天津医科大学斜视与小儿眼科-1

斜视与小儿眼科-1

作者：更新日期： 2020-04-17 访问次数： 455

李某某，男，63岁

Mr.Li, male, 63 years old

主诉：左眼突然视力下降2天，伴随眼痛、眼胀、头痛

Chiefcomplaint：A suddentdecrease of visual acuity for 2 days, accompany with eye pain, fullness andheadache.

一．病例特点

General Information

病史

现病史：患者于入院前2天突然发现左眼视力下降，伴随眼痛、眼胀、头痛。来我院门诊就诊检查发现左眼眼压高，给予2%美开朗、派立明局部点眼治疗，药物控制不佳。

既往史：既往体健。否认外伤史。

个人史、家族史均无异常。

Medicalhistory

Present medical history：

The patient had a sudden decreaseof visual acuity in the left eye, accompany with eye pain, fullness andheadache. In the out-patient department, IOP of the left eye was above normalstandard. The patient was given 2% Carteolol Hydrochloride Eye Drops Bid, BrinzolamideEye Drops Tid. The treatment of eye drop could not control the IOP.

Past medical history：No special record. No trauma history.

Personal history and familyhistory are unremarkable.

眼部检查

右眼：VOD 0.6，IOP 17mmHg，

右眼检查未见明显异常

左眼：VOS手动/眼前，眼压>60mmHg

眼睑肿胀，结膜充血、水肿，角膜肿，前房浅，中央2CT，周边1/3CT，瞳孔中度散大，对光反射极迟钝，晶状体密度增高，玻璃体血性混浊，眼底窥不清。（图1-2）

图1 图2

OcularExamination:

Right eye:V OD:0.6, IOP:17 mmHg

The righteye was normal.

Left eye:VOS HM/BE.,IOP> 60mmHg

The lid was swollen, conjunctivalcongestion, chemosis, corneal edema. The anterior chamber was shallow, with 2CTin the center，1/3CT periphery. The pupil was moderately dilated, light reflex was slow, lens densitywas increased, vitreous was bloody opacities, the rest was unclear.(Figure 1-2)

辅助检查

2010年12月13日B超检查：左眼玻璃体弥漫点状低回声，团状、膜状中强回声后连视盘及球壁。提示左眼玻璃体积血，脉络膜下腔积血？（图3）

Ancillaryexamination

B scan(2010.12.13): the vitreous was diffuse hypoechoicspots, lumps, membrane linked to the optic disc and wall of eyeball, whichhinted vitreous hemorrhage and subarachnoid hemorrhage?(Figure 3)

图3

血象异常会诊结果

2010年12月20日行血常规检查示血小板389×109/L(正常值为100-362.5×109/L)，血小板品均体积7.2fL（7.4-11fL），血小板分布宽度7.8fL（8-17fL），凝血酶原时间15.3秒（11-14秒），纤维蛋白原定量5.17g/L(2-4 g/L)。

Abnormalhaemogram results

The result of blood (2010.12.20) showed platelet 389 ×109 / L (normal: 100-362.5 × 109 / L), platelet mean size 7.2fL(7.4-11fL), platelet distribution width 7.8fL (8 - 17fL), prothrombin time15.3 seconds (11-14 seconds), fibrinogen 5.17g / L (2-4 g/ L).

初步诊断：

左眼继发性青光眼病因待查？

左眼脉络膜下腔出血？

左眼玻璃体积血

左眼老年性白内障初发期

Primarydiagnosis:

Secondary glaucoma cause of unknown OS?

Subarachnoid hemorrhage OS？

Vitreous hemorrhage OS

Age-related cataract initial phase OS

二、治疗经过及结果汇报

Treament and Results:

药物治疗：

2010年12月13日来我院门诊：给予250ml甘露醇静脉点滴、尼目克司25mg Q8h口服，2%美开朗os Bid、派立明osTid、阿法根os Bid等药物点眼降眼压。

2010年12月15日来我院复查，眼科检查：左眼视力手动/眼前，眼压54mmHg，眼睑肿胀，结膜充血、水肿，角膜血染，余窥不清。复查B超：左眼玻璃体内见对吻状致密点状低回声，球壁增厚不均。提示左眼脉络膜下积血？（图4-5）

图4

图5

2010年12月20日复查，眼科检查：左眼视力LP，眼压50mmHg，眼睑肿胀，结膜充血、水肿，角膜血染，余窥不清。B超检查：玻璃体弥漫点状低回声，强回声膜状带后连视盘及球壁，球壁前弥漫点状低回声，提示左眼玻璃体积血，深层出血？（图6）

图6

2010年12月21日行左眼TCP治疗，治疗后给予可乐必妥os Qid、普南扑灵os Bid、百力特os Bid、典必殊膏os Qn点眼抗炎，尼目克司25mg Q8h口服，2%美开朗osBid、派立明os Tid、阿法根os Bid等药物点眼降眼压，凯扶兰口服止痛。

2010年12月27日复查，眼科检查：左眼视力LP，眼压22mmHg。B超检查：左眼球壁粗糙、增厚，玻璃体内弥漫点状低回声，提示左眼视网膜水肿，玻璃体积血，玻璃体混浊（炎性？）（图7）

图7

后患者失访。

Drugtreatment:

2010.12.13:

In the outpatient department, thepatient was given 250 ml mannitol, Methazolamide Tablets 25mg Q8h, 2% CarteololHydrochloride Eye Drops os Bid, Brinzolamide Eye Drops os Tid, BrimonidineTartrate Opthealmic Solution os Bid.

2010.12.15:

VOS: HM/BE, IOP: 54 mmHg. The left eye lid wasswollen, conjunctival congestion, chemosis, cornea cruenta. The rest was unclear.

B scan: The left eye vitreous was hypoechoic pykno-spots on the kiss-shaped and uneven wall thickening of eyeball,which hinted subarachnoidl hemorrhage?

2010.12.20:

VOS: LP.,IOP: 50 mmHg. The left eye lid was swollen, conjunctival congestion, chemosis, cornea cruenta. The rest was unclear.

B scan: the left eye vitreous was diffuse hypoechoicspots, lumps, membrane linked to the optic disc and wall of eyeball, indicatingvitreous hemorrhage, deep bleeding?

2010.12.21:

The left eye was performed TCP treatment, and givenCravit os Qid, Pranoprofen os Bid, Prednisolone Acetate os Bid, Tobramycin And Dexamethasone os Qn,Methazolamide Tablets 25mg Q8h, 2% Carteolol Hydrochloride os Bid, Brinzolamide os Tid, Brimonidine Tartrate Opthealmic os Bid, and Diclofenac Potassium Tablets to control the pain.

2010.12.27:

VOS:Visual: LP. IOP:22 mmHg.

B scan: the wall of eyeball was rough and thickening, theleft eye vitreous was diffuse hypoechoic spots, indicating retinal edema, vitreous hemorrhage and vitreous opacities(inflammatory ?)

Thepatients was lost to follow up.

三、查房记录

Consultation

杨瑾副主任：

根据病史及眼部检查，考虑患者诊断为继发性青光眼，但患者否认青光眼家族史，外伤史，全身病史。发生继发性青光眼有多种考虑，首先，血象异常是否是造成眼科疾病的病因，需要进一步完善相关血液科检查，如出凝血功能检测等。第二，虽然患者主诉否认外伤史，但仍要高度怀疑考虑钝挫伤造成继发青光眼的可能性，第三，患者为老年男性，考虑是否为年龄相关性黄斑变性——湿性AMD造成的新生血管突然破裂出血。

Dr.Yang Jin：

According to the medical history and the eyeexamination, patient with secondary glaucoma was considered to be diagnosed.However, the patient denied glaucoma family history, trauma history and otherpast history. There were many considerations of secondary glauma: firstly, theabnormal hemogram should be ruled out the possibility ofhaematology, other haematology examination, such as blood clotting function wasneeded to completed. Secondly, tramatic secondary glaucoma must be suspected,although the patient denied trauma history. Thirdly, in consideration of an oldmale patient, AMD causing neovessels sudden rupture and hemorrhage should becarefully ruled out.

四、病例相关知识

Relative knowledge

外伤性青光眼

眼球钝挫伤致前房积血可继发早期眼内压升高。血液可阻塞小梁网，也可因外伤后小梁水肿所致。治疗首选药物，若眼压持续升高可手术介入，尤其当再次发生出血时。顿挫伤晚期的眼内压与直接房角损害有关。外伤与青光眼之间的关系尚不明确。临床检查可见前房加深，房角镜检见房角后退。药物治疗通常有效，必要时行引流手术。眼前节的破裂或顿挫性撕裂常伴随前房消失。虹膜疝入伤口可自发形成前房，或通过手术形成前房。如果伤后前房不能形成，必将形成虹膜前粘连而导致不可逆的房角关闭。

Glaucomasecondary to trauma

Contusion injuries of the globe may be associated withan early rise in intraocular pressure due to bleeding into the anterior chamber(hyphema). Free blood blocks the trabecular meshwork, which is also renderededematous by the injury. Treatment is initially medical, but surgery may berequired if the pressure remains elevated, which is particularly likely ifthere is a second episode of bleeding. Late effects of contusion injuries onintraocular pressure are due to direct angle damage. The interval between theinjury and the development of glaucoma may obscure the association. Clinically,the anterior chamber is seen to be deeper than in the fellow eye, andgonioscopy shows recession of the angle. Mecical therapy is usually effective,but drainage surgery may be required. Laceration of contusional rupture of theanterior segment is associated with loss of the anterior chamber. If thechamber is not reformed soon after the injury either spontaneously, by iresincarceration into the wound, or surgically peripheral anterior synechiae willform and result in irreversible angle closure.

年龄相关性黄斑变性

年龄相关性黄斑变性是老年人永久性致盲的首要原因。本病临床和病理表现差异较大，可分为两种类型：非渗出型（干性）和渗出型（湿性）。虽然AMD的病人通常只呈现非渗出性的改变，但患者常因此病造成严重视力丧失，主要原因是视网膜下新生血管的形成以及相关的渗出性黄斑病变。从脉络膜长至视网膜下的新生血管是诱发玻璃膜疣发展为黄斑脱离和不可逆性中心视力丧失的最重要的原因。湿性AMD造成的新生血管突然破裂出血可导致视力突然丧失。

Age-relatedmacular degeneration

Age-related macular degeneration is the leading causeof permanent blindness in the elderly. The disease includes a broad spectrum ofclinical and pathologic findings that can be classified into two groups:nonexudative (dry) and exudative (wet).Although patients with age-relatedmacular degeneration usually manifest nonexudative changes only, the majorityof patients who experience severe vision loss from this disease do so from thedevelopment of subretinal neovascularization and related exudative maculopathy.Ingrowth of new vessels from the choroid into the subretinal space is the mostimportant change that presisposes patient with drusen to macular detachment anirreversible loss of central vision. Neovessels sudden rupture andhemorrhage in wet AMD could cause a sudden loss of visual acuity.