Detailed Treatment Process
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Female, 62 years old, with a history of glaucoma. The following is an excerpt from the discharge summary of the first surgery. Age: 50 years Admission time: 08/20 17:03 Discharge time: 08/28 08:00 Admission diagnosis: OU acute angle-closure glaucoma (acute attack in left eye, preclinical stage in right eye) Discharge diagnosis: OU acute angle-closure glaucoma Admission brief history: Chief complaint: Left eye distension and pain with headache, nausea, and vomiting for 1 day. Present illness: One day before admission, the patient developed left eye distension and pain with blurred vision, accompanied by headache, nausea, and vomiting (gastric contents), without any obvious trigger or history of trauma. She presented to the emergency department of our hospital. Examination revealed left corneal edema, shallow anterior chamber, dilated and fixed pupil, and digital intraocular pressure of Tn+2. She was admitted with a preliminary diagnosis of “acute angle-closure glaucoma in the left eye” for further treatment. Over the previous two months, she had experienced several episodes of transient blurred vision in both eyes and had sought care at another hospital, where intraocular pressure was not found to be elevated. Since onset, she had been alert and in good spirits, with normal appetite and bowel and bladder function. She denied any history of diabetes or hypertension, familial hereditary disease, or drug allergy. Physical examination summary: T: 36.8 ℃ P: 76 beats/min R: 18 breaths/min BP: 130/70 mmHg Right eye (Vod): 1.0, cornea lustrous, anterior chamber clear and slightly shallow, PAC approximately 1/3 CT, pupil round and reactive to light (+), lens relatively clear, fundus: optic disc margins clear, C/D 0.2, retina flat. NCT: 17.8 mmHg. Left eye (Vos): 0.3 (no improvement with correction), mixed conjunctival injection, corneal edema, KP (−), anterior chamber turbidity (++), PAC approximately 1/4 CT, pupil diameter approximately 4 mm and fixed, lens relatively clear, fundus: hazy, optic disc margins faintly visible and clear, C/D 0.2, retina flat. Tn+2. The above is the discharge summary from the first hospitalization. The following is the discharge summary from the second hospitalization 12 years later. Age: 62 years Admission time: 03-13 10:42 Discharge time: 03-17 08:00 Admission diagnosis: Uncontrolled intraocular pressure after glaucoma surgery (left eye), complicated cataract (left eye) Discharge diagnosis: Uncontrolled intraocular pressure after glaucoma surgery (left eye), complicated cataract (left eye) I. Admission brief history Present illness: More than 13 years earlier, the patient experienced left eye distension and pain with headache and vomiting. She was diagnosed at our hospital outpatient clinic with “acute angle-closure glaucoma in the left eye” and underwent bilateral peripheral iridotomy. She had been followed regularly in the outpatient clinic since surgery. Recently she noticed blurred vision and came to our hospital for treatment. Outpatient examination revealed lens opacity in the left eye and elevated intraocular pressure. Pilocarpine eye drops were prescribed twice daily to the left eye, and she was admitted with a diagnosis of “poorly controlled intraocular pressure after anti-glaucoma surgery in the left eye and complicated cataract.” Since onset, the patient had been alert and in good spirits, with normal appetite, sleep, and bowel and bladder function, and no significant weight change. Past history: The patient denied hypertension or diabetes. She underwent breast cancer surgery 11 years ago. Eye surgery and trauma history as described in present illness. She denied other surgical or trauma history, food or drug allergies, or contact with COVID-19 epidemic areas. II. Physical examination summary T: 36.7 ℃ | P: 68 beats/min | R: 17 breaths/min | BP: 144/76 mmHg Right eye (Vod): 0.6, NCT: 22.4 mmHg; right conjunctiva without injection, cornea transparent, anterior chamber depth adequate, aqueous humor clear, iris peripheral iridotomy at 11 o’clock, pupil round, diameter approximately 3 mm, reactive to light, lens opacity C3N2P2, mild vitreous opacity; fundus: optic disc margins faintly visible and clear, C/D approximately 0.5, retina flat. Left eye (Vos): 0.2, NCT: 37.7 mmHg; left conjunctiva without injection, cornea transparent, anterior chamber depth adequate, aqueous humor clear, iris peripheral iridotomy at 1 o’clock, pupil round and miotic (drug-induced, diameter approximately 1 mm), reactive to light, lens opacity C3N3P2, mild vitreous opacity; fundus: not visible. Auxiliary examinations: Chest X-ray: Slightly increased and disordered lung markings with blurring; tortuous aorta. Please correlate with clinical findings, history, and other examinations; follow up as needed. Electrocardiogram: Normal. Ocular B-ultrasound: Small to moderate amounts of dotted and clustered opacities in the vitreous of both eyes. Posterior vitreous detachment echoes visible in both eyes. OCT: No obvious abnormalities in the macular region of either eye. III. Hospital course and treatment After admission, relevant examinations were completed. On March 15, under local anesthesia, the patient underwent “left eye phacoemulsification + IOL implantation + trabeculectomy + amniotic membrane transplantation.” The procedure went smoothly. Postoperative anti-inflammatory and infection-prevention treatment was given routinely. She was discharged with approval from the attending physician. Treatment outcome: Other. IV. Condition at discharge Chief complaint: No significant discomfort. Examination: Left eye pinhole visual acuity 0.6, NCT 33.4 mmHg, conjunctival injection (+), corneal edema, normal anterior chamber depth, aqueous flare (+), pupil round, diameter approximately 3 mm, reactive to light, intraocular lens in place, mild vitreous opacity, fundus: optic disc margins faintly visible and clear, retina flat. V. Post-discharge medications and recommendations Levofloxacin eye drops four times daily to the operated eye; gatifloxacin gel three times daily to the operated eye; tobramycin eye drops four times daily to the operated eye; brinzolamide eye drops twice daily to the right eye; pilocarpine eye drops twice daily to the right eye. Closely monitor changes in the fundus. Return to the ophthalmology clinic in one week. Seek immediate care if significant discomfort occurs. Follow up any abnormal laboratory or examination results from hospitalization with the relevant departments after discharge. The above is the discharge summary from the second hospitalization. After discharge, the patient continued to experience blurred vision. At a subsequent outpatient visit, pupil size was measured at 5–6 mm. A doctor verbally informed the patient that the blurred vision was due to a dilated and fixed pupil.