李某女 47岁

Mrs. Li  47 years old  Female  

一、病例特点

General information

主诉

右眼抗青光眼术后渐进性视物不清4月。

Chief Complaint

Progressive vision loss in right eye about 4 month after trabeculectomy

病史

现病史：患者于9月前行右眼抗青光眼手术，近4月自觉右眼视物模糊，逐于我院门诊就诊，检查发现右眼前房近消失，虹膜局部前粘，眼压高，为进一步治疗入院。

Medical History

Present history：Trabeculectomy were performed in right eye 9 months before. Progressive vision loss in right eye about 4 month after surgery. In out-patient department, IOP of the right eye was high, anterior chamber  was shallow and nearly disappeared, anterior synthetic of the iris and corneal, then she was admitted to our hospital for further diagnosis and therapy.

眼部检查

右眼：远视力0.12，眼压26.8mmHg。结膜上方滤过泡扁平弥散。角膜轻肿，前房近消失，虹膜膨隆，局部前粘，瞳孔欠圆，全周后粘，对光反射消失，晶状体皮质混浊，眼底小瞳下窥不入（图1）。

左眼：远视力1.0，眼压18mmHg。角膜透明，中轴2.5CT，周边1/3CT，瞳孔圆，Ф3mm，虹膜纹理清，对光反射存，晶状体基本透明，眼底小瞳下见视盘界清色可，C/D=0.4，黄斑中心凹反光可见。

Ocular Examination

Right eye: VOD0.12，IOP26.8mmHg, bleb was flat, corneal edema, anterior chamber was shallow and nearly disappeared focal, anterior synthetic of the iris and corneal  partly, non-round pupil, posterior synechia of the iris, cortical lens opacity, funds counld not be seen clearly.（fig 1）

Left eye: VOS1.0 IOP18mmHg, cornea clear, anterior chamber was 2.5CT in the center, 1/3CT in periphery, the pupil diameter was 3mm, substantially transparent lens, fundus showed C/D0.4.

二、辅助检查

Auxiliary examination

B超：右玻璃体混浊，网膜在位（图2）。

UBM：右角膜前表面粗糙，虹膜晶体隔前移，虹膜与角膜内表面相贴，局部虹膜与角膜粘连，12点位附近虹膜回声中断；左眼全周房角开放度小（图3）。

中心视野：见图4。

角膜中央厚度：双眼480μｍ。

右眼角膜内皮计数：1971.9个/mm2

B scan, UBM and central visual field（fig 2、3、4）

Central corneal thickness：480μｍOU

Corneal endothelial count：1971.9/mm2 OD

三、初步诊断

Impression

右眼抗青光眼术后高眼压

右眼年龄相关性白内障

High intraocular pressure after anti-glaucoma surgery OD

Age-related cataract OD

四、治疗和结果

Treatment and preliminary results

药物控制眼压，入院第2天：

给予20%甘露醇250ml静脉点滴后，行右眼白内障超声乳化+人工晶状体植入术+复合小梁切除术。

Combination therapycontrolled the intraocular pressure. In the second day：

The patient was gived 250ml mannitol before surgery, and then received phacoemulsification, intraocular lens implantation combined trabeculectomy with MMC.

术后第1天：

VOD0.2，IOP15mmHg，滤过弥散，角膜水肿，前房纤维素样渗出，前房中轴2.5CT，颞侧周边虹膜前粘，人工晶状体位正。

常规抗炎点眼治疗，隔日球旁注射地塞米松5mg。YAG激光清扫渗出膜。

1st day post operation：

VOD0.2, IOP was 15mmHg, filtration diffusion, corneal edema, fibrinous exudation in the anterior chamber,. temporal anterior synechia of the iris, IOL in position.

Anti-inflammatory eye drops was given, and 5mg dexamethasone periocular injection every other day. The exudative fibrin in anterior chamber was treated by Nd:YAG laser.

出院时情况：

VOD0.5，IOP18mmHg，滤过弥散，角膜水肿，前房纤维素样渗出基本吸收，前房中轴3CT，颞侧周边虹膜前粘，人工晶状体位正。

Ocular examinations when the patient was discharged：

VOD0.5, IOP was 18mmHg, bleb diffuse, corneal clear, no fibrinous exudation in the anterior chamber,temporal anterior synechia of the iris,anterior chamber was 3CT in the center.

五、查房记录

Summary

杨瑾副主任医师查房：

根据患者目前的病史，症状及体征，分析患者病情：患者9月前曾行右眼小梁切除术，当时手术顺利，前房形成，术后眼压稳定出院，术后2w后至此次入院未到医院复查。近4月右眼视物模糊，到我院就诊发现，眼压高，前房近消失，虹膜部分前粘，瞳孔缘虹膜后粘，晶状体皮质混浊。不除外患者术后存在滤过过强，曾有过揉眼，或术后迟发性前房炎症反应导致部分虹膜前粘，前房变浅；瞳孔缘虹膜后粘、根切处虹膜前粘及手术区滤过道瘢痕化等导致房水滤过减少，眼压增高。行右眼白内障超声乳化+人工晶状体植入联合小梁切除术，白内障摘除后瞳孔阻滞解除，小梁切除术建立新的滤过通道。术中用粘弹剂钝性分离前粘连的虹膜组织，前房内留置少量粘弹剂，形成前房。术后激素治疗减轻前房反应。YAG激光清扫渗出膜，提高手术成功率。

Dr. Yang Jin:

The right eye was underwent trabeculectomy 9 months ago, and operation smoothly, when the patient was discharged, anterior chamber was normal, IOP was stable.The patient did not follow up. Progessive loss of vision in right eye started from postoperation 4 months. IOP of the right eye was high in clinic, anterior chamber nearly disappeared, anterior and  posterior synechia of the iris, cortical lens opacities. According to the patient’s medical history, symptoms and signs, the patient could have excessive filtration, anterior uveitis and rub her eye. Persistent hypotony after flitering surgery could make anterior chamber shallow, anterior synechia, posterior synechia of the iris. The increase of IOP after operation was related to the fibrous thinkening of the filtration membrane in the operation area and the peripheral anterior synechia. The patient was received phacoemulsification, intraocular lens implantation combined trabeculectomy. Phacoemulsification relieved papillary block. Trabeculectomy established new channel of filtration. , the viscoelastics solution was used to maintain anterior chamber and dissect anterior synechia. Cortical steroid therapy after surgery reduced inflammation. Filtration exudation in anterior chamber was treated by Nd:YAG laser. All above could improve the success rate of trabeculectomy.

图1      

图2

图3

图4