這是一個八十歲男性，雙眼曾接受青光眼手術( Trabeculectomy OU )，一眼於半年前於台北市某大教學醫院接受白內障手術，如圖所示；術後至今視力已無光感，理學檢查如下並請參閱圖示：
ECCE with long clear cornea incision and stitch exposure in the fellow eye, single eye with total cupping in the fellow eye, decentrated IOL with severe capsular fibrosis, IOL haptic half in half out is highly suspected
Fixed small pupil with 360 degree synechia, a large filtering bleb over 12 o’clock position, shallow chamber, not detectable fundus condition,
現在病人躺臥在手術室的顯微鏡下準備接受另外一眼白內障手術，如圖所示：
How to approach this case? 請各位大哥大姐們說說您的看法。
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COMMENT: Arrange Flash VEP , If VA=NLP , I do not operate this p't. If I wanna operate this case, I will initially IV Mannitol to reduce Vitreous pressure then Op (some operator PPV a little , but I don't suggest it because it will result in retina break.?) Temporal Phaco + iris retractor + Dye 是首選, S/P Trabeculectomy 再開 Phaco ECCE , the incidence of PC tear sometimes is high . If VL, Vitreous 一定要吃乾淨 ,否則Prognosis 就像 previous OP eye 一樣Poor
COMMENT: Challenging points: 1. single eye: take good care, pre-OP diclophenac sol. for 2 days 2. small pupil: Micro-scissor pupiloplasty Personally, I don't like to use iris retractor or hook to dilate the pupil. It is not predictable and not reliable to restore the pupil function. 3. shallow AC and poor cornea endothelial condition: Transe pars plana deep puncture or vitrectomy is my favorite way to deepen the anterior chamber. Mannitl IV drip will take the risk of heart or other disorder in the elderly. The AC is not deep enough to perform phaco safly only by using mannitl IV drip. 4. Any kind of dye is usful to perform CCCC. I will not use it in this case.
COMMENT: Anterior Vitreous Tapping to Manage Positive Vitreous Pressure during Triple Procedures .Anun Vongthongsri, MD There are many potential risks to pars plana anterior vitreous tapping, including vitreous hemorrhage, retinal tearing, RD, endophthalmitis, macular edema, macular pucker, and choroidal hemorrhage. The surgeon should also be more cautious when the operated eye is highly inflamed. A further randomized study and long-term follow up will be necessary to determine the long-term efficacy and safety of this technique.
COMMENT: You are exactally right. I agree with you. 想像與臨床常有一段距離 我不是Retinal Man 碰觸後節是大家認為的禁忌 但是就Phaco surgeron來說 Anterior vitrectomy and Vitreous tappping是必須熟練了解而不生畏懼 Risk 兩害取其輕是我的取決目標 Posterior approach risk factors:vitreous hemorrhage, retinal tearing, RD, endophthalmitis, macular edema, macular pucker, and choroidal hemorrhage 目前我只碰到trace vitreous hemorrhage (knocking the wood) 似乎沒有想像的可怕 況且mannital效果有限 如打的不夠快效果更差 打的夠快有可能老人家生命有危險 所以我目前不再使用mannitalIV drip 即使是Angle closure glaucoma acute attack 我盡量使用AC tapping 如果情況適合 直接Vitreous tapping or vitrectomy and phacoemulsification 或許你一定認為太魯莽 同樣的Risk 兩害取其輕是我的取決目標 與其等到下次看到病人360 degree synechia 倒不如先把前房擴大 想像與臨床常有一段距離 臨床結果告訴我 如果是我的父母 我也會如此 想想多年前的topical......我在台上被指者鼻子被罵的臭頭....當時我只有一句話.... When something is new, they say it is dangerous and impossible. When something is true, they always say I have been done this for a long time. 或許是錯的 或許是對的 臨床與時間會證明的 當然小心謹慎是上策 兩害取其輕是我的取決目標 謝謝您的回應與參與 相信這也是大家的問題
COMMENT: Vongthongsri MD 的Report 其實Very Good,那段話是Vongthongsri 那篇２００５文章最後的警語. As My experience,打Mannitol IVD 碰到最大的side effect 是p't 尿急,影響手術,生命危險?倒是不曾Face. 不知大師可否再分享Anterior Vitreous Vitrectomy to Manage shallow AC Phaco case的Video.以供小弟增進功力
COMMENT: Just a moment. Let me prepare the digital video file.
COMMENT: 很抱歉一直沒把VT video放上,因為eye ball penetration and bleeding 覺得有一點血腥,一般人看到可能不太舒服,以後有機會在學會課程裡再討論,謝謝您不時的回應. -----