Mr.Guo,male,65 years old
Presenthistory : The patient had a sudden eye pain in his right eye,accompanied with headache for 4 hours .The IOP was above normal anduncontrolled by drugs .
Past history : Trabeculectomy was performed in his left eye 10 yrs ago .
Personal history, family history showed no abnormality
左眼：VOS0.4,IOP17mmHg, 结膜滤过扁平，角膜透明，前房中轴2CT，周边，1/3CT，瞳孔直径5mm，晶状体混浊，眼底C/D0.8。Ocular examination :
Right eye : VOD0.5 IOP55mmHg, conjunctival congestion, corneal edema, paracentral adherent corneal leukoma, anterior chamber was shallow, 1.5CT in the center, 1/4CT peripherily. The pupil diameter was 2mm. with partial posterior synechia. The lens was opaque, and the funds was unreachable.（fig 1）
Left eye: VOS0.4 IOP17mmHg，bleb flattened, cornea clear, anterior chamber was shallow with 2CT in the center, 1/3CT peripherily, The pupil diameter was 5mm, the lens cortex has mediate opacity, and C/D showed 0.8 .
B超：左眼玻璃体混浊（图2）B scan: vitreous opacity in left eye. （fig 2）
Acute angle-closure glaucoma accompanied with adhesive small pupil OD
Vitreous opacities OU
Age-related cataract OU
Post trabeculectomy OSAdhaerent Corneal Leukoma OD
入院第1天：甘露醇250ml静脉点滴 bid，尼目克司25mg Bid，派立明OS TID, 阿法根 OS tid 降眼压。
First day: The patient was given 250ml mannitol twice a day, Wethazolamide 25mg twice a day, Azopt OS Tid, Alphegan OS TID to controll his intraocular pressure.
Second day: The patient had a sudden decreasing of visual acuity. VOD HM, corneal edema more severely, It was considered pupillary block, and then the laser peripheral iridectomy was performed, but is unhelpful to control IOP which is still was 57 mmHg.
Third day: The patient was given 250ml mannitol, and then underwent phacoemulsification, intraocular lens implantation combined with trabeculectomysmoothly.
First day after operation: VOD HM, corneal edema, fibril exudation in the anterior chamber, filtration bleb diffussed, IOP was 15mmHg .Anti-inflammatory eye drops was given, and 5mg dexamethasone peribulbal injection every other day.
10th day after operation: VOD HM, corneal edema was relieved, exudation absorbed, the intraocular pressure was normal, but the vitreous cavity was found opacity. B scan: There was diffuse hypoechoic spots, lumps, and strong echo membrane in the vitreous cavity. （fig 3）
Dr. Liu Zeng-Ye:
visual acuity cannot be recovered, most likely due to vitreous opacities which is relative to ; 1) infectious endophthalmitis; 2) the aseptic inflammation; 3) vitreous hemorrhage. Since the vitreous opacity was gray, yet the anterior segment reaction was not heavy,the low virulence bacterial induced endophthalmitis can not be excluded such as Staphylococcus epidermidis.
11th day after operation:Treated with vancomycin (10mg/ml)OD Q2h, then vancomycin (50mg/ml) and 2.5mg dexamethasone peribulbal injection every other day. B scan was examined every other day. （fig 4）
25th day after operation: VOD HM, vitreous opacity. B scan: There was diffuse hypoechoic spots, lumps, and strong echo membrane in the vitreous cavity. （fig 5）
30th day after operation: the right eye underwent vitrectomy. During the operation,the vitreous and aqueous was extracted and sent to stain and culture,but no pathogens was found. The retina was found spot hemorrhage, which may contribute to the vitreous opacity. After vitrectomy, visual acuity was 0.5, intraocular pressure was nomal, and retina attached. （fig 6、7）
It will increase the risk of bleeding when performing the combined surgery of glaucoma and cataract under high IOP. The malignant glaucoma must be alerted in this condition. Before operation, when sudden vision blurring happened, the B scan should be done to find the abnormalities.If not confirmed, the vitrectomy should be considered to restore vision as necessary as we can..
入院第1天 First day
入院第1天 First day
前三联术后第10天 P/s 10d(phaco+IOL+trabeculectomy)
前三联术后第11天 P/s 11d(phaco+IOL+trabeculectomy)
前三联术后第25天 P/s 25d(phaco+IOL+trabeculectomy)
玻璃体切割术后 P/s TPPV
玻璃体切割术后 P/s TPPV