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病历摘要李×,男,24岁,社员。因左眼被铁片击伤5小时,疼痛、流泪、失明,在公社卫生院包扎后,于1979年1月24日急转我院诊疗.眼部检查:右眼正常,视力1.5.左眼无光感,眼睑轻度肿胀充血,结膜混合充血,角膜混浊.前房充满新鲜血液,瞳孔看不清.角膜缘自4点钟向后有一斜形破裂,长约10毫米,创口嵌有色素膜和玻璃体,眼球变形下陷.诊断:左眼巩膜挫裂伤、前房积血.治疗经过:左眼局部消毒,于局麻下探查伤口,剪除嵌顿的玻璃体,整复色素膜、巩膜,创口间断缝合。术毕球结膜下注入庆大霉素2万单位加强的松龙0.5毫升,肌注青、链霉素,静注50%葡萄糖液40毫升加维生素 C1000毫克,口服强的松片及维生素 A、D、B、C 等,静点50%葡萄糖液500毫升加氢化可的松150毫克,红霉素1克。
Medical record Li ×, male, 24 years old, member. Because the left eye was injured by iron 5 hours, pain, tearing, blindness, dressing in commune hospitals, in January 24, 1979 emergency hospital in our hospital .Optical examination: the right eye is normal, visual acuity 1.5. Left eye No light feeling, mild eyelid swelling and congestion, conjunctival hyperemia, corneal opacity .Frontal is full of fresh blood, the pupil can not see .Because limbus from 4 o’clock backward a oblique rupture, about 10 mm, the wound embedded pigment Film and vitreous, the eyeball deformation subsidence .Diagnosis: left eye scleral contusion, anterior chamber hemorrhage .After treatment: local disinfection of the left eye, under the local anesthesia to explore the wound, cut the incarcerated vitreous, the entire repair pigment, sclera, Suture intermittent wound. Surgery, subconjunctival injection of gentamicin 20,000 units to enhance the 0.5 ml of pineal, intramuscular injection of streptomycin, intravenous 50% glucose solution 40 ml plus vitamin C1000 mg, oral prednisone tablets and vitamin A, D, B, C, etc., static point 50% glucose solution 500 ml hydrocortisone 150 mg erythromycin 1 g.