杨某某，男，12岁

Mr. Yang, 12 years old，Male

一、病例特点

General Information

主诉

右眼被塑料子弹打伤后视物不清5天。

Chief complaint

Blurred vision of the right eye after hitting by plastic projectile for 5 days.

病史

现病史：患者于5天前右眼不慎被塑料子弹打伤，伤后右眼流泪、视物不清，急来我院门诊，发现右眼前房积血（图1），给予双眼包扎、制动并给予典必殊水点眼。今日来我院门诊复查，测右眼眼压高，以“右眼继发性青光眼”收入院。

Medical History

Present history: The patient suffered tearing and blurred vision of the right eye after hitting by plastic projectile from toy gun for 5 days. The patient was found hyphema of the right eye in our emergency department after the trauma (figure 1). Both eyes were patched and the patient was administered tobradex eye drops. The patient was found high intraocular pressure of the right eye during the follow-up and was admitted to our hospital for further trearment.

眼部检查

右眼：视力0.8，右眼角膜透明，前房深，房水闪光（++），前房积血部分吸收，鼻下虹膜根部离断，瞳孔斜椭圆形（图2），晶状体透明，眼底未见异常。眼压36.1mmHg。

左眼：未见明显异常，视力1.0，眼压19.8mmHg。

Ocular examination

Vod 0.8, the cornea was clear, the anterior chamber was deep, aqueous flare (++), hyphema, the iris root was dehiscenced at the nasal-inferior area (Figure 2), the pupil was oval, the lens was transparent and the fundus was normal. The IOP was 36.1mmHg.

Vos 1.0, IOP 19.8mmHg. There was no significant abnormality in the left eye.

二、辅助检查

Acessory Examination

右眼UBM：前房中央深度2.85mm，前房内弥漫点状低回声，3点位虹膜回声中断，房角后退，下方团絮状回声与虹膜回声相连。（图3）

UBM OD: The central anterior chamber depth was 2.85mm, diffused hypoechoic spots in the anterior chamber, interruption of the iris echo and angle recession at 3 o’clock. (Figure 3)

右眼房角镜：1点位至3点位房角后退，3点位至5点位虹膜根部离断，可见睫状突，下方积血膜遮挡房角。

Gonioscopy OD: angle recession from 1 o’clock to 3 o’clock, iris root dehiscence and visible ciliary processes from 3 o’clock to 5 o’clock, the inferior angle was not visible for hyphema.

心电图：窦性心动过缓（45次/分）。

ECG: sinus bradycardia (45 bear per minute).

三、初步诊断

Diagnosis

右眼继发性青光眼

右眼钝挫伤

右眼前房积血

右眼虹膜根部离断

右眼房角后退

右眼虹膜睫状体炎

Secondary glaucoma OD

Blunt ocular trauma OD

Hyphema OD

Iris root dehiscence OD

Angle recession OD

Iridocyclitis OD

四、治疗经过和结果：

Treatment and results

入院后给予右眼典必殊水QID，典必殊膏QN抗炎，尼目克司片25mg BID，派立明 TID，阿法根 BID控制眼压。

The patient was administered tobradex eye drops four times per day, tobradex ointment one time per day, Azopt three times per day, Alphagan two times per day, oral Methazolamide 25mg two times per day.

入院第二天：

Vod1.2，右眼角膜透明，前房深，房水闪光（+），前房积血明显吸收，鼻下虹膜根部离断，瞳孔斜椭圆形，晶状体透明，眼底未见异常。眼压38.1mmHg。

给予20%甘露醇200ml静脉点滴，地塞米松5mg入壶×3天。

The 2nd day after treatment:

Vod 1.2, the cornea was clear, the anterior chamber was deep, aqueous flare (+), hyphema was absorbed obviously, the iris root was dehiscenced at the nasal-inferior area, the pupil was oval, the lens was transparent and the fundus was normal. The IOP was 38.1mmHg. Intravenous 20% mannitol (200ml) and intravenous dexamethasone (5mg) were used for 3 days.

入院第五天：

Vod1.2，右眼角膜透明，前房深，房水闪光（+），前房积血吸收，鼻下虹膜根部离断，瞳孔斜椭圆形，晶状体透明，眼底未见异常。眼压33mmHg。

考虑患者可能对糖皮质激素敏感，停用典必殊水及典必殊膏，改用0.1%氟美童QID；考虑尼目克司片的全身副作用，停用尼目克司片。

The 5th day after treatment:

Vod 1.2, the cornea was clear, the anterior chamber was deep, aqueous flare (+), hyphema disappeared, the iris root was dehiscenced at the nasal-inferior area, the pupil was oval, the lens was transparent and the fundus was normal. The IOP was 33mmHg. High susceptibility to corticosteroid of the patient was suspected and the tobradex eye drops and ointment were discontinued and 0.1% fluorometholone was used. The oral Methazolamide was also stopped for the potential systemic side effects.

入院第七天：

Vod1.2，右眼角膜透明，前房深，房水闪光（+），鼻下虹膜根部离断，瞳孔斜椭圆形，晶状体透明，眼底未见异常。眼压31.9mmHg。

给予右眼选择性激光小梁成形（激光光凝颞侧房角小梁网），激光后2小时眼压22.1mmHg，接下来四天眼压为：22.4 mmHg，27.3 mmHg，31.0 mmHg，34.1 mmHg。

The 7th day after treatment

Vod 1.2, the cornea was clear, the anterior chamber was deep, aqueous flare (+), the iris root was dehiscenced at the nasal-inferior area, the pupil was oval, the lens was transparent and the fundus was normal. The IOP was 31.9mmHg. The patient was performed selective laser trabeculoplasty in the temporal trabecular meshwork. The IOP at 2 hours after trabeculoplasty was 22.1mmHg and 22.4 mmHg, 27.3 mmHg, 31.0 mmHg, 34.1 mmHg for the following 4 days.

入院第十二天：

Vod1.2，右眼角膜透明，前房深，房水闪光（+），鼻下虹膜根部离断，瞳孔斜椭圆形，晶状体透明，眼底未见异常。眼压28mmHg。

再次给予右眼选择性激光小梁成形（激光光凝上方房角小梁网，能量0.5-0.9mJ，约35点）。后眼压波动于20-25mmHg，于入院第十四天出院。

The 12th day after treatment:

Vod 1.2, the cornea was clear, the anterior chamber was deep, aqueous flare (+), the iris root was dehiscenced at the nasal-inferior area, the pupil was oval, the lens was transparent and the fundus was normal. The IOP was 28mmHg.

The patient was performed selective laser trabeculoplasty again in the superior trabecular meshwork. Then, the IOP of the right eye ranged from 20 to 25mmHg, and the patient was discharged at the 14th day.

出院后门诊复查：

患者于受伤后45天时，逐渐停用所有降眼压药，眼压稳定于20mmHg以下。

At the 45 days after the initial trauma, all the anti-glaucoma medications were taped off, and the IOP was stable under 20mmHg.

五、查房讨论

Discussion

邢小丽副主任医师：

Dr.Xing Xiao-li:

眼钝挫伤导致高眼压的原因

Mechanisms of blunt trauma induced high intraocular pressure

继发于眼钝挫伤的青光眼发病机制复杂，可包含多个方面。

1.小梁网的炎症、水肿。大多数眼钝挫伤都会伴随着小梁网的炎症水肿，而小梁网的炎症水肿会直接阻碍房水的外流，导致眼压升高。

2.前房出血。前房出血是眼钝挫伤的主要表现，据报道，其发生率为25%-53.8%。前房出血导致青光眼的机制包括：

a. 大量的血液充满前房时，机械性地阻塞小梁网，房水排出受阻，出现眼压升高。

b. 长期不能吸收的出血，机化造成周边虹膜前粘连，发生继发性闭角型青光眼。

c. 伤后与前房出血并存的小梁功能损害也是常见的眼压升高的原因。

d. 血影细胞性青光眼。

3. 晶状体因素。晶状体脱位后常继发青光眼，但并非所有的晶状体脱位都会继发青光眼。a. 瞳孔阻滞。脱位入前房的晶状体，嵌顿于瞳孔区的晶状体，脱位于玻璃体的晶状体形成的玻璃体疝均可导致瞳孔阻滞。

b. 房水生成增加。脱位的晶状体可能会摩擦刺激睫状体，导致房水生成增多。

4. 房角后退。伴随前房出血的病例，房角后退的发生率较高，晚期可发生青光眼。因此，对挫伤性前房出血病例，当血液吸收后，应做详尽的房角镜检查，对有房角后退或后退范围较大的病例，需做长期的随访观察。

The pathogenesis of glaucoma secondary to blunt trauma is complicated and the mechanisms may include:

1. Inflammation and edema of the trabecular meshwork. Most of the ocular blunt trauma is companied by the inflammation and edema of the trabecular meshwork, which will impede the outflow of the aqueous and lead to elevated intraocular pressure.

2. Hyphema. Hyphema is a main presentation of ocular blunt trauma and the incidence is reported to vary from 25% to 53.8%. The mechanisms of hyphema induced glaucoma include:

a. Obstruction of the trabecular meshwork by the blood in the anterior chamber.

b. Peripheral anterior synechia from the organization of the blood.

c. Functional damage of the trabecular meshwork by the blunt trauma.

d. Ghost cell glaucoma.

3. Lens dislocation. Lens dislocation usually lead to secondary glaucoma, but not all the lens dislocation will develop glaucoma.

a. Pupillary block. The lens dislocated to the anterior chamber, incarcerated in the pupil or dislocated to the vitreous cavity can all lead to pupillary block.

b. The dislocated lens will scrub the ciliary body and lead to increased production of aqueous.

4. Angle recession. Angle recession is prevalent in the ocular blunt trauma patients with hyphema and will develop glaucoma in the late stage. Detailed gonioscopy examination is suggested if the blood is absorbed and a long-term follow-up is needed for the angle recession patients.

刘爱华副主任医师：

Dr Liu Ai-hua

房角后退

Angle recession

钝挫伤使睫状肌的环行纤维与纵行纤维分离，虹膜根部向后移位，前房角加宽变形，称为房角后退。在正常人群中，房角后退发生率很低；在眼前段挫伤者中，发生率为60%-94%；在眼前段挫伤伴有前房出血者中，发生率为56%-100%。房角后退常常伴随着眼部其他损伤表现：

1. 前房出血。

2. 角膜损伤：角膜浅层或全层水肿混浊，后弹力层皱褶，内皮色素沉着。

3. 虹膜及瞳孔损伤：虹膜根部离断，瞳孔缘虹膜撕裂，瞳孔扩大，虹膜周边前粘连，虹膜震颤。

4. 晶状体混浊或脱位。

5. 眼后节损伤：黄斑水肿，黄斑囊样变性，黄斑裂孔，脉络膜破裂，视网膜裂孔，玻璃体出血，视神经损伤等。

房角损害可在伤后立即影响房水的产生和排出，导致眼压升高，一般能自然消退，仅有少数成为典型的青光眼；也可在伤后十几年后导致房角后退性青光眼，一般认为不超过10%，房角后退的范围越大，发生青光眼的机率越大。

Angle recession is characterized by the split of the circular and longitudinal muscles of the ciliary body, the posterior location of the iris root and the widened and deepened anterior chamber angle. The prevalence of angle recession is low in healthy subjects. Some investigators have reported that more than 60% of eyes with nonpenetrating traumatic injuries will have some degree of angle recession. Careful gonioscopy has revealed that between 56% and 100% of patients with traumatic hyphema have some degree of angle recession. Signs of trauma in the angel recession patients should be sought:

1. hyphema.

2. corneal scars, corneal edema, folds of the Descemet’s membrane, pigmentary deposits.

3. iris root dehiscence, ruptures of the iris sphincter, iridodenesis, peripheral anterior synechia.

4. localized opacities or dislocation of the lens.

5. macular edema, cystoid macular degeneration, macular hole, choroidal rupture, retinal tear, vitreous hemorrhage, optic nerve injury, etc.

Angle recession can disturb the production and outflow of the aqueous immediately after the trauma and lead to elevated intraocular pressure, which will resolve spontaneously. Only a few cases will eventually develop glaucoma, which is estimated to be less than 10%. Some investigators have reported cases of angle recession glaucoma developing more than 50 years after the initial injury. The association between the extent of angle recession and the development of glaucoma has also been reported.

季健主任医师：

Dr. Ji Jian:

房角后退性青光眼的治疗

Treatment of angle recession glaucoma

1. 药物治疗。眼钝挫伤后早期的眼压升高一般是自限性的，大多可被药物控制。包括Alpha2肾上腺能激动剂，碳酸酐酶抑制剂，糖皮质激素，高渗剂等药物都可能有效。曾有报道房角后退性青光眼应用毛果芸香碱后眼压升高，推测原因为毛果芸香碱减少了葡萄膜巩膜通道的房水外流。

2. 激光治疗。激光小梁成形术成功率不高。Scharf报告一组13例房角后退性青光眼行小梁成形术，36个月成功率为23%；另一组11例患者，12月成功率为27%。

3. 手术治疗。房角后退性青光眼与慢性开角型青光眼相比，滤过性手术成功率较低。手术失败的原因主要是术后前3个月内滤过道的纤维化，滤过手术成功率低可能与眼外伤增加了术后成纤维细胞的生长有关。

因此对于房角后退性青光眼患者，首次手术就应考虑应用抗代谢药物，以提高手术成功率。

1. Medications. The intraocular pressure rise that occurs immediately after ocular blunt trauma is usually self-limited, and in the majority of cases, can be controlled wtih medications alone. Glaucoma medications that decrease aqueous formation, such as beta blockers, carbonic anhydrase inhibitors, or alpha2-agonists, may be useful. There have been reports that miotics may cause a paradoxical increase in intraocular pressure in patients with angle recession, possibly by decreasing the uveoscleral outflow.

2. Laser. Argon laser trabeculoplasty is usually unsatisfactory and fails to lower the intraocular pressure in this group of patients. Scharf et al reported the 36 months success rate of ALT in 13 angle recession glaucoma patients was 23%, and the 12 months success rate was 27% in another 11 patients.

3. Surgery. Trabeculectomy has also been reported to have a lower success rate in eyes with angle recession glaucoma as compared to eyes in patients with open-angle glaucoma. It has been suggested that an increased tendency for fibroblast proliferation may be responsible for the decrease in the success rate of glaucoma surgery.

Thus, antimetabolites are suggested even in the first surgery procedure to improve the success rate.

图1：右眼前节像  前房积血，瞳孔不圆。

Figure 1 Hyphema and the oval pupil.

图2  鼻下方虹膜根部离断，瞳孔不圆

Figure 2 Iris root dehiscence and the oval pupil.

图3 鼻侧房角后退，虹膜根部离断

Figure 3 Angle recession and the iris root dehiscence by UBM.