J Cataract Refract Surg. 1998 Aug;24(8):1018-26.
A 68-year-old diabetic Pakistani presented with a 3 year history of progressive bilateral painless loss of vision. Although he was previously untreated for glaucoma, his examination revealed the following: visual acuity, finger counting in the right eye and 20/60 in the left; intraocular pressure (IOP), 41 and 31 mm Hg, respectively. Physical findings included bilateral shallow anterior chambers, minimal nuclear and cortical cataract formation, and extensive glaucomatous optic nerve cupping and atrophy worse in the right eye than in the left. Gonioscopy revealed angles narrowed to grade 1 for 360 degrees in both eyes. Visual field analysis was commensurate with the marked degree of optic nerve damage and reduced visual acuity. Bilateral laser iridotomies and a combination of topical antiglaucoma agents reduced IOP to the mid-20s in both eyes. Subsequently, the right eye had an uneventful trabeculectomy with application of intraoperative mitomycin. Postoperatively, the patient developed posterior aqueous entrapment and was managed with topical cycloplegics, aqueous suppressants, and corticosteroids. After a few weeks, a shallow anterior chamber was present centrally, a filtration bleb was noted, and IOP was 9 mm Hg. Unexpectedly, the patient returned to his native country, discontinued medications, and was lost to follow-up for 1 year. Upon his return, he presented with these findings: visual acuity, hand motion in the right eye and 20/60 in the left eye; IOP, 10 and 30 mm Hg, respectively. Physical findings in the right eye (Figure 1) included a superiorly oriented, thin-walled filtration bleb, a formed anterior chamber with multiple broad peripheral and midperipheral synechias, and a bound pupil covering a dense nuclear sclerotic cataract. The left eye had progressive glaucomatous optic nerve changes. Given the patient's history, now would you manage the glaucoma in the left eye, and what surgical methods would you plan for the right eye, assuming cataract surgery is indicated?
一名68岁的巴基斯坦糖尿病患者，有3年渐进性双侧无痛性视力丧失病史。尽管他之前未接受过青光眼治疗，但检查发现如下情况：视力，右眼仅能数指，左眼为20/60；眼压（IOP），右眼41mmHg，左眼31mmHg。体格检查发现双侧前房浅，晶状体核及皮质轻度混浊形成白内障，青光眼性视神经杯状凹陷及萎缩广泛，右眼比左眼更严重。房角镜检查显示双眼房角均狭窄至1级，360度范围。视野分析与视神经损害的严重程度及视力下降程度相符。双侧激光虹膜切开术联合局部抗青光眼药物治疗使双眼眼压降至25mmHg左右。随后，右眼顺利进行小梁切除术并术中应用丝裂霉素。术后，患者出现后房水潴留，采用局部睫状肌麻痹剂、房水生成抑制剂及皮质类固醇进行处理。几周后，中央前房变浅，可见滤过泡，眼压为9mmHg。出乎意料的是，患者返回其祖国，停止用药，失访1年。他再次就诊时，检查结果如下：视力右眼仅能看到手动，左眼为20/60；眼压分别为10mmHg和30mmHg。右眼的体格检查（图1）包括一个向上的薄壁滤过泡，一个已形成的前房，伴有多个广泛的周边及中周虹膜粘连，以及一个覆盖致密核性硬化性白内障的固定瞳孔。左眼有进行性青光眼性视神经改变。鉴于患者的病史，假设需要进行白内障手术，你现在会如何处理左眼的青光眼，以及你会为右眼计划何种手术方法？
