometropia Inhibition of the fovea occurs to eliminate the abnormal binocular interaction caused by one defocused image and one focused image. This type of amblyopia is more common in patients with anisohypermetropia than anisomyopia. Small amounts of hyperopic anisometropia, such as 1-2 diopters, can induce amblyopia. In myopia, mild myopic anisometropia up to -3.00 diopters usually does not cause amblyopia. Hypermetropic anisometropia of 1.50 diopters or greater is a long-term risk factor for deterioration of visual acuity after occlusion therapy. Strabismus The patient favors fixation strongly with one eye and does not alternate fixation. This leads to inhibition of visual input to the retinocortical pathways. Incidence of amblyopia is greater in esotropic patients than in exotropic patients. Strabismic anisometropia These patients have strabismus associated with anisometropia. Visual deprivation Amblyopia results from disuse or understimulation of the retina. This condition may be unilateral or bilateral. Examples include cataract, corneal opacities,ptosis, and surgical lid closure. [10] Organic Structural abnormalities of the retina or the optic nerve may be present. Functional amblyopia may be superimposed on the ©Bimbel UKDI MANTAP organic visual loss.

Physical Visual acuity Diagnosis of amblyopia usually requires a 2-line difference of visual acuity between the eyes; however, this definition is somewhat arbitrary and a smaller difference is common. Crowding phenomenon A common characteristic of amblyopic eyes i s difficulty in distinguishing optotypes that are close together. Visual acuity often is better when the patient is presented with single letters rather than a line of letters. Diagnosis is not an issue in children old enough to read or with use of the tumbling E. Testing in preverbal children If the child protests with covering of the sound eye, amblyopia can be diagnosed if it is dense. Fixation preference may be assessed, especially when strabismus is present. Induced tropia test may be performed by holding a 10-prism diopter before one eye in cases of an orthophoria or a microtropia. In infants who cross-fixate, pay attention to when the fixation switch occurs; if it occurs near primary position, then visual acuity is equal in both eyes. Caution should be used when obtaining Teller acuity in children, as grating acuity may be less reduced than Snellen acuity, especially in strabismic amblyopia. Contrast sensitivity Strabismic and anisometropic amblyopic eyes have marked losses of threshold contrast sensitivity, especially at higher spatial frequencies; this loss increases with the severity of amblyopia. Neutral density filters Patients with strabismic amblyopia may have better visual acuity or less of a decline of visual acuity when tested with neutral density filters compared to the normal eye. This was not found to be true in patients with anisometropic amblyopia or organic disease. Binocular function Amblyopia usually is associated with changes in binocular function or stereopsis. Eccentric fixation Some patients with amblyopia may consistently fixate with a nonfoveal area of the retina under monocular use of the amblyopic eye, the mechanism of which is unknown. This can be diagnosed by holding a f ixation light in the midline in front of the patient and asking them to fixate on it while the normal eye is covered. The reflection of the light will not be centered. Refraction Cycloplegic refraction must be performed on all patients, using retinoscopy to obtain an objective refraction. In most cases, the more hyperopic eye or the eye with more astigmatism will be the amblyopic eye. If this i s not true, one needs to investigate further for ocular ©Bimbel UKDI MANTAP pathology.



Katarak (kekeruhan lensa)


Nuclear Age-related

Cortical Subcapsular

Congenital Katarak

Childhood

Acquired

Traumatic

Secondary

Kausa: infeksi intrauterin. Bila sentral, tebal, unilateral, >2mm hrs segera OP dlm 2 bln pertama

Korpal, thermal, radiasi ion

Intraocular disease

Uveitis kronis, glaukoma, retinal detachment, retinitis pigmentosa

Systemic disease

DM, hipokalsemia, myotonic dystrophy, dermatitis atopik, dll

Druginduced ©Bimbel UKDI MANTAP

Klorpromazin, miotikum long act,

KATARAK-SENILIS


Ilmu Penyakit Mata Ed 3. Jakarta: Balai Penerbit FKUI; 2006

KATARAK-SENILIS Katarak senilis adalah kekeruhan lensa yang terdapat pada usia lanjut, yaitu usia di atas 50 tahun Epidemiologi : 90% dari semua jenis katarak Etiologi :belum diketahui secara pasti

multifaktorial:

Faktor biologi, yaitu karena usia tua dan pengaruh genetik Faktor fungsional, yaitu akibat akomodasi yang sangat kuat mempunyai efek buruk terhadap serabu-serabut lensa. Faktor imunologik Gangguan yang bersifat lokal pada lensa, seperti gangguan nutrisi, gangguan permeabilitas kapsul lensa, efek radiasi cahaya matahari. Gangguan metabolisme umum 4 stadium: insipien, imatur, matur, hipermatur Gejala : distorsi penglihatan, penglihatan kabur/seperti berkabut/berasap, mata tenang Penyulit : Glaukoma, uveitis Tatalaksana : operasi (ICCE/ECCE)


NUCLEAR: progresif perlahan, miopisasi (krn indeks refraksi second sight (mampu melihat dekat tanpa kacamata), umumnya bilateral SUBCAPSULAR: bisa anterior/posterior, anterior: metaplasia fibrosa dr epitel anterior lensa; posterior: migrasi sel epitel ke posterior,

visus jauh CORTICAL: bilateral, silau saat melihat sumber cahaya


kejadian

Lensa bengkak krn termasuki air

Opasitas tersebar dipisahkan olh area bersih

Korteks seluruhnya opak

visus

> 6/60

5/60 -1/60

1/60


Kapsul mengecil dan mengkerut krn air keluar dr lensa -0

Protein struktural larut dalam air yang disebut disintesis pada serabut lensa dan menjadi 90 persen dari keseluruhan protein lensa 5,6. Kristalin-subunit yang saling berhubungan dan terpisahkan secara konstan 6. Kemampuan kristalinlensa yang didenaturasi oleh beberapa faktor termasuk oksidasi dan panas, bergantung pada sifat dinamis strukturnya. Kristalinmemiliki struktur dan fungsi yang serupa dalam membantu mengurangi hamburan cahaya pada lensa7. Glikasi kristalin- yang disebabkan oleh diabetes yang tak terkontrol dapat menekan efisiensi kemampuannya karena terbentuknya cross-linkages di antara subunit-subunit protein. Hal tersebut kemudian menyebabkan agregat dari protein yang terdenaturasi meningkatkan hamburan cahaya dan dan menurunkan transparansi lensa8.



TES BAYANGAN (SHADOW TEST) Tujuan tes bayangan adalah untuk mengetahui derajat kekeruhan lensa. Dasarpemeriksaan adalah makin sedikit lensa keruh pada bagian posterior maka makin besarbayangan iris pada lensa yang keruh tersebut, sedang makin tebal kekeruhan lensa makinkecil bayangan iris pada lensa. Alat yang digunakan adalah lampu sentolop dan loup. Tehniknya adalah sentolopdisinarkan pada pupil dengan membuat sudut 45º dengan dataran iris, dengan loup dilihatbayangan iris pada; lensa yang keruh.Penilaiannya : a. Bila bayangan iris pada lensa terlihat besar dan letaknya jauh terhadap pupil berartilensa belum keruh seluruhnya (belum sampai ke depan); ini terjadi pada katarak imm atur, keadaan ini disebut shadow test (+). b. Apabila bayangan iris pada lensa kecil dan dekat terdapat pupil berarti lensa sudahkeruh seluruhnya (sampai pada kapsul anterior) terdapat pada katarak matur,keadaan ini disebut shadow tes(-). c. Bila katarak hipermatur, lensa sudah keruh seluruhnya, mengecil serta terletak jauhdi belakang pupil, sehingga bayangan iris pada lensa besar dan keadaan ini disebutpseudopositif ©Bimbel UKDI MANTAP

Tatalaksana Katarak Non bedah: memperbaiki fungsi visual sementara, memperlambat Bedah: METODE

CARA

Keterangan

EKIK (ekstraksi katarak intrakapsular)

Membuang lensa dan kapsul scr keseluruhan

Ind: Katarak tak stabil, menggembung, hipermatur, terluksasi KI: Absolut: anak, ruptur kapsul krn trauma. Relatif: miop tinggi, marfan, morgagni, vitrous ke COA

EKEK (ekstraksi katarak ekstrakapsular)

Membuang nukleus dan korteks mel kapsul anterior lalu menanam IOL

Irisan kecil, risiko astigmat rendah. Tdk bs utk zonula lemah

SICS (small incision cataract surgery)

Irisan sangat kecil, hampir tdk butuh jahitan

Baik utk sklerosis nukleus derajat 2 dan 3, subkapsular posterior, awal kortikalis

EKEK + fakoemulsifikasi

Menggunakan ultrasonik utk memecah nukleus dan ©Bimbel UKDI MANTAP

Pirenoxine Pirenoxine (abbreviated PRX, trade name Catalin) is a medication used in the possible treatment and prevention of cataracts. A report in the journal of Inorganic Chemistry showed that in liquid solutions pirenoxine could cause decreased cloudiness of a crystallin solution produced to mimic the environment of the eye. Pirenoxine interacts with selenite or calcium ions that have been proven as factors leading to the formation of lens cataract.[1] Pirenoxine reduces the cloudiness of the lens solution containing calcium by 38% and reduced the cloudiness of the selenite solution by 11%

Systematic (IUPAC) name 1,5-Dioxo-4H-pyrido[3,2-a]phenoxazine-3-carboxylic acid Clinical data Trade names

Catalin

Pregnancy cat.

?

Legal status

? Identifiers

CAS number

1043-21-6

ATCvet code

QS01XA91

PubChem

CID 4846

ChemSpider

4846

UNII

27L0EP6IZK Chemical data

Formula Mol. mass ©Bimbel UKDI MANTAP

C16H8N2O5 308.24512 g/mol


RETINOPATI DIABETIKA Hiperglikemia

hilangnya pericyte endotel, penebalan membrana basalis. SS: melihat titik2 dan benda mengapung, pandangan kabur, sulit melihat saat malam. Tx: fotokoagulasi laser, anti-VEGF


TINGKAT KEPARAHAN

GAMBARAN FUNDUSKOPI

Retinopati (-)

Gambar lapisan Fundus normal retina

Mild NPDR

Beberapa mikroanurisma

Moderate NPDR

Lbh berat dr mild tp lbh ringan dr severe

Severe NPDR

1 dari: >20 pendarahan intraretina pd 4 kuadran, venous beading pd 2 kuadran, intraretinal microvascular abnormality pd 1 kuadran, proliferasi (-)

PDR

Neovaskularisasi (NVD or NVE), pendarahan vitreous, pendarahn retina


RETINOPATI DIABETIKA 1.

2. 3.

4.

Kelainan2: Edema retina: krn kebocoran kapiler esp di makula (macular edema). Hard exudate: krn transudasi plasma kronis Pendarahan retina: krn gangguan permeabilitas mikroaneurisma Cotton wool spots: nerve fiber layer retina iskemik



RETINOPATI DIABETIKA 1.

2. 3.

4.

Kelainan2: Edema retina: krn kebocoran kapiler esp di makula (macular edema). Hard exudate: krn transudasi plasma kronis Pendarahan retina: krn gangguan permeabilitas mikroaneurisma Cotton wool spots: nerve fiber layer retina iskemik




Preretinal Hemorrhages

Hemorrhages

Berlokasi di antara retina dan dinding posterior vitreous (subhyaloid) / dibawah lapisan Bentuknya bisa tidak beraturan, atau boat shape, dengan batas atas mendatar, dan batas bawah melengkung, yang akan menghalangi retina dan vasa2 retina Penyebab : trauma, neovaskularisasi retina (diabetic retinopathy, radiation retinopathy, oklusi vasa), perdarahan dari CNV, hypertensive retinopathy, Valsava retinopathy, posterior vitreous detachment, shaken-baby syndrome, dan retinopathy o/k gangguan darah

Intraretinal Hemorrhages Beberapa tipe : pola flamed-shaped, dot/blot, Roth spot. Apabila terjadi bilateral, biasanya berkaitan dengan gangguan sistemik (DM/HT) Flame shaped : batasnya feathery, lokasinya di retina superfisial, dimana disana terletak lapisan serabut saraf. Biasanya terjadi pada retinopati hipertensi dan okusi vena Dot/blot : tampak seperti titik, lingkaran kecil (dot) atau bahkan lebih besar (blot) dan berlokasi di lapisan outer plexiform. Biasanya tampak di retinopati diabetik

Subretinal Hemorrhages Berlokasi di bawah retina neurosensorik (spasium di antara lapisan retina neurosensorik dan RPE (retinal pigment epithelium)) Tampak sebagai warna yang gelap dengan vasa retina jelas di atasnya Bentuknya tidak beraturan (amorphous) o/k tidak ada ikatan yang kuat antara retina neurosensorik dengan RPE. Biasanya terjadi pada ablasio retina khususnya di polus posterior

Essential of Ophtalmology, 2007



RETINOPATI HIPERTENSI S: biasanya asimptomatis, Px: penyempitan arteri2 retina, bilateral. Kronis: AV nicking, sklerosis arteri (cooper/silver wiring), cotton wool, flame-shaped hemorrhages, makroaneurisma, oklusi vasa retina Akut/maligna: hard exudates, edema retina, cotton wool, flame-shaped hemorrhages, papiledem. Tx: kontrol HT ©Bimbel UKDI MANTAP


Hypertensive retinopathy features : Mild to moderate hypertension: Variable degrees of arteriolar narrowing Hemorrhages in the retinal nerve -shaped Exudates, including some that fan out around the center of the Cotton wool spots Microaneurysms Moderate to severe hypertension: In cases of severe hypertension , the retinal arterioles are much narrower than normal, and there is edema of the optic nerve head . Arteriolosclerosis accompanies long standing hypertension and commonly affects the retinal and choroidal vessels. The thickened retinal arterioles become attenuated, increasingly tortuous, and of irregular caliber. ©Bimbel UKDI MANTAP

At sites where the arterioles cross veins, the veins may appear kinked (arteriovenous nicking) , but the venous diameter is not narrower distal to the compression, an appearance which indicates that the kinked appearance of veins is not due to compression by a taut sclerotic artery. Instead it reflects sclerosis within the venous walls, because retinal arteries and veins share a common adventitia at sites of arteriovenous crossings.

The abnormal retinal arterioles appear clinically as parallel white lines at sites of vascular crossings (arterial sheathing). The narrowed lumen of the retinal vessels decreases the visibility of the blood column and makes them first appear orange on opthalmoscopic Eventually as the blood column becomes completely obscured, light reflected from the sclerotic vessels appear as threads of silver wire


Hypertensive Retinopathy Modified Scheie Classification Grade 0 - No changes Grade 1 - mild generalized retinal arteriolar narrowing Grade 2 - more severe generalized narrowing, focal areas of arteriolar narrowing and arteriovenous (AV) nicking Grade 3 - grade 1 and 2 signs plus the presence of microaneurysms, retinal hemorrhages, hard exudates and cotton-wool spots Grade 4, - accelerated (malignant) hypertensive retinopathy, consists of signs in the preceding three grades plus optic disc swelling and macular edema ©Bimbel UKDI MANTAP

Age-Related Macular Degeneration


lipofusin+, radikal bebas), deposit laminar basal, perubahan kapiler koroid. Tipe AMD noneksudatif (dry ARMD)

EMD eksudatif (wet ARMD)

Gejala

parasentral,

Gangguan penglihatan

Tanda

Terapi

pucat, macular DRUSEN keras dan lunak, atrofi EPR

Vit C, vit E, beta karoten, zinc, cupric oxide, sayur hijau. TX RF (HT, dislipidemia, rokok).

dan cairan subretinal atau makropsia, skotoma sentral detach EPR yg berhubungan dgn CNV (choroidal ©Bimbel UKDI MANTAP neovascularization)

Anti-VEGF

ARMD

Dry ARMD with fine drusen

Dry ARMD with soft drusen

Wet ARMD


Retinitis Pigmentosa Definisi: Retinitis pigmentosa is the most common of a group of hereditary progressive retinal degenerations or dystrophies. There is considerable variation and overlap among the various forms of retinitis pigmentosa. Common to all o f them is progressive degeneration of the retina, specifically of the light receptors, known as the rods and cones. The rods of the retina are involved earlier in the course of the disease, and cone deterioration occurs later. In this progressive degeneration of the retina, the peripheral vision slowly constricts and central vision is usually retained until late in the disease. Etiologi: Retinitis pigmentosa is an inherited condition which involves both eyes. If it starts in one eye, the other eye usually develops the same condition in a number of years. Most cases are familial, inherited in a variety of ways, including dominant, recessive, and sex-linked recessive. Some cases are sporadic and lack a family history of the disease. A thorough genetic pedigree, often with the aid of a genetic counselor, is essential in determining risk of future generations acquiring the disease. SS: Since retinitis pigmentosa begins as rod degeneration, the patient first notices increasing difficulty in night vision, followed by difficulty seeing in the periphery. Slowly progressive constriction of the visual field leads to tunnel vision. A small area of central vision in both eyes usually persists for years. Generally night blindness precedes tunnel vision by years or even decades. Total blindness eventually ensues in most cases. The age of appearance of legal blindness ranges ©Bimbel UKDI MANTAP from as early as childhood to as late as the 40s.

Retinitis Pigmentosa


6 otot ekstraokular Inervasi= LR6(SO4)3


M. Rectus Lateral et Medial


M. Rectus superior et inferior M. Rectus Superior

M. Rectus Inferior Aksi primer : depresi Aksi sekunder

: extorsi

Aksi tersier : adduksi Seperti SR...aksi primer meningkat saat abduksi dan menurun saat adduksi SR dan IR sm2 adduksi pd aksi


M. Obliquus superior et inferior M. Obliquus Superior

M. Obliquus Inferior


Isolated third nerve palsy SS: diplopia binokular, ptosis, dg/tanpa nyeri. Bila pupil terkena: fixed, dilated, tdk reaktif. Etiologi 1. Pupil terkena: aneurisma (esp. arteri comunicans post.); tumor, trauma. 2. Pupil sehat: iskemik Tx: tergantung etiologi

Defek n.III kanan dgn ptosis

Posisi anatomis: eksotropia OD dan dilatasi pupil

Lirik ke kiri: OD tdk bs adduksi

Lirik ke kanan: OD bisa abduksi normal ©Bimbel UKDI MANTAP

Isolated fourth nerve palsy SS: diplopia binokular vertikal/oblik, sulit membaca, bs asimptomatik. Defisiensi gerakan ke inferior, mata yg terkena tampak hipertropik pd posisi anatomis. Pasien biasanya mendongakkan kepala ke bahu kontralateral utk menghilangkan diplopia. Etiologi: trauma, infark (DM/HT), kongenital, idiopatik, demyelinisasi. Tx: tx penyebab, patch, operasi

Defek n.IV kiri: pd posisi anatomis hipertropia OS

Lirik ke kanan: overaksi m.obliqus inferior OS ©Bimbel UKDI MANTAP

Isolated sixth nerve palsy SS: diplopia binokular horizontal, memburuk saat melihat jauh. Defisiensi gerakan ke lateral. Proptosis(-). Etiologi: vaskulopati (DM, HT, aterosklerotik), massa pd sinus cavernosus, dll. Tx: tx penyebab, patch, operasi.

Defek n.VI kanan: OD bisa adduksi penuh

Lirik ke kanan: abduksi OD terbatas ©Bimbel UKDI MANTAP

Strabismus Misalignment of one or both eyes so as the eye (eyes) is not looking straight at the object of regard.

Significance In children Children need normally aligned eyes to develop vision. Strabismus in childhood is the second most common presentation of retinoblastoma. Strabismus is a common presentation for refractive errors.

In adult Frequent sign of neurological disease Frequent presentation of systemic disease ( Thyroid disease & Myasthenia) Cosmetology

Anatomy & Physiology Muscle

Nerve

Function

Testing

MR

3 rd

Nasal

Look to nose

LR

6th

Temporal

Look away

SR

3rd

Elevate, intorts, adducts

Up & Out

IR

3 rd

Depress, extrorts, adduct

Down & Out

Anatomy & Physiology Muscle

Nerve

Function

Testing

Superior Oblique

4th

Intorts, depress, abducts

Look Down & In

Inferior

3rd

Extrorts, elevates, Look Up & In abducts

Oblique

ESOTROPIA EXOTROPIA HIPERTROPIA HIPOTROPIA

ORTO tengah pupil

15 * ET tepi pupil

30* ET tepi limbus

45 *ET luar limbus

ADDITIONAL CLASSIFICATIONS constant or intermittent bilateral unilateral

the frequency it occurs

both eyes converge or diverge at the same time if it always involves the same eye

alternating when the turning is sometimes the right and other times the left eye Latent or manifest (phoria or tropia)

from: American Optometric Association

Causes of Strabismus Congenital: imbalance between and contraction

Refractive errors Loss of vision Paralysis or Neuromuscular Restrictive: thyroid eye disease Tumors

innervations

Presenting symptoms of Strabismus Deviation of the eye (cosmesis) Double vision Torticollis (abnormal head posture) Unexplained visual loss in a normal looking eye (Microtropia)

Defek Lapang Pandang


Gangguan sistem lakrimal Lapisan air mata NORMAL DEFISIENSI air mata Sebab-sebab: Kerusakan gld lakrimal olh inflamasi, neoplasma Gld lakrimal bs kongenital atau akuisita Sumbatan duktus sekretorius (mis pd SJS) Lesi neurogenik Disfungsi gld Meibom (banyak pd org tua) Dari dalam ke luar: 1. Musin: melapisi kornea dan konjungtiva, dihasilkan sel goblet konjungtiva 2. Air: dihasilkan oleh gld lacrimalis, Krause, dan Wolfering 3. Lemak: berhub dg udara, mencegah penguapan, dihasilkan olh Meibom dan Zeis

DEFISIENSI musin

Karena kerusakan sel goblet yg disebabkan defisiensi vitamin A atau sikatrik konjungtiva shg ©Bimbel UKDI MANTAP xerois

Gangguan sistem lakrimal EPIPHORA Overflow of tears onto the face. A clinical sign that constitutes insufficient tear film drainage from the eyes tears will drain down the face rather than through the nasolacrimal system Etiology : Occular irritation and inflammation (including trichiasis and entropion) Obstructed tear outflow tract which is divided according to its anatomical location (i.e. ectropion, punctal, canalicular or nasolacrimal duct obstruction) due to aging (a spontaneous process), conjunctivochalasis, infection (i.e. dacryocystitis), rhinitis, and in neonates or infants, failure of the nasolacrimal duct to open


Gangguan sistem lakrimal EPIPHORA Diagnosis : by history presentation and observation of the lids Fluorescein dye to examine for punctal reflux by pressing on the canaliculi in which the clinician should note resistance of reflux as it irrigates through the punctum into the nose

Management : If epiphora is caused by ectropion or entropion, lid repair is indicated. A surgical procedure called a dacryocystorhinostomy is done to join the lacrimal sac to the nasal mucosa in order to restore lacrimal drainage


Gangguan sistem lakrimal Dakriodenitis

Dakriosistis

Radang pd gld lakrimalis. Sering pd anak sbg komplikasi peny sistemik ex. morbili, dewasa ec trauma. SS: nyeri dan bengkak di orbita bag temporal

Radang pd sakus lakrimalis krn sumbatan duktus nasolakrimalis, biasanya unilateral. SS: epifora, eksudat, uji regurgitasi+, sakit, merah, NT pd daerah nasal. Etio: S.aureus, S.pneumoniae, Candida albicans, H.influenza






Lid Malposition Entropion

Ectropion

Inversion of lower lid, most commonly due to agerelated tissue laxity. Causes discomfort due to lashes, rubbing on the inferior cornea, especially on downgaze, e.g. reading.

Outward turning of lower eyelid from globe, usually in elderly patients. Frequently associated with epiphora (watery eye) and chronic conjunctivitis.


Lash Disorders Trichiasis Inward misdirection of lashes, causing irritation. Refer for a more definitive procedure: surgery, cryotherapy or laser therapy.

Distichiasis Abnormal accessory lashes arising near meibomian gland orifices. May be congenital, but is more frequently acquired secondary to scarring, e.g. ocular cicatricial pemphigoid.


Eye Corpus Alienum Dapat berupa: Metalik: Fe, Pb, Al, Cu, dll. Non metalik: Kayu, kaca, kapur, dll Dapat ditemukan: Diluar bola mata: kornea, konjungtiva, atau palpebra Didalam bola mata Sering korpus alienum logam di kornea: Serbuk besi ketika memakai gerinda mesin atau percikan dari las dengan kecepatan yang cukup tinggi dan secara mendadak tertananam dan melukai kornea. Anamnesis dan gejala klinis Subyektif: Penderita mengeluh dengan adanya benda asing yang masuk ke mata Obyektif: Pelebaran pembuluh darah perikornea, corpus alienum, visus menurun atau normal. Cara pemeriksaan: Anestesi local dengan pantocain tetes 2% Pemeriksaan dengan lampu senter dan loupe atau dengan slitlamp. Penatalaksanaan Anestesi local dengan pantocain tetes 2% Pasang speculum mata Pengeluaran corpus alienum dengan: Kapas lidi steril Ujung jarum suntik No. 25 steril ©Bimbel UKDI MANTAP

Pemeriksaan Visus PRINSIP PENGUKURAN VISUS

Membedakan 2 titik terpisah Besar 1 menit busur Besar tiap huruf 5 menit


Pemeriksaan Visus TES PINHOLE

KARTU SNELLEN

PECAHAN = jarak pemeriksan ----------------------------------Jarak huruf terkecil yang masih dapat terbaca (kode/skore) TIDAK ADA SATUAN PENCATATAN : Pecahan 6/50 - 6/6 Decimal

Cincin landolt c eye chart

Uji sheridan/gardiner


Pemeriksaan Visus Visus 1/60 (Hitung jari = Counting Finger) Visus 1/300 (Hand Movement) Proyeksi (Superior, Inferior, Nasal, Temporal) Visus 1/~ (light Perception) Visus nol (No Light Perception)

Pemeriksaan Bola Mata Pemeriksaan segmen anterior : Supersilia, palpebra, konjungtiva tarsal, konjungtiva bulbi, kornea, kamera okuli anterior, iris, pupil, dan lensa.

Pemeriksaan segmen posterior : Badan kaca, retina, papil saraf optik



Visual Pathway and Pupillary Light Reflex

Relative Afferent Pupillary Defect (RAPD) / Marcus Gunn Pupil




Berhadapan jarak 1 m Pemeriksa dianggap normal

tes

definisi

Anel Test

Uji patensi saluran lakrimalis dengan cara memasukkan jarum tumpul ke punctum lakrimal ke dalam sakus lakrimal, kemudian larutan garam fisiologis disemprotkan. Tes Anel + bila ada rasa asin di tenggorokan dan Tes Anel bila tidak ada asing (ada gangguan patensi).

Macam-macam Pemeriksaan

Uji Fluoresin

untuk melihat adanya defek pada epitel kornea. Kertas fluoresin dibasahi terlebih dahulu dengan garam fisiologis kemudian diletakkan pada saccus konjungtiva inferior setelah terlebih dahulu penderita diberi anestesi lokal. Penderita diminta menutup matanya selama 20 detik, kemudian kertas diangkat. Defek kornea akan terlihat berwarna hijau dan disebut sebagai uji fluoresin positif.

Amsler Grid

Untuk mengetahui fungsi penglihatan sentral makula. Untuk melihat adanya skotoma pada lapang pandang dan dokumentasi metamorfopsia.

Shadow Test

Utk mengetahui stadium katarak. Apabila lensa belum keruh seluruhnya, ketika disinari menggunakan senter dari depan bola mata dengan sudut ± 45o, sinar akan dipantulkan dan mengenai iris sehingga terbentuk bayangan iris pada pupil yang terlihat seperti bulan sabit. shadow test (+).

Hirschberg Test

a screening test that can be used to assess whether a person has strabismus (ocular misalignment). Performed by shining a light in the person's eyes and observing where the light reflects off the corneas. When doing the test, the light reflexes of both eyes are compared, and will be symmetrical in an individual with normal fixation.

Schirmer Test

Untuk memeriksa produksi air mata, dengan cara menyisipkan kertas saring di fornix inferior kemudian tunggu 5 menit. Normalnya produksi air mata minimal 10 mm dari pangkal kertas saring basah oleh air mata.

Seidel Test

Untuk mengetahui adanya perforasi kornea, dengan cara setelah fluoresin menempel pada kornea dilakukan sedikit penekanan kornea. Apabila ada lubang kornea maka fluoresin ©Bimbel UKDI MANTAP

Anel test Amsler grid

Schirmer test

Seidel test Hirschberg test ©Bimbel UKDI MANTAP

Vitamin A deficiency : Xerophtalmia


Color Blindness


Cause


Gejala


Test For Color Blindness


Mata.pdf

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