娄某某，男，46岁

一．病例特点

主诉：左眼外伤后反复眼红眼痛视力下降16个月

现病史：病人于16个月前左眼外伤（植物异物伤？），伤后2个月左眼眼红，眼痛，视力下降。于2010-11-8外院行左眼白内障摘除+人工晶状体植入术，术后视力恢复可。术后给予全身及局部抗炎抗感染治疗。2011-3-25再次出现眼红眼痛，视力下降，外院就诊诊为左眼虹膜炎，并以左眼虹膜炎，双眼糖尿病性视网膜病变收入院，住院期间发现左眼眼压升高，给予左眼降眼压治疗及抗炎抗感染免疫抑制剂治疗，双眼视网膜光凝治疗各1次，出院后炎症反复发作，伴眼压升高。于2011-06-17因左眼全葡萄膜炎入外院，给予抗炎抗感染治疗，好转出院。后炎症再次复发，于2011-10-08因左眼葡萄膜炎，左眼角膜深层异物入外院，行左眼深层角膜异物取出+前房冲洗术，术后抗炎抗感染治疗，效果不明显，出院。发病期间反复眼压升高，最高可达60mmHg。我院门诊以“左眼葡萄膜炎（性质待查），左眼继发性青光眼，双眼糖尿病性视网膜病变”收入院诊治。发病以来，精神好，饮食、睡眠和大小便均正常。

既往史：糖尿病5年

家族史: 否认家族遗传病史

眼部检查：

右眼：远视力0.6，眼压9.2mmHg。晶状体皮质及后囊下混浊，核II级，玻璃体点条状混浊，眼底模糊可见视网膜陈旧性激光斑，黄斑区可见渗出。

左眼：视力手动/眼前，眼压17.2（2%美开朗OS BID）mmHg。结膜混合性充血，角膜瞳孔中央区缝线1针，角膜口闭合，角膜片状KP，前方深度可，房水闪辉及细胞，虹膜纹理模糊，瞳孔圆，直径3mm，光反射弱，人工晶状体位于后房，前部玻璃体可见大量纤维样渗出，眼内窥不入。

Mr. Lou, male, 46 years old

一．General Information

Chief complaint: The patient had red eye and ophthalmodynia combined with vision decreased recurrent of his left eye after trauma for 16 months.

Present medical history: The patient suffered from decreased vision acuitiy,red eye, ophthalmodynia of his left eye after trauma 16 months ago ( plant foreign body injury?). The ideal recovery of vision acuity were acquired after the cataract extraction combined posterior chamber intraocular lens implantation of left eye one year ago. Postoperation he was given  anti-inflammatory and anti-infection treatment. Four months later, he was hospitalized again for the iritis os, DR ou. During this hospitalization, his intraocular pressure was increased .Treatment to lower IOP and retinal photocoagulation of both eye was given in the meantime .Due to the uveitis relapse again ,he accepted by the hospital for the anti-inflammatory and anti-infection treatment .One month ago he had Cornea deep layer foreign body remove +anterior chamber irrigation. The improvement was not significant and he was admitted to our hospital .

Past medical history: Diabetes mellitus for 5 yearsos

Family history :unmarkable.

Ocular examinations:

Right eye :VA was 0.6, IOP was 9.2mmHg. Cortical and subcapasular opacity of the lens, and vitreous opacity were noticed. Fundus examination found laser spot in retina and exudation in macula lutea.

Left eye: VA was HM, IOP was 17.2mmHg. Conjunctival congestion. The corneal wound was sutured and healing well, which was located at the central of cornea. We could found keratic precipitates.  Anterior chamber was deep with flare and cells. The texture of iris was blur, pupil was round with a slightly weaker direct light reflex. IOL was in the posterior chamber. There was dense fiber-appearance opacity of anterior vitreous, making the retina undetectable.

辅助检查：

B超示：左眼玻璃体混浊

UBM示：前房内散在点状低回声

诊断：

左眼全葡萄膜炎

左眼继发性青光眼

双眼糖尿病性视网膜病变

二．诊治经过：

术前用药：2%卡替洛尔每日2次点左眼降压治疗及双眼抗炎抗感染治疗

2011-11-24行左眼玻璃体切除术，术中取前房液及玻璃体腔液涂片及培养，未见致病菌。

术后第一天：

视力0.02，眼压4mmHg，结膜巩膜切口闭

合好，角膜缝线在位，角膜水肿，少许KP，

前方深度可，瞳孔圆，直径4mm，人工晶

状体在位，眼底模糊

术后第三天：

视力0.06，眼压32mmHg，角膜水肿较前减

轻，眼底可见黄斑区水肿，大量硬性渗出，

余情况同前。予2%美开朗BID, 醋甲唑胺

25mg BID降眼压治疗。

术后第五天：

视力0.12，眼压12mmHg，结膜轻度充血，角膜透明，余情况同前。

为明确诊断和进一步治疗，术后行OCT检查示左眼黄斑前膜，水肿，硬性渗出

FFA检查示右眼PRP术后，左眼葡萄膜炎，网膜循环瘀滞，糖尿病性视网膜病变3期

三．病例讨论：

术后就该患者葡萄膜炎的性质及是否需要进一步行玻璃体腔注射抗生素进行了一次病例讨论：

Ancillary examination:

B-scan showed vitreous opacity of the left eye

UBM showed some scattered low-echo in anterior chamber

Primary diagnosis:

Panuveitis OS

Secondary glaucoma OS

Diabetic retinopathy OU

二．Treatment

The patient was administered medications to control the intraocular pressure before surgery and had received vitrectomy on November 24th ,2011. The AC and vitreous tap were negative.

The first day after surgery:

VOD:0.02, IOP:4mmHg. The corneal was edema and the suture was located. There were some keratic precipitates in corneal endothelia. Anterior chamber was deep and the pupil was round. IOL was in the posterior chamber. Retina was blur.

The third day after surgery:

VOD:0.06, IOP:32mmHg. The corneal edema was relieved. Large hard exudation and edema could been seen in macula lutea. Carteolol Hydrochloride and Methazolamide were added to control intraocular pressure.

The fifth day after surgery:

VOD:0.12, IOP:12mmHg. Conjunctival slightly congestion and the corneal was clear.

Two more ancillary examination for diagnosis and further treatment after the surgery:

OCT of left eye showed the macular epiretinal membrane , edema , hard exudation.

FFA revealed post-PRP of right eye. Left eye uveitis , retinal circulation stasis , diabetic retinopathy in stage 3

三．Consultation

The properties of Uveitis, whether the intravitreal antibiotic injection was necessity were discussed after the surgery.

程朝晖主治医师：现病人眼部情况稳定，眼前节轻微炎症反应，眼底细节清晰，考虑若为感染性疾病则弱毒力致病菌可能性大，但使用抗生素眼内注射为积极方法。患者全身使用激素，且糖尿病血糖控制欠佳，进一步使用激素需要小心。

张晓敏副主任医师：

1．患者外伤史明确，特别是可疑植物外伤史，且患者炎症反应与外伤关系密切

2．患者眼部炎症反应迁延不愈，且多为单眼发病，且未合并全身性系统疾病，与非感染性葡萄膜炎症状有差异

3．患者为糖尿病病人，血糖控制欠佳，病程反复发作与低毒力致病菌感染症状较吻合

4．考虑使用玻璃体腔注药术为诊断性用药

汪建涛主任医师：

1．患者植物性外伤史与眼内炎症密切相关，存在植物外伤导致真菌感染和厌氧菌感染可能。由于白内障术前已经存在前房积脓，因此眼内炎可能性大，病原学检查不能排除

2．考虑患者糖尿病史，全身使用激素，需要密切关注血糖情况，需要注意激素用量和时间

3．患者长时间局部使用激素，但眼底C/D0.4-0.5，所以虽然眼压高，暂不考虑激素性青光眼可能，恢复后进行视野等相关视功能检查

4．目前患者培养阴性，但不能排除眼内炎诊断，应该在本次玻璃体切割术后进行玻璃体腔注射万古霉素。目前玻璃体腔清晰，没有眼内炎症反应的表现，查找文献关于该情况下眼内注药的依据，如果没有，行玻璃体腔注射万古霉素为诊断性治疗方案。

根据讨论结果，于2011-11-30行左眼玻璃体腔注射万古霉素1mg/0.1ml，地塞米松0.4mg

Dr. Chen Zhaohui

The patient is in a stable condition with slight reaction of anterior segment and clear fundus . Treatment with intravitreal antibiotic injection is a positive method if a infectiousdiseases caused by the low-toxic force pathogenic bacteria is suspected. But we should keep special care for the further use glucocorticoid because the poorly controlled blood glucose.

Dr. Zhang Xiaomin

It is clear that intraocular inflammation of the patient is close related to the trauma history especially the suspicious plant foreign body injury .Think about the protracted illness, monocularinvolvement happened without Systemic disease, the inflammation is different with the non-infectious uveitis. Consider the long disease durationis in agreement with the Low-toxic force infection, we are going to use the intravitreal injection as a diagnostic therapy.

Dr. Wang Jiantao

Because of the close relationships between intraocular inflammationand trauma history, the patient has the chances of fungus and anaerobic infection in addition.We cannot exclude this two infections for the hypopyon had been existed before the cataract surgery. Taking into account the diabetes mellitus and Systemic using steroid, the blood glucose and the dosage of steroid should given close attention .Although a long local use of steroid, the patient’s C/D is 0.4-0.5, we don’t consider the high intraocular pressure is related to corticosteroid. Perimetry should be given after recovery. All in all, the entophthalmia could not be eliminated though there was no pathogenic bacteria found in aqueous humor and vitreous humor. But the vitreous is clear now and no sign shows the entophthalmia.Supporting from some basis of intravitreal injection in this situation for the further treatment is still needed, if not , using the intravitreal injection as a diagnostic treatment.

出院情况：左眼视力0.2，眼压12.0mmHg，结膜轻度充血，角膜透明，KP，前方深度可，房闪（+），虹膜纹理清，瞳孔圆，直接3mm，光反射存，人工晶状体位正，玻璃体混浊，眼底视盘介清，色可，视网膜在位，黄斑区大量硬性渗出。

图一 B超示：左眼玻璃体混浊

Fig1  B-scan showed vitreous opacity of the left eye

图二  UBM示：前房内散在点状低回声

Fig2  UBM showed some scattered low-echo in anterior chamber

Post-treatment:

Based on the discussion, the patient received intravitreal vancomycin and dexamethasone

on November 30th ,2011. At the 10th day after vitrectomy surgery, the vision was 0.2, IOP was 12.0mmHg. Conjunctival slightly congestion. The corneal was transparent but still had some keratic precipitates. Anterior chamber was deep with flare. The texture of iris was clear. Pupil was round with direct light reflex existence. IOL was in the posterior chamber. Vitreous opacity, large hard exudation in macula lutea. No other significant abnormality was found.

图三 左眼眼前节照相示结膜混合性充血，角膜瞳孔中央区缝线1针，角膜片状KP，前方房水闪辉及细胞，人工晶状体位于后房

Fig3  The anterior segment photo of left eye showed Conjunctival congestion. The corneal wound was sutured and healing well, which was located at the central of cornea. We could found keratic precipitates.  Anterior chamber was deep with flare and cells. IOL was in the posterior chamber.

图四 术后行OCT检查示左眼黄斑前膜，水肿，硬性渗出

Fig4  OCT of left eye showed the macular epiretinal membrane , edema , hard exudation.

OD

OD

OS

OS

图五 FFA检查示右眼PRP术后，左眼葡萄膜炎，网膜循环瘀滞，糖尿病性视网膜病变3期

Fig5  FFA revealed post-PRP of right eye. Left eye uveitis , retinal circulation stasis , diabetic retinopathy in stage 3