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Abstract: The patient in this case is a relatively young male, due to trauma resulting in pain and bleeding in the left eye, and pain and discomfort in many parts of the body, so he came to the clinic, according to the results of the specialist examination, was admitted to the hospital for treatment with corneal grapevine swelling, according to the patient’s condition was treated with left eye bulb removal with prosthetic table implantation, postoperative recovery is good, after 8 days of hospitalization was discharged, agreed to his home medication treatment.
Basic information】Male, 39 years old
Type of disease】Corneal staphyloma
Hospital】The First Affiliated Hospital of Xi’an Jiaotong University
Date of Consultation】January 2022
Treatment plan】Surgical treatment (left eyeball removal, prosthetic table implantation) + injectable medication (cefuroxime sodium for injection, flurbiprofen ester injection) + topical medication (levofloxacin hydrochloride eye drops, diclofenac sodium eye drops, tobramycin dexamethasone eye drops, sodium vitrate eye drops)
Treatment Period】Hospitalization for 8 days, review after 1 month
Effectiveness of treatment】The pain in the left eye and the whole body was relieved, and no postoperative complications occurred.
I. Initial consultation
The patient is a 39-year-old male. He reported that he was injured in his left eye, head, face and whole body 2 days ago. He was diagnosed as having a ruptured left eye and was scheduled for surgery (details unknown). The patient refused to leave the hospital on his own. However, the discomfort worsened, so he came to our hospital today. The outpatient clinic performed a specialist examination, which showed that the visual acuity of the right eye was 3.4, the left eye had no light perception, the IOP on finger test of the left eye was T-1, the tear ducts of both eyes were flushed freely, both nystagmus, the right eye was not congested, the cornea was clear, the pupil was normal, the lens was absent and the vitreous was cloudy; the left eye was congested, the corneal grapevine was swollen, and some of the eye contents were seen to be dislodged and embedded. So the outpatient clinic was admitted to the hospital for treatment of corneal grapheme.
II. Treatment history
The patient was admitted to the hospital and an orbital CT examination was completed, which showed that the lens of the left eye was unclear, patchy high density was seen in the eye, and the fatty interstitial space around the eye was blurred, suggesting the presence of hemorrhage in the left eye. Combined with the results of the left orbital examination, it was considered appropriate to perform a left orbital extraction with prosthetic table implantation, and after communication with the patient and his family, treatment was actively carried out. Preoperative blood, urine, liver and kidney function tests were completed, and no contraindications to surgery were identified, so left eye removal with prosthesis implantation was performed. After the operation, the patient was given cefuroxime sodium for injection to fight infection and flurbiprofen ester injection for analgesia, and the patient’s vital signs were closely monitored. The patient was discharged after 8 days of hospitalization and was instructed to continue using levofloxacin hydrochloride eye drops, diclofenac sodium eye drops, tobramycin dexamethasone eye drops, and vitreous acid sodium eye drops after discharge.
III. Treatment effect
The patient had pain and bleeding in the left eye, and pain and discomfort in many parts of the body before treatment. After admission and surgical treatment, the patient’s vital signs continued to be stable without nausea and vomiting, except for a slight swelling and pain in the left eye. On the eighth day of hospitalization, the patient was in good general condition, with no headache, dizziness, or generalized pain. Ophthalmologic examination indicated that the left eyelid was mildly swollen, the conjunctiva was congested and edematous, and there was no secretion or oozing blood, and the patient recovered well after surgery.
IV. Precautions
After the surgery, the patient’s ocular discomfort subsided, and I was happy for the patient to see that the prosthetic eye was very beautiful and did not affect her appearance, and she was relieved of her psychological burden. I also told the patient that although he recovered well after surgery and could be discharged from the hospital, he still needed to pay close attention to his right eye and should seek medical consultation if he had symptoms such as loss of vision and pain in his right eye; he should maintain his positive and optimistic psychological state and accept his new self now; he also told his family that the furnishings at home should be fixed and should not be moved at will so that the patient would not accidentally trip over them. In addition, the patient’s family members should be instructed that the furnishings in the home should be fixed and should not be moved around to avoid the patient tripping.
V. Personal insight
The patient in this case came to the hospital for treatment at the first time after the injury, but because he was resistant to surgical treatment, he did not communicate with the doctor and came to the hospital only when his symptoms worsened, and he was also resistant to surgery at the early stage of treatment. For such patients, in addition to treating the patient’s physical injuries, it is also necessary to pay attention to the patient’s psychological problems, which can help treat the disease better.