Detailed Treatment Process
Male, 54 years old The following are the medical records from the hospitalization period for the second surgery. Admission Record Admission Date: January 22, 08:19 History Taking Date: January 22, 08:48 Record Date: January 22, 08:48 History Provided By: Patient himself Chief Complaint: More than 5 months after right eye vitrectomy and silicone oil tamponade. History of Present Illness: More than 5 months ago, the patient underwent right eye vitrectomy + air-fluid exchange + silicone oil injection due to "right eye diabetic vitreous hemorrhage." Postoperative recovery was good. Recently, he came to our department's outpatient clinic for re-examination and was found to have "lens opacity, flat retina, and partial emulsification of silicone oil." Hospitalization for cataract surgery + silicone oil removal was recommended. He is now admitted for surgical treatment. Further history reveals that the patient has refractive error of about -2.0D and denies recent ocular trauma. The patient has a history of diabetes, with blood glucose controlled by oral medication. He has a history of hypertension, controlled by medication. In 2014, he underwent coronary artery stent placement, with good postoperative recovery. Since onset, the patient has been alert, in good spirits, with normal appetite, normal bowel and urinary function, and no change in body weight. Past History: In September last year, he underwent right eye vitrectomy + air-fluid exchange + silicone oil injection at our hospital. Specialist Examination Right eye: Counting fingers in front of the eye, corrected visual acuity 0.05, no obvious abnormalities in the external eye, conjunctiva without congestion, cornea clear, anterior chamber clear, pupil round, iris pattern clear, lens opaque, vitreous cavity filled with silicone oil with partial emulsification, fundus optic disc margin clear, color pale red, retina flat, with scattered extensive laser spots visible, macular edema, NCT: 16 mmHg. Left eye: 0.4, corrected visual acuity 0.6, no obvious abnormalities in the external eye, conjunctiva without congestion, cornea clear, anterior chamber clear, pupil round, iris pattern clear, lens with mild opacity, punctate opacities in the vitreous cavity, fundus optic disc margin clear, color pale red, retina flat, with extensive scattered laser spots, NCT: 15 mmHg. Auxiliary Examinations January 22: B-ultrasound: Right eye silicone oil tamponade, no RD or ChD seen. OCT: Right eye macular edema with thickening. Preliminary Diagnosis: 1. Right eye silicone oil eye; 2. Bilateral complicated cataract; 3. Bilateral diabetic retinopathy; 4. Diabetes; 5. Hypertension Date: January 22
Surgical Record Admission Date: January 22 Surgery Date: January 22 Surgery Start and End Time: January 22, 12:35 to January 22, 13:45 Preoperative Diagnosis: Right eye silicone oil eye; bilateral complicated cataract; bilateral diabetic retinopathy; diabetes; hypertension Surgery Performed: Right eye phacoemulsification + intraocular lens implantation Intraoperative Diagnosis: Right eye complicated cataract; right eye silicone oil eye; bilateral diabetic retinopathy Anesthesia Method: Local anesthesia Incision Method: Puncture Main Surgical Findings: Right eye lens opacity, silicone oil tamponade, silicone oil emulsification, flat retina, macular edema. Surgical Procedure: 1. Patient placed in supine position, routine ophthalmic disinfection and draping; lidocaine retrobulbar nerve block anesthesia, eyelid speculum placed; 2. 15-degree puncture knife made side incision at 3:00 limbus, 3.0 mm puncture knife made clear corneal incision at 11:30-12:00 limbus; 3. Viscoelastic needle slowly inserted into anterior chamber from edge of 3 mm corneal incision, injecting viscoelastic while maintaining anterior chamber; 4. Capsulorhexis forceps inserted through 3 mm corneal incision into anterior chamber to perform continuous curvilinear capsulorhexis of anterior capsule, diameter about 5 mm; 5. Small amount of irrigation fluid injected with rounded needle along 3 mm corneal incision into junction of lens cortex and capsule for hydrodissection; 6. Nuclear splitter inserted through side incision, phacoemulsification tip inserted through 3 mm corneal incision to emulsify and aspirate opaque lens nucleus and part of cortex. Phaco power: 10%, duration: 1'04''; switched to aspiration device to remove residual cortex, posterior capsule polished; 7. Appropriate amount of viscoelastic reinjected into capsular bag and anterior chamber, foldable intraocular lens implanted into capsular bag through 3 mm corneal incision using intraocular lens injector; intraocular lens manipulator adjusted the intraocular lens to centered and stable position; 8. Aspiration device inserted through 3 mm incision into anterior chamber to remove viscoelastic from capsular bag and anterior chamber before withdrawal; 9. 10-0 suture closed 12 o'clock corneal incision; incision checked for watertight seal, anterior chamber depth appropriate, intraocular lens in capsular bag in correct position; 10. 25G puncture knife used 3.8 mm from limbus to pre-place infusion port into vitreous cavity at 7:00; 23G puncture knife 3.5 mm from limbus created oil removal port at 11 o'clock; 11. Oil removal tip connected to negative suction, silicone oil aspirated at 600 mmHg suction; 12. 8-0 suture closed 11 o'clock scleral incision; infusion cannula removed and that incision sutured; patient's vision checked as HM in front of eye; intraocular pressure Tn; 13. Eyelid speculum removed, antibiotic ointment applied to conjunctival sac, operative eye covered 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 (In Time): January 22, 08:19 Discharge Time (Out Time): January 23, 10:47 Admission Condition (including main symptoms and signs): Admitted due to more than 5 months after right eye vitrectomy and silicone oil tamponade. Right eye: Counting fingers in front of the eye, corrected visual acuity 0.05, no obvious abnormalities in external eye, conjunctiva without congestion, cornea clear, anterior chamber clear, pupil round, iris pattern clear, lens opaque, vitreous cavity filled with silicone oil with partial emulsification, fundus optic disc margin clear, color pale red, retina flat, scattered extensive laser spots visible, macular edema, NCT: 16 mmHg. Left eye: 0.4, corrected visual acuity 0.6, no obvious abnormalities in external eye, conjunctiva without congestion, cornea clear, anterior chamber clear, pupil round, iris pattern clear, lens mild opacity, punctate opacities in vitreous cavity, fundus optic disc margin clear, color pale red, retina flat, extensive scattered laser spots, NCT: 15 mmHg. Admission Diagnosis: 1. Right eye silicone oil eye; 2. Bilateral complicated cataract; 3. Bilateral diabetic retinopathy; 4. Diabetes; 5. Hypertension Laboratory Results (including main admission and discharge findings and dates) January 23, Glycated Hemoglobin Determination (High Performance Liquid Chromatography) (Sample: Blood): High performance liquid analysis - glycated hemoglobin 7.30% ↑ January 22, Hepatitis B Quantitation (Sample: Blood): Hepatitis B surface antigen (HBsAg) 0.00 (-) IU/mL, Hepatitis B core antibody (Anti-HBc) 10.35 (+) S/CO ↑, Hepatitis B e antigen (HBeAg) 0.29 (-) S/CO, Hepatitis B e antibody (Anti-HBe) 0.03 (+) S/CO ↓, Hepatitis B surface antibody (Anti-HBs) 555.64 (+) mIU/ml ↑, Pre-S1 antigen negative, Hepatitis B core IgM antibody (Anti-HBcIgM) 0.10 (-) S/CO January 22, Hepatitis C Antibody Determination (Anti-HCV) (Sample: Blood): Hepatitis C antibody (Anti-HCV) 0.08 (-) S/CO January 22, Serum Fructosamine Determination (Glycated Albumin Determination) (Sample: Blood): Glycated albumin (GA) 16.03% ↑ January 22, Blood Lipid Routine (Sample: Blood): Apolipoprotein A1 0.88 g/L ↓, Apolipoprotein B 1.44 g/L ↑, Triglycerides 4.94 mmol/L ↑, Total Cholesterol 6.09 mmol/L ↑, High Density Lipoprotein Cholesterol 0.94 mmol/L ↓, Low Density Lipoprotein Cholesterol 4.54 mmol/L ↑, Lipoprotein a 165.0 mg/L, Apolipoprotein E 76.00 mg/L ↑ January 22, Blood Free Fatty Acid Determination (Sample: Blood): Free fatty acid (FFA) 0.60 mmol/L January 22, Blood Homocysteine Determination (Sample: Blood): Homocysteine 16.70 umol/L ↑ January 22, Blood Cell Analysis (Five Classifications) (Sample: Blood): Basophils 0.04 * 10⁹/L, Basophil % 0.50%, Eosinophils 0.10 * 10⁹/L, Eosinophil % 1.20%, Hematocrit 49.0%, Hemoglobin 170.0 g/L, Lymphocytes # 2.00 * 10⁹/L, Lymphocyte % 24.80%, Mean HGB Content 30.5 PG, Mean HGB Concentration 347.0 g/L, Mean Red Blood Cell Volume 87.8 FL, Monocytes # 0.44 * 10⁹/L, Monocyte % 5.50%, Mean Platelet Volume 10.1 FL, Neutrophils # 5.48 * 10⁹/L, Neutrophil % 68.00%, Large Platelet Ratio 26.5%, Plateletcrit 0.170%, Platelet Distribution Width 12.3%, Platelet Count 169 * 10⁹/L, Red Blood Cells 5.58 * 10¹²/L, Red Blood Cell Distribution Width (SD) 39.80 FL, White Blood Cell Count 8.06 * 10⁹/L January 22, Emergency Biochemistry (Sample: Blood): γ-Glutamyl Transferase 82.0 U/L ↑, Creatine Kinase 372.00 U/L ↑, Lactate Dehydrogenase 502.0 U/L, Alanine Aminotransferase 96.0 U/L ↑, Uric Acid 383.3 umol/L, Alkaline Phosphatase 80.00 U/L, Blood Glucose 8.90 mmol/L ↑, Aspartate Aminotransferase 48.0 U/L, Urea Nitrogen 4.28 mmol/L, Total Bilirubin 19.1 umol/L, Total Protein 76.2 g/L, Creatinine 73.6 umol/L, Albumin 42.80 g/L, Albumin/Globulin Ratio 1.28 ↓, Globulin 33.40 g/L ↑; January 22, Plasma Antithrombin Activity Determination (AT-A) (Instrument Method) (Sample: Blood): Plasma antithrombin activity determination (ATIII) 77.20% January 22, Fibrin (Original) Degradation Product Determination (FDP) (Sample: Blood): Fibrinogen degradation products 2.20 mg/L; January 22, Coagulation Routine (Anticoagulant) (Sample: Blood): Prothrombin Time 12.80 Sec, International Normalized Ratio 1.1, Partial Thromboplastin Time 29.10 Sec, Fibrinogen Concentration 2.09 g/L, Thrombin Time 17.5 Sec; Special Examinations (including X-ray, electrocardiogram, endoscopy, isotope, etc., and dates) January 22: B-ultrasound: Right eye silicone oil tamponade, no RD or ChD. OCT: Right eye macular edema with thickening. Corneal endothelial count right eye 2898 cells/mm². Treatment Course (including surgical details and dates) After admission, relevant preoperative examinations were completed. On January 22, under nerve block anesthesia, right eye phacoemulsification + intraocular lens implantation + silicone oil removal was performed. Intraoperative diagnosis: right eye silicone oil eye; right eye complicated cataract; right eye diabetic retinopathy. Surgery went smoothly, patient returned to ward safely, given methylprednisolone for anti-inflammation, furosemide for detumescence, and hemostatic treatment. Pathological Diagnosis: None Discharge Diagnosis: 1. Right eye silicone oil eye; 2. Bilateral complicated cataract; 3. Bilateral diabetic retinopathy; 4. Diabetes; 5. Hypertension Discharge Condition (including main symptoms and signs): On the first day after surgery, the patient's general condition was satisfactory, with no discomfort complaints. Ophthalmic examination: Operated eye visual acuity: FC in front of the eye, mild eyelid edema, conjunctival congestion, corneal edema, Descemet's membrane folds, limbal sutures in place, Tyn (+), pupil round and medically dilated, small amount of flocculent exudate at pupil margin, intraocular lens in place, vitreous cavity unclear, faintly visible flat retina with scattered laser spots. NCT: 10 mmHg. Discharge Orders: 1. Medications for operated eye: Compound tropicamide twice every morning and twice before bedtime; tobramycin dexamethasone eye drops every hour for three consecutive days followed by re-examination, levofloxacin four times daily. 2. Rest well, avoid breath-holding, constipation, heavy physical labor and other actions that increase abdominal and intraocular pressure, avoid excessive fatigue of the operated eye, avoid trauma, and attend regular follow-ups.
After the surgery, the patient reported that his right eye vision was zero.