Eye Bleeding\Two Surgeries\Blindness

Male, 54 years old The following are the medical records from the hospitalization for the second surgery.

Admission Record Admission date: January 22, 08:19 History taken: January 22, 08:48 Record date: January 22, 08:48 History provided by: the patient himself Chief complaint: more than 5 months after right-eye vitrectomy with silicone oil injection. Present illness: More than 5 months ago, the patient underwent right-eye vitrectomy, gas-fluid exchange, and silicone oil injection for “diabetic vitreous hemorrhage in the right eye.” He recovered well after the operation. During a recent outpatient follow-up at our department, “lens opacity, attached retina, and partial emulsification of the silicone oil” were found, and hospitalization for cataract surgery combined with silicone oil removal was recommended. He was admitted for surgical treatment. Further history revealed that the patient had refractive error of approximately -2.0 D and denied recent ocular trauma. He had a history of diabetes, well controlled with oral medication, and hypertension, also well controlled with medication. Three years ago, he underwent coronary stent placement and recovered well afterward. Since the onset of the current condition, the patient has remained alert, with normal mental status, appetite, bowel and bladder function, and no change in body weight. Past history: In September last year, he underwent right-eye vitrectomy, gas-fluid exchange, and silicone oil injection at our hospital. Specialist examination Right eye: visual acuity counting fingers, best-corrected visual acuity 0.05; no obvious abnormalities of the external eye; conjunctiva not congested; cornea clear; anterior chamber clear; pupil round; iris pattern clear; lens opaque; silicone oil filling the vitreous cavity with partial emulsification; optic disc with clear margins, pale pink; retina attached, with scattered extensive laser spots; macular edema; NCT: 16 mmHg. Left eye: uncorrected visual acuity 0.4, best-corrected visual acuity 0.6; no obvious abnormalities of the external eye; conjunctiva not congested; cornea clear; anterior chamber clear; pupil round; iris pattern clear; mild lens opacity; punctate opacities in the vitreous cavity; optic disc with clear margins, pale pink; retina attached, with extensive scattered laser spots; NCT: 15 mmHg. Auxiliary examinations January 22: B-ultrasound: right eye filled with silicone oil, no retinal detachment or choroidal detachment. OCT: macular edema with increased thickness in the right eye. Preliminary diagnosis: 1. Silicone oil eye, right; 2. Complicated cataract, both eyes; 3. Diabetic retinopathy, both eyes; 4. Diabetes; 5. Hypertension. Date: January 22.

Surgical Record Admission date: January 22 Surgical date: January 22 Surgery start and end time: January 22, 12:35 to 13:45 Preoperative diagnosis: silicone oil eye, right; complicated cataract, both eyes; diabetic retinopathy, both eyes; diabetes; hypertension. Procedure performed: phacoemulsification and intraocular lens implantation, right eye. Intraoperative diagnosis: complicated cataract, right eye; silicone oil eye, right; diabetic retinopathy, both eyes. Anesthesia: local. Incision: puncture. Main intraoperative findings: opaque lens in the right eye, silicone oil filling with emulsification, attached retina, macular edema. Surgical procedure: 1. The patient was placed in the supine position; routine ophthalmic disinfection and draping were performed. Retrobulbar block with lidocaine; eyelid speculum inserted. 2. A 15-degree puncture knife was used to make a side-port incision at 3:00 at the corneal limbus; a 3.0 mm puncture knife was used to create a clear corneal incision from 11:30 to 12:00. 3. A viscoelastic needle was slowly inserted through the 3 mm corneal incision into the anterior chamber, and viscoelastic was injected to maintain the chamber. 4. Capsulorhexis forceps were inserted through the 3 mm incision to perform continuous curvilinear capsulorhexis, approximately 5 mm in diameter. 5. A small amount of irrigation fluid was injected with a blunt needle along the 3 mm incision at the junction of cortex and capsule for hydrodissection. 6. A chopper was inserted through the side port and the phacoemulsification handpiece through the 3 mm incision; the opaque lens nucleus and part of the cortex were emulsified and aspirated. Ultrasound energy: 10%, duration: 1'04''. The aspiration handpiece was then used to remove residual cortex, followed by posterior capsule polishing. 7. Viscoelastic was reinjected into the capsular bag and anterior chamber; a foldable intraocular lens was implanted into the capsular bag using an injector through the 3 mm incision. The lens was centered and stabilized with a manipulator. 8. The aspiration handpiece was reinserted through the 3 mm incision to remove viscoelastic from the capsular bag and anterior chamber. 9. The 12 o'clock corneal incision was closed with 10-0 suture. The incisions were checked for watertightness; the anterior chamber was of normal depth, and the intraocular lens was well positioned in the bag. 10. A 25G puncture knife was used 3.8 mm from the limbus to create an infusion port at 7:00; a 23G puncture knife 3.5 mm from the limbus created the oil removal port at 11:00. 11. The oil removal cannula was connected to suction at 600 mmHg and silicone oil was aspirated. 12. The 11 o'clock scleral incision was closed with 8-0 suture; the infusion cannula was removed and that incision was sutured. Visual acuity was hand motion in front of the eye; intraocular pressure was normal. 13. The eyelid speculum was removed, antibiotic ointment was applied to the conjunctival sac, and the operated eye was patched with gauze. Intraoperative events and management: none. Patient's general condition at end of surgery: good. Date: January 22, 14:00.

Discharge Summary Admission time: January 22, 08:19 Discharge time: January 23, 10:47 Admission status (including main symptoms and signs): Admitted for more than 5 months after right-eye vitrectomy with silicone oil injection. Right eye: counting fingers at front of eye, best-corrected visual acuity 0.05; no obvious abnormalities of the external eye; conjunctiva not congested; cornea clear; anterior chamber clear; pupil round; iris pattern clear; lens opaque; silicone oil filling the vitreous cavity with partial emulsification; optic disc with clear margins, pale pink; retina attached, with scattered extensive laser spots; macular edema; NCT: 16 mmHg. Left eye: uncorrected visual acuity 0.4, best-corrected visual acuity 0.6; no obvious abnormalities of the external eye; conjunctiva not congested; cornea clear; anterior chamber clear; pupil round; iris pattern clear; mild lens opacity; punctate opacities in the vitreous cavity; optic disc with clear margins, pale pink; retina attached, with extensive scattered laser spots; NCT: 15 mmHg. Admission diagnosis: 1. Silicone oil eye, right; 2. Complicated cataract, both eyes; 3. Diabetic retinopathy, both eyes; 4. Diabetes; 5. Hypertension. Laboratory results (including main findings on admission and discharge and dates) January 23, HbA1c (high-pressure liquid chromatography) (blood): 7.30% ↑ January 22, hepatitis B panel (blood): HBsAg 0.00(-) IU/mL, Anti-HBc 10.35(+) S/CO ↑, HBeAg 0.29(-) S/CO, Anti-HBe 0.03(+) S/CO ↓, Anti-HBs 555.64(+) mIU/ml ↑, pre-S1 antigen negative, Anti-HBc IgM 0.10(-) S/CO. January 22, Anti-HCV (blood): 0.08(-) S/CO. January 22, glycated albumin (blood): 16.03% ↑ January 22, lipid profile (blood): apolipoprotein A1 0.88 g/L ↓, apolipoprotein B 1.44 g/L ↑, triglycerides 4.94 mmol/L ↑, total cholesterol 6.09 mmol/L ↑, HDL-C 0.94 mmol/L ↓, LDL-C 4.54 mmol/L ↑, lipoprotein(a) 165.0 mg/L, apolipoprotein E 76.00 mg/L ↑. January 22, free fatty acids (blood): 0.60 mmol/L. January 22, homocysteine (blood): 16.70 μmol/L ↑. January 22, complete blood count (5-part) (blood): basophils 0.04 × 10⁹/L (0.50%), eosinophils 0.10 × 10⁹/L (1.20%), hematocrit 49.0%, hemoglobin 170.0 g/L, lymphocytes 2.00 × 10⁹/L (24.80%), MCH 30.5 pg, MCHC 347.0 g/L, MCV 87.8 fL, monocytes 0.44 × 10⁹/L (5.50%), MPV 10.1 fL, neutrophils 5.48 × 10⁹/L (68.00%), large platelet ratio 26.5%, plateletcrit 0.170%, PDW 12.3%, platelets 169 × 10⁹/L, RBC 5.58 × 10¹²/L, RDW-SD 39.80 fL, WBC 8.06 × 10⁹/L. January 22, emergency biochemistry (blood): GGT 82.0 U/L ↑, CK 372.00 U/L ↑, LDH 502.0 U/L, ALT 96.0 U/L ↑, uric acid 383.3 μmol/L, ALP 80.00 U/L, glucose 8.90 mmol/L ↑, AST 48.0 U/L, BUN 4.28 mmol/L, total bilirubin 19.1 μmol/L, total protein 76.2 g/L, creatinine 73.6 μmol/L, albumin 42.80 g/L, A/G ratio 1.28 ↓, globulin 33.40 g/L ↑. January 22, antithrombin III activity (blood): 77.20%. January 22, FDP (blood): 2.20 mg/L. January 22, coagulation panel (blood): PT 12.80 sec, INR 1.1, APTT 29.10 sec, fibrinogen 2.09 g/L, TT 17.5 sec. Special examinations (including X-ray, ECG, endoscopy, isotope scans, etc., and dates) January 22: B-ultrasound: right eye filled with silicone oil, no retinal or choroidal detachment. OCT: macular edema with increased thickness in the right eye. Corneal endothelial count: right eye 2898 cells/mm². Treatment course (including surgery and dates) After admission, preoperative examinations were completed. On January 22, under retrobulbar block anesthesia, the patient underwent right-eye phacoemulsification, intraocular lens implantation, and silicone oil removal. Intraoperative diagnosis: silicone oil eye, right; complicated cataract, right; diabetic retinopathy, right. The procedure was uneventful. He returned to the ward and was given methylprednisolone for anti-inflammation, furosemide for edema reduction, and hemostatic agents. Pathological diagnosis: none. Discharge diagnosis: 1. Silicone oil eye, right; 2. Complicated cataract, both eyes; 3. Diabetic retinopathy, both eyes; 4. Diabetes; 5. Hypertension. Discharge status (including main symptoms and signs): On the first postoperative day, the patient was in good general condition with no subjective discomfort. Ophthalmic examination: operated eye visual acuity counting fingers at front of eye; mild eyelid swelling; conjunctival congestion; corneal edema with Descemet’s folds; limbal sutures in place; Tyndall effect (+); pupil round and pharmacologically dilated with a small amount of flocculent exudate at the margin; intraocular lens in position; vitreous cavity view unclear but retina appeared attached with scattered laser spots. NCT: 10 mmHg. Discharge instructions: 1. Medications for the operated eye: compound tropicamide twice daily (morning and bedtime); tobramycin-dexamethasone eye drops every hour for three consecutive days, then follow-up; levofloxacin four times daily. 2. Rest adequately, avoid straining, constipation, heavy physical labor or any activity that increases abdominal or intraocular pressure; avoid excessive fatigue of the operated eye; avoid trauma; attend regular follow-up visits.

After the surgery, the patient reported that his right-eye vision was zero.