2 眼科学报, 2018, 33(1) ykxb.amegroups.com 眼眼压 28 mmhg(1 mmhg=0.133 kpa), 左眼眼压 17 mmhg 右眼结膜充血, 鼻侧纤维血管膜长入角膜约 2 mm, 尖端指向瞳孔, 角膜雾状水肿, 前房无晶状体深,Tyn(+), 虹膜震颤, 纹理

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1 眼科学报 Yan Ke Xue ao 2018, 33(1) ykxb.amegroups.com 1 doi: /j.issn View this article at: 中山眼科中心病例挑战专栏继发性青光眼术中发生暴发性脉络膜上腔出血 1 例李晓莉 1,2, 张良 1 1, 孟倩丽 (1. 广东省人民医院眼科, 广东省眼病防治研究所, 广东省医学科学院, 广州 ; 2. 汕头大学医学院, 广东汕头 ) [ 摘要 ] 暴发性脉络膜上腔出血 (subchoroidal expulsive hemorrhage,seh) 是内眼手术中罕见且严重的并发症, 广东省人民医院眼科收治 1 名因晶状体完全脱位继发青光眼的女性患者,73 岁, 其手术过程中发生 SEH, 现报告如下通过回顾病例, 讨论及分析 SEH 的原因危险因素及治疗 [ 关键词 ] 暴发性脉络膜上腔出血 ; 继发青光眼 ; 晶体脱位 Subchoroidal expulsive hemorrhage in secondary glaucoma: case report LI Xiaoli 1,2, ZHNG Liang 1, MENG Qianli 1 (1. Department of Ophthalmology, Guangdong General Hospital, Guangdong Eye Institute, Guangdong cademy of Medical Sciences, Guangzhou ; 2. College of Medical, Shantou University, Shantou Guangdong , China) bstract Keywords Subchoroidal expulsive hemorrhage (SEH) is one of the rarest and worst complications of intraocular surgery. We treated one patient with secondary glaucoma due to complete dislocation of the lens, who developed SEH during the surgery. In this case report, the causes, risk factors and treatment of subchoroidal expulsive were discussed and analyzed by reviewing the case. subchoroidal expulsive hemorrhage; secondary glaucoma; lens dislocation 暴发性脉络膜上腔出血 (subchoroidal expulsive hemorrhage,seh) 是内眼手术中罕见且严重的并发症, 广东省人民医院眼科收治 1 名因晶状体完全脱位继发青光眼的患者, 术中发生 SEH, 现报告如下 1 临床资料患者, 女性,73 岁, 因右眼外伤后视力下降 30 年, 突发眼红痛 4 d 于 2017 年 5 月 23 日入院患者 30 余年前因农作时被木柴打伤右眼, 视力明显下降, 当时未诊治 4 d 前突发右眼眼红眼痛, 遂到当地医院就诊, 予妥布霉素地塞米松滴眼液噻吗心安滴眼液及甘露醇治疗, 症状无缓解转来广东省人民医院患者否认既往糖尿病高血压病冠心病病史眼部体查 : 右眼视力, 光感 / 定位准, 红绿可辨 ; 左眼视力 0.1, 矫正至 0.4 右收稿日期 (Date of reception): 通信作者 (Corresponding author): 孟倩丽, mengqly@163.com

2 2 眼科学报, 2018, 33(1) ykxb.amegroups.com 眼眼压 28 mmhg(1 mmhg=0.133 kpa), 左眼眼压 17 mmhg 右眼结膜充血, 鼻侧纤维血管膜长入角膜约 2 mm, 尖端指向瞳孔, 角膜雾状水肿, 前房无晶状体深,Tyn(+), 虹膜震颤, 纹理窥不清, 瞳孔 4 mm 4 mm, 对光反射 ( ), 晶状体缺如, 眼底窥不清左眼角膜透明, 前房中深, 瞳孔 3 mm 3 mm, 对光反射存在, 晶状体浑浊 C2N3P1, 眼底除后极部散在玻璃膜疣外, 未见明显异常辅助检查 : 眼部超示右眼玻璃体混浊, 晶状体完全脱位于视乳头上方 ( 图 1) 光学相干断层扫描 (optical coherence tomography,oct) 示左眼黄斑区未见明显异常诊断 :1) 右眼继发性青光眼 ;2) 右眼晶状体完全脱位 ;3) 右眼翼状胬肉 ; 4) 左眼老年性白内障 ;5) 左眼屈光不正患者入院予全身及局部激素抗炎局部降眼压 ( 布林佐胺滴眼液酒石酸溴莫尼定滴眼液噻吗心安滴眼液 ) 保护角膜预防感染等治疗入院第 3 天时在球后睫状神经阻滞麻醉下行右眼玻璃体切除 + 晶状体咬切术手术当天术前右眼眼压 28 mmhg, 视力为手动 / 眼前, 角膜水肿较前缓解, 余眼部体查大致同前术中见玻璃体絮状混浊, 晶状体完全脱位于视乳头上方切除混浊玻璃体, 玻切头咬切晶状体皮质, 见棕黄色晶状体核, 置晶状体核于前房, 做上方角膜缘切口挽出晶状体核挽核瞬间患者出现烦躁不安, 诉眼部胀痛, 手术显微镜下见瞳孔区红光反射消失, 前房变浅, 上方虹膜从角膜缘切口脱出玻璃体溢出, 眼底见鼻侧及颞侧脉络膜棕红色球形隆起, 对吻面积大, 窥不清眼底视乳头及黄斑区结构 ( 图 2) 考虑 SEH, 立刻关闭角膜缘切口术后予止血止痛镇静脱水等治疗, 患者诉眼痛较术中略减轻, 可忍受术后第 1 天, 患者右眼视力手动 /20 cm, 眼压 7.5 mmhg, 右眼角膜轻度水肿, 后弹力层皱褶, 房水轻混, 上方虹膜嵌顿于角膜缘切口, 前房深, 瞳孔向上移位 ( 图 3), 前置镜下隐约见眼底颞侧脉络膜隆起, 余结构窥不清眼部超示 : 右眼脉络膜上腔出血 ( 图 3) 当日在表面麻醉下行右眼虹膜还纳术术后第 2 天, 右眼视力手动 /20 cm, 眼压 7.5 mmhg, 右眼虹膜已还纳, 瞳孔近圆形, 余体查大致同前术后第 6 天, 右眼视力指数 / 眼前 ( 颞侧 ), 眼压 15.2 mmhg, 角膜水肿基本消退, 角膜后弹力层皱褶消退, 眼前段体查大致同前 ( 图 4), 眼底见颞侧和鼻侧脉络膜视网膜球形隆起, 隐约见视盘 ( 图 4) 超示 : 右眼脉络膜脱离范围较前减小, 脉络膜上腔出血较前吸收 ( 图 4C) 患者病情基本稳定, 诉无特殊不适, 予带药出院术后第 13 天复诊, 右眼视力指数 / 眼前 ( 颞侧 ), 眼压 10.9 mmhg, 角膜透明, 房水清, 玻璃体前散在虹膜色素附着 ( 图 5), 眼底见颞侧和鼻侧脉络膜视网膜球形隆起, 视盘可见 ( 图 5), 余体查大致同前术后第 27 天复诊, 右眼视力 0.01, DS/ 6.00 DC 40 矫至 , 眼压 8.2 mmhg, 右眼角膜透明, 房水清, 前房深, 瞳孔水滴样颞上移位, 对光反射迟钝 ( 图 6), 眼底后极部显露, 隐约见豹纹状视网膜改变 ( 图 6) 眼部超示 : 右眼脉络膜脱离范围较前明显减小 ( 图 6C) 图 1 术前眼部超示右眼玻璃体混浊, 晶状体完全脱位于视乳头上方 Figure 1 Preoperative ocular ultrasound showed the vitreous opacity and lens completely dislocated above the optic nerve in the right eye 图 2 术中显微镜下见鼻侧及颞侧视网膜脉络膜棕红色球形隆起, 对吻面积大, 窥不清眼底视乳头及黄斑区结构 Figure 2 Under the microscope, two brown-red spherical chorioretinal bulges from the nasal and temporal sides with a large area covered the optic disc and the macular area

继发性青光眼术中发生暴发性脉络膜上腔出血 1 例李晓莉, 等 3 图 3 术后第 1 天 Figure 3 The first day after surgery ()

eye was mild edema with the folds of the corneal posterior elastic layer, part of the

ultrasound showed the suprachoroidal hemorrhage in the right eye.

眼底见颞侧和鼻侧脉络膜视网膜球形隆起, 隐约见视盘 ;(C) 超示右眼脉络膜脱离范围较前减小, 脉络膜上腔出血较前吸收 () The iris of the right

spherical chorioretinal bulges were shown in the fundus with the optic disc visible

the absorption of the suprachoroidal hemorrhage in the right eye.

眼底见颞侧和鼻侧脉络膜视网膜球形隆起变小, 视盘可见 () The corneal and aqueous humor was clear, and iris

3 继发性青光眼术中发生暴发性脉络膜上腔出血 1 例李晓莉, 等 3 图 3 术后第 1 天 Figure 3 The first day after surgery () 右眼角膜轻度水肿, 后弹力层皱褶, 上方虹膜嵌顿于角膜缘切口, 瞳孔向上移位 ;() 超示右眼脉络膜上腔出血 () The corneal of the right eye was mild edema with the folds of the corneal posterior elastic layer, part of the iris incarcerated in the corneal incision, and the pupil shifted upward; () Ocular ultrasound showed the suprachoroidal hemorrhage in the right eye. C 图 4 术后第 6 天 Figure 4 The 6th day after surgery () 右眼虹膜还纳, 瞳孔近圆形 ;() 眼底见颞侧和鼻侧脉络膜视网膜球形隆起, 隐约见视盘 ;(C) 超示右眼脉络膜脱离范围较前减小, 脉络膜上腔出血较前吸收 () The iris of the right eye returned to the anterior chamber and the pupil was nearly round; () Two brown-red spherical chorioretinal bulges were shown in the fundus with the optic disc visible vaguely; (C) Ocular ultrasound showed the reducing of choroidal detachment as well as the absorption of the suprachoroidal hemorrhage in the right eye. 图 5 术后第 13 天 Figure 5 The 13th day after surgery () 右眼角膜透明, 房水清, 玻璃体前散在虹膜色素附着 ;() 眼底见颞侧和鼻侧脉络膜视网膜球形隆起变小, 视盘可见 () The corneal and aqueous humor was clear, and iris pigment diffused in front of the vitreous; () The temporal and nasal chorioretinal bulges were smaller and the optic disc was visible in the right eye.

chamber was deep, and the pupil shifted to the temporal and upper side, like a water drop; () The choroidal detachment obviously reduced, with the optic disc and macular area visible; (C) Ocular

2 讨论脉络膜上腔出血又称驱逐性出血, 是内眼手术中 ( 暴发性 ) 或术后 ( 迟发性 ) 出现的严重并发症, 临床上较少见但破坏性极为严重 [1] 其发病机制多认为由眼内压过低, 睫状后长或后短动脉破裂或大血管支的动静脉部分破裂所致 [2-3] 其诱发因素多种, 全身危险因素包括 : 高龄高血压糖尿病动脉粥样硬化凝血功能障碍等 [4] 眼部危险因素包括 : 青光眼白内障眼内炎症

4 4 眼科学报, 2018, 33(1) ykxb.amegroups.com C 图 6 术后第 27 天 Figure 6 The 27th day after surgery () 右眼角膜透明, 房水清, 前房深, 瞳孔水滴样颞上移位 ;() 眼底见脉络膜脱离较前明显减轻, 可见视盘及黄斑区 ; (C) 超示右眼脉络膜脱离范围较前明显减小 () The corneal and aqueous humor was clear, the anterior chamber was deep, and the pupil shifted to the temporal and upper side, like a water drop; () The choroidal detachment obviously reduced, with the optic disc and macular area visible; (C) Ocular ultrasound showed the choroidal detachment obviously reduced in the right eye. 2 讨论脉络膜上腔出血又称驱逐性出血, 是内眼手术中 ( 暴发性 ) 或术后 ( 迟发性 ) 出现的严重并发症, 临床上较少见但破坏性极为严重 [1] 其发病机制多认为由眼内压过低, 睫状后长或后短动脉破裂或大血管支的动静脉部分破裂所致 [2-3] 其诱发因素多种, 全身危险因素包括 : 高龄高血压糖尿病动脉粥样硬化凝血功能障碍等 [4] 眼部危险因素包括 : 青光眼白内障眼内炎症高度近视及既往内眼手术史等 [5] 术中或术后眼压急骤降低和持续的低眼压被认为是驱逐性脉络膜上腔出血的诱因之一同时, 患者紧张术中屏气咳嗽等亦可诱发脉络膜上腔出血本例患者 73 岁高龄, 出现继发性青光眼核性晶状体挽出晶体核瞬间眼压骤降, 都是引起脉络膜上腔出血的原因术中一旦出现 SEH, 治疗关键为及时发现, 迅速关闭切口, 控制眼压, 全身及局部使用皮质类固醇激素减轻眼部炎症, 止痛剂止血剂镇静剂等酌情使用 [6] 术后应定期复查眼部超, 了解眼底出血吸收情况, 必要时可在术后 2 周左右行巩膜切开脉络膜上腔放液及玻璃体视网膜手术为避免 SEH, 应根据每位患者全身及眼部情况制定个体化治疗方案, 排除全身高危因素, 术前控制眼压, 做好宣教, 安抚患者紧张情绪, 避免术中屏气咳嗽等举止 ; 术中注意手术切口不宜过大, 避免眼压巨幅波动, 动作轻巧, 手术时间尽量缩短及时且正确的处理, 可最大程度的挽救患者视力, 提高其生活质量参考文献 1. Healey PR, Herndon L, Smiddy W. Management of suprachoroidal hemorrhage[ J]. J Glaucoma, 2007, 16(6): 张贤文, 崔兰, 黄洁成, 等. 暴发性脉络膜上腔出血治疗分析 [ J]. 中国实用眼科杂志, 2013, 31(6): ZHNG Xianwen, CUI Lan, HUNG Jiecheng, et al. Clinical analysis of the treatment of fulminant choroidal hemorrhage[ J]. Chinese Journal of Practical Ophthalmology, 2013, 31(6): 王洪军. 脉络膜上腔暴发性出血的防治探讨 [ J]. 健康必读, 2012(8): 32. WNG Hongjun. Prevention and treatment of subchoroidal expulsive hemorrhage[ J]. Gems of Health, 2012(8): Wang LC, Yang CM, Yang CH, et al. Clinical characteristics and visual outcome of non-traumatic suprachoroidal haemorrhage in Taiwan[ J]. cta Ophthalmol, 2008, 86(8): Lavinsky F, Moisseiev J, Levkovitch-Verbin H. The surgical management of massive intraoperative and postoperative suprachoroidal hemorrhage: anatomic and functional outcomes[ J]. rq ras oftalmol, 2013, 76(4):

5 继发性青光眼术中发生暴发性脉络膜上腔出血 1 例李晓莉, 等 5 6. 赵琳, 权彦龙, 王建明, 等. 内眼手术术中及术后暴发性脉络膜上腔出血的原因处理和预后 [ J]. 眼科新进展, 2016, 36(2), ZHO Lin, QUN Yanlong, WNG Jianming, et al. Reasons, treatment and prognosis of massive suprachoroidal hemorrhage in or after intraocular surgery[ J]. Recent dvances in Ophthalmology, 2016, 36(2): 本文引用 : 李晓莉, 张良, 孟倩丽. 继发性青光眼术中发生暴发性脉络膜上腔出血 1 例 [ J]. 眼科学报, 2018, 33(1): 1-5. doi: / j.issn Cite this article as: LI Xiaoli, ZHNG Liang, MENG Qianli. Subchoroidal expulsive hemorrhage in secondary glaucoma: case report[ J]. Yan Ke Xue ao, 2018, 33(1): 1-5. doi: / j.issn

戊酸雌二醇片联合宫颈注射利多卡因用于绝经后妇女取环的临床效果评价陆琴芬, 等 371 Keywords groups, no removal difficulties and failure, was statistically s

戊酸雌二醇片联合宫颈注射利多卡因用于绝经后妇女取环的临床效果评价陆琴芬, 等 371 Keywords groups, no removal difficulties and failure, was statistically s 370 临床与病理杂志 J Clin Pathol Res 2015, 35(3) http://www.lcbl.net doi: 10.3978/j.issn.2095-6959.2015.03.009 View this article at: http://dx.doi.org/10.3978/j.issn.2095-6959.2015.03.009 戊酸雌二醇片联