Detailed Treatment Process
Female, 62 years old, with a history of glaucoma The following is part of the discharge summary for the first surgery Age 50 years Admission time (In time): 08/20 17:03 Discharge time (Out time): 08/28 08:00 Admission diagnosis (Cause): OU acute angle-closure glaucoma (acute attack in left eye, preclinical stage in right eye) Discharge diagnosis (Diagnosis): OU acute angle-closure glaucoma Brief history on admission (Brief History): Chief complaint: Left eye distension and pain with headache, nausea and vomiting for 1 day Present history: One day before admission, the patient developed left eye distension and pain and blurred vision without obvious cause, accompanied by headache, nausea and vomiting. The vomitus was gastric contents. There was no history of trauma. Today she presented to the emergency department of our hospital. Examination showed left eye corneal edema, shallow anterior chamber, dilated and fixed pupil, and finger-measured intraocular pressure Tn+2. She was admitted for further treatment with a provisional diagnosis of "acute angle-closure glaucoma in the left eye." In the past 2 months, she had several episodes of transient blurred vision in both eyes. She had visited another hospital, where no elevated intraocular pressure was found. Since onset, she remained conscious with normal mental status, normal appetite, and normal urination and defecation. She denied history of diabetes or hypertension; denied family history of genetic diseases; denied drug allergy history. Physical Examination Summary: T (body temperature): 36.8 ℃ P (pulse): 76 beats/min R (respiration): 18 breaths/min BP (blood pressure): 130 / 70 mmHg Vod (right eye visual acuity): 1.0, cornea lustrous, anterior chamber clear and slightly shallow, PAC about 1/3 CT, pupil round and reactive to light (+), lens relatively clear, fundus: optic disc margin clear, C/D 0.2, retina flat. NCT: 17.8 mmHg. Vos (left eye visual acuity): 0.3 (no improvement with correction), mixed conjunctival congestion, corneal edema, KP (-), anterior chamber turbid (++), PAC about 1/4 CT, pupil diameter about 4 mm and fixed, lens relatively clear, fundus: hazy, optic disc margin faintly visible and clear, C/D 0.2, retina flat. Tn+2. The above is the first discharge summary The following is the discharge summary for the second hospitalization 12 years later Age (Age): 62 years Admission time (In Time): 03-13 10:42 Discharge time (Out time): 03-17 08:00 Admission diagnosis (Cause): Uncontrolled intraocular pressure after glaucoma surgery (left eye), complicated cataract (left eye) Discharge diagnosis (Diagnosis): Uncontrolled intraocular pressure after glaucoma surgery (left eye), complicated cataract (left eye) I. Brief history on admission (Brief History) Present history: More than 13 years ago, the patient was diagnosed with "acute angle-closure glaucoma in the left eye" at our hospital outpatient clinic due to left eye distension and pain accompanied by headache and vomiting, and underwent "peripheral iridectomy in both eyes." After surgery, she had regular follow-up visits at the outpatient clinic. Recently she felt blurred vision and came to our hospital for treatment. Outpatient examination revealed lens opacity in the left eye and elevated intraocular pressure in the left eye. Pilocarpine eye drops were prescribed for the left eye Bid. She was admitted with the diagnosis of "poorly controlled intraocular pressure after anti-glaucoma surgery in the left eye and complicated cataract." Since onset, the patient has been conscious and mentally clear, with normal appetite and sleep, no special changes in urination or defecation, and no obvious weight change. Past history: The patient denied history of hypertension or diabetes; underwent breast cancer surgery in 2010; eye surgery and trauma history as in present history; denied other surgical or trauma history; denied food or drug allergy history; denied contact history with COVID-19 epidemic areas. II. Physical Examination Summary T: 36.7 ℃ | P: 68 beats/min | R: 17 breaths/min | BP: 144 / 76 mmHg Vod: 0.6, NCT: 22.4 mmHg, right eye conjunctiva without congestion, cornea transparent, anterior chamber depth acceptable, aqueous humor clear, iris peripheral iridectomy at 11 o'clock position, pupil round, diameter about 3 mm, light reflex present, lens opacity C3N2P2, mild vitreous opacity, fundus: optic disc margin faintly visible and clear, C/D about 0.5, retina flat. Vos: 0.2, NCT: 37.7 mmHg, left eye conjunctiva without congestion, cornea transparent, anterior chamber depth acceptable, aqueous humor clear, iris peripheral iridectomy at 1 o'clock position, pupil round and miotic due to medication with diameter about 1 mm, light reflex present, lens opacity C3N3P2, mild vitreous opacity, fundus: not visible. Auxiliary examinations: 【Chest X-ray】 Lung markings slightly increased, disordered and blurred; tortuous aorta; please correlate with clinical findings, history and other examinations, and follow up. 【Electrocardiogram】 Normal electrocardiogram. 【Ocular B-ultrasound】 A few to moderate dotted and clumped turbid echoes detected in the vitreous of both eyes. Posterior detachment light bands seen in both eyes. 【OCT】 No obvious abnormalities in the macular area of both eyes. III. Disease course and treatment After admission, the patient completed relevant examinations. On March 15, under local anesthesia, she underwent "left eye Phaco + IOL implantation + trabeculectomy + amniotic membrane transplantation." The operation was successful. Postoperative routine anti-inflammatory and infection-prevention treatment was given. She was discharged after approval by the supervising physician. Treatment outcome: others IV. Condition at discharge Chief complaint: The patient reported no obvious discomfort. Physical examination: Vos: pinhole visual acuity = 0.6, NCT: 33.4 mmHg, conjunctival congestion (+), corneal edema, normal anterior chamber depth, aqueous flare (+), pupil round, diameter about 3 mm, light reflex present, intraocular lens in place, mild vitreous opacity, fundus: optic disc margin faintly visible and clear, retina flat. V. Post-discharge medications and recommendations Levofloxacin eye drops, four times daily in the operated eye; gatifloxacin gel, three times daily in the operated eye; tobramycin eye drops, four times daily in the operated eye; brinzolamide eye drops, twice daily in the right eye; pilocarpine eye drops, twice daily in the right eye. Closely monitor changes in fundus condition. Return to ophthalmology clinic in one week for follow-up. Seek immediate medical attention if there is obvious discomfort. Pay attention to abnormal laboratory tests and examinations during hospitalization and arrange follow-up visits in relevant departments after discharge. The above is the discharge summary for the second hospitalization After discharge, the patient continued to experience blurred vision. During a subsequent outpatient follow-up, the pupil size was 5-6 mm. A doctor verbally told the patient that the blurred vision was due to dilated and fixed pupil.