孟某某，女，43岁

Mrs Meng ,female,43 years old

一、病例特点

General Information

病史

现病史：患者于2010.11.28砂轮砸伤颜面部后意识丧失，于外院就诊，当时查视力：VOU指数／1250px，给予清创缝合等治疗，治疗后右眼视力未见明显提高，且眼压高，为进一步治疗于2011.1.10收入我院。

个人史、月经史、婚育史、家族史均无异常。

Medical history

Present medical history：

Thepatient had suffered from unconsciousness on November 28th, 2010 after a bashat the facial region by a grinding wheel. She was sent to the emergencydepartment and underwent debridement and suturing. The visual acuity of botheye was FC/1250pxat that time. During treatment, the vision of the right eye could not beimproved, the intraocular pressure increased and was not well controlled. Thepatient wasrefered to our Eye Center onJanuary 10th, 2011.

Theprevious medical history, menstruation history, obstetrical history and familyhistory of the patient were all unremarkable.

查体

全身一般情况良好

Physical examination

Bodystate is in good condition generally.

眼科检查

右眼：

VOD0.01,矫正-5.25DS=0.12，眼压37.1mmHg。右眼球运动可，右眼上睑、下睑皮肤缝合瘢痕，眼睑轻度肿胀（图1），角膜下部上皮少量缺失，角膜基本透明，晶状体脱位于前房，前表面贴于角膜后表面，上方嵌顿于瞳孔区，晶状体基本透明，上方虹膜与角膜相贴（图2），瞳孔散大，欠圆，对光反射无，眼底：隐约可见视乳头色淡，视盘鼻侧小片状视网膜下陈旧性出血，1/3PD大小，小片状渗出，余窥不清。

左眼：VOS0.6矫正视力-0.5DS=0.8，眼压16.2mmHg，角膜透明，前房深，瞳孔圆，对光反应存在，晶状体基本透明，眼底:视乳头边清色可，网膜平，黄斑中心凹反光未见。

Ocular Examinations

Right eye:

VOD:0.01,BCVA:-5.25DS=0.12, IOP:37.1mmHg. The movement of right eye was normal. Skinscars could be seen on the upper eyelid and lower eyelid (Fig 1). The corneawas clear, a few localized corneal epithelial abrasion was present at theinferior part of the cornea. The lens was mainlytransparent but dislocated into the anterior chamber, and attached to thecornea endothelium, and the upper equator of the lens was incarceratedin the pupilary area. The superior iris was pushed toward the cornea by thedislocated lens (Fig 2). The pupil was dilated and irregular. Both direct andindirect light reflex of the pupil were negative. The color of the opticpapilla was pale, and there was subretinal hemorrhage and hard exudationat thenasal area of the optic disc.

Left eye:

VOS:0.6,BCVA:-0.5DS=0.8, IOP:16.2mmHg. The cornea was clear, the anterior chamber wasdeep, the pupil was round and the light reflex was positive, the lens wasclear, and the retina was flat.

辅助检查

Ｂ超示右眼玻璃体混浊(图3)。

角膜内皮细胞计数：由于晶状体紧贴角膜后，角膜内皮计数不清。

UBM示右眼晶状体脱入前房，中央前房消失，全周虹膜与角巩膜相贴，周边前房消失（图4）。

Ancillary examination

B-scanrevealed vitreous opacity of the right eye (Fig 3).

Thecorneal endothelium cell counting was not available maybe because of the attachmentof the lens with the corneal endothelium.

UBMdemonstrated that the lens of the right eye was dislocated into the anteriorchamber, and the iris was contact to the corneosclera in all quadrants. (Fig 4)

初步诊断

右眼钝挫伤

右眼外伤性晶状体全脱位

右眼继发性青光眼

右眼视神经挫伤

Impression

Blunttrauma OD

Traumatic lens luxationOD

Secondary glaucoma OD

Optic nerve contusion OD

二、治疗经过及结果汇报

Treatment and Results

1.术前药物治疗：

派立明点右眼每日3次降眼压治疗，弥可保1片每日三次口服及维生素B1片1片每日三次口服营养视神经。

2.手术治疗：

2011.1.12行右眼晶状体摘除术＋玻璃体前部切除术。

3.术后１天：

VOD手动／750px，眼压11.8mmHg，角膜水肿，前房深可，房闪不清，瞳孔圆，直径2.5mm，对光反射无，前房残留一气泡，晶状体缺如，给予抗炎抗感染治疗及贝复舒膏促进角膜恢复。

术后４天：

VOD手动／750px，眼压23.7mmHg，角膜水肿较前减轻，余情况同前，加用派立明2次/日降眼压治疗

术后5天：

VOD手动／750px，矫正+15.0DS=0.8，眼压23.8mmHg，角膜仅瞳孔区雾状水肿明显，余基本透明，其余情况同前，加用2%美开朗Q12H降眼压治疗之后病情稳定，维持治疗不变，于2010.01.26术后14天出院.

出院时情况：

VOD手动／750px，矫正视力0.4，眼压18.6mmHg，角膜下方片状轻度水肿，前房深度可，瞳孔圆，直径3mm,对光反射无，晶状体缺如。复查角膜内皮检查，结果示角膜内皮细胞237.9个/mm２

4.术后随访：

出院后滴用2%美开朗降眼压治疗，弥可保营养神经治疗。

术后一月VOD手动/750px，矫正视力0.3，眼压14.4mmHg,停用2%美开朗；术后三月，VOD手动/1250px,矫正视力0.4，眼压9.6mmHg，电生理检查示右眼60´方格未引出典型NPN波形，视锥反应，b波振幅轻度下降；左眼正常。

The patientwas administered multiple medications to control the intraocular pressurebefore surgery and the lens was removed combined with anterior vitrectomy onJanuary 12th, 2011.

The first day after surgery:

VOD:HM/750px, IOP:11.8mmHg. The cornea was edema; theanterior chamber was deep with aqueous flare. The pupil was round and with nolight reflex. The lens was absent. The Levofloxacin, Pranoprofen, Flumetholoneye drops and the Recombinant Bovine Basic Fibroblast Growth Factor EyeOintment were administered.

The 4th day after the surgery:

VOD:HM/750px, IOP:23.7mmHg. The corneal edema was relieved and the Brinzolamide was added to controlintraocular pressure.

The 5th day after surgery:

VOD:HM/750px,corrected vision 20/50(+15.0DS),IOP:23.8mmHg.The cornea was almost clear, and the Carteolol hydrochloride was added to reduceintraocular pressure.

At the14th days after surgery, the vision was HM/750px, corrected vision was 20/50, IOP was 18.6mmHg.The cornea was clear and the anterior chamber was deep and quiet. The pupil wasround and fixed. The lens was absent. The non-contact specular microscopyshowed the density of the corneal endothelium cell was 237.9/mm2.The patient was discharged from hospital.

Atthree month follow-up, the vision was HM/1250px and could be corrected to 20/50 and the IOP was9.6 mmHg. The VEP showed no typical NPN wave in the 60´square of right eye, indicating optic nerve injury from the previoustrauma.

三、查房记录

Case discussion

根据病史及眼部检查，患者继发性青光眼诊断明确，就该患者外伤导致继发性青光眼原因及治疗方案、术后恢复情况进行了一次病例讨论。

According to the medical history and the eye examination,the diagnosis of secondary glaucoma was established. The mechanisms, thetreatment and the prognosis of secondary glaucoma from trauma were discussed.

刘伟医师：

外伤导致继发性青光眼的主要原因是小梁网的炎症，水肿。其他原因有:

1.房角后退：潜伏期可达10年，应及时做房角镜/UBM检查并监测患者的眼压变化，后退范围超过半周者发病可能性增大，小梁网损害是影响房水外流、引起眼压升高的真正原因。

2.前房出血：眼压升高发生率与出血多少有关，机制包括出血机械性地阻塞小梁网；血液长期不吸收，机化，导致周边前粘连；伤后与出血并存的小梁功能损害；前房出血常与炎性反应并存；血影细胞性青光眼.

3.晶状体脱位：

（1）瞳孔阻滞：晶状体脱入前房后后囊膜与瞳孔缘虹膜相贴；脱入玻璃体造成玻璃体疝；嵌顿在瞳孔区。

（2）脱位的晶状体摩擦刺激睫状体造成房水分泌增多。

（3）瞳孔阻滞以及晶状体倾斜推挤虹膜造成周边虹膜前粘连。

Dr.Wei Liu

Theinflammation and swelling of the trabecular meshwork is the most common causeof secondary glaucoma after blunt ocular trauma. Other mechanisms including:

1.Chamber angle recession. The incubation period of angle recession glaucoma mayextend to as long as 10 years, so it is necessary to peform UBM or gonioscopyexamination timely and monitor the IOP of the patients during the follow-up.The possibility of angle recession glaucoma increases if the recession is morethan 180 degree. The damage of the trabecular meshwork is the nature ofdecreased aqueous outflow and elevated intraocular pressure.

2.Hyphema. The incidence of increased intraocular pressure relates to the degreeof bleeding. The mechanisms include the direct obstruction of the trabecularmeshwork by the blood; the peripheral anterior synechiae resulted from the fibrosisof the persistent bleeding; the dysfunction and the inflammation of thetrabecular meshwork coexisting with bleeding after trauma and ghost cellglaucoma.

3. Lensdislocation:

(1)Pupillary block: if the lens is dislocated into anteriorchamber, the posterior capsule of lens could adhere to the pupil rim; if thelens is dislocated into the vitreous, the vitreous hernia will form at thepupil area; or the lens incarcerated into pupil area will block the pupildirectly.

(2)Theincreased secretion of the aqueous resulted from the rubs of the dislocatedlens rubs to the ciliary body.

(3)Pupillaryblock and the lens tilt will push the iris forward and lead to peripheralanterior synechiae.

刘爱华主治医师：

外伤性青光眼的治疗，应根据不同的病因和情况来决定。晶体不全脱位者若晶状体透明,则先用药物控制眼压。对无法控制眼压者，应尽快手术，并根据具体情况，制定合理的手术方案。如无前房角粘连或后退，可行晶状体摘除术;如伴有前房角损伤或前房角粘连，可联合小梁切除术;对于晶状体半脱位伴有玻璃体疝形成者，可联合前部玻璃体切除术；对晶状体全脱位于玻璃体腔，可行后部玻璃体切除加晶状体摘除术。

Dr Aihua Liu

Thetreatment of traumatic glaucoma depends on the etiology and the eye conditionsof different patients. The patient of lens subluxation can be administereddrugs to control intraocular pressure if the lens is transparent. If the IOPcan not be controlled by medications, surgical treatment is necessary. If thereis no synechiae or recession of anterior chamberangle, just removing the lens will work; if there is coexisting injury oradhesion of anterior chamber angle, the combined trabeculectomy will benecessary; if there is coexisting vitreous hernia, the combined anteriorvitrectomy will be necessary; if the lens dislocated into the vitreous cavity,the combined vitrectomy should be performed.

季建主任医师：

对于此例患者，由于药物控制眼压不理想，手术治疗是有必要的。手术中应注意操作轻柔，减少对角膜内皮的损伤，不排除玻璃体前部或全部切除，术中有晶状体脱入后房或玻璃体可能。手术后一般不主张同期植入人工晶体，可选择二期人工晶体植入术。影响手术后视力的因素很多，除了与手术方式有关外，与合并有眼球其他部位的损伤有很大关系，而术后并发症也是影响术后视力恢复的一个重要因素。该患者术中晶状体摘除术后，玻璃体部分脱入前房，联合前部玻璃体切除。术后反应性眼压升高，予以药物控制。随访眼压控制良好，但视力欠佳，电生理检查显示外伤眼视神经挫伤导致功能障碍，影响视力恢复。

Dr Jian Ji

For this patient, the surgical interventionis indicated the lens was dislocated into the anterior chamber,causingsecondary glaucoma. Gentle maneuver has to be applied to protect the ornealendothelium during surgery. It is possible that the lens may drop into thevitreous cavity during surgery. Therefore, vitrectomy should be prepared. Theprimary IOL implantation is not recommended. A secondary IOL implantation canbe performed if necessary. The vision recovery can be affected by many factors,such as the surgical procedure, the combined damage of the fundus and thepostoperative complication etc. For this patient, the vitreous escaped into theanterior chamber after lens removal, so the anterior vitrectomy was performed.The intraocular pressure was slightly high after surgery, and was well controlledby medications. However, the visual acuity was poor because of the optic nerveinjury confirmed by VEP examination.

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