Abstract：
A 62-year-old woman with a history of moderate myopia, long-standing open-angle glaucoma (OAG), and Fuchs dystrophy in both eyes was referred for consultative care. She had prior trabeculectomy in 1984 and 1992 in the left and right eyes, respectively. She is 3 months post-Descemet-stripping endothelial keratoplasty (DSEK) in the left eye, now referred with uncontrolled intraocular pressure (IOP) despite maximum tolerated medical therapy. Current medical therapy for IOP consists of acetazolamide 250 mg by mouth 2 times a day, brimonidine 2 times a day in the left eye, dorzolamide 2 times a day in the left eye, and timolol 2 times a day in the left eye. The patient has a history of presumed steroid response; however, her corneal surgeon has requested that the steroid be continued for the next several months because of the recent DSEK. The IOP in the left eye has ranged from the mid-20s to mid-30s since DSEK. The right eye has consistently had pressure in the low teens and below for many years without topical antihypertensive medications. Examination revealed stable visual acuity at 20/30 and 20/40 in the right and left eyes, respectively, IOP was 12 mm Hg in the right eye and 25 mm Hg in the left eye by Goldman applanation, irregular but reactive pupils without afferent defect, and full confrontational visual fields. Slitlamp examination showed superior low avascular bleb, moderate-to-severe guttae, and posterior chamber IOL in the right eye. The left eye showed superior low diffuse bleb, clear DSEK graft, quiet chamber, superonasal iridectomy, and posterior chamber IOL with an open posterior capsule. The conjunctiva was moderately scarred but a repeat trabeculectomy or Xen Gel stent (Abbvie) appeared possible. The angles were wide open in each eye. Fundus examination was normal aside from myopic, anomalous-appearing nerves with an approximate cup-to-disc ratio of 0.90 in both eyes. Humphrey visual field showed nonspecific changes on the right and moderate nasal defect on the left eye, stable to previous examinations dating back to 2018 (Figure 1JOURNAL/jcrs/04.03/02158034-202407000-00018/figure1/v/2024-07-10T174240Z/r/image-tiff and Figure 2JOURNAL/jcrs/04.03/02158034-202407000-00018/figure2/v/2024-07-10T174240Z/r/image-tiff). Optical coherence tomography (OCT) of the retinal nerve fiber layer (RNFL) revealed moderated thinning in both eyes that was also stable to prior examinations (Figure 3JOURNAL/jcrs/04.03/02158034-202407000-00018/figure3/v/2024-07-10T174240Z/r/image-tiff). Her axial length measured 25.23 and 26.34 mm in the right and left eyes, respectively. Central corneal thickness was 553 μm in the right eye and 563 μm in the left eye before her DSEK procedure. What would be your approach to management of this patient\'s left eye, addressing the following: Rationale for your procedure of choice? Would you over-rule the corneal surgeon and stop the steroid in an attempt to obviate the need for glaucoma surgery? Does the age of onset of glaucoma affect your surgical decision making? Note that patient age at the time of trabeculectomy was 22 years. Are some procedures better suited for patients after DSEK surgery?
摘要：
一名62岁女性，有中度近视史，长期开角型青光眼（OAG），两只眼睛的Fuchs营养不良被推荐接受咨询治疗。她曾在1984年和1992年进行过左眼和右眼小梁切除术，分别。她在左眼进行Descemet剥离内皮角膜移植术（DSEK）后3个月，尽管接受了最大的耐受药物治疗，但现在仍转诊为不受控制的眼内压（IOP）。目前IOP的药物治疗包括乙酰唑胺250毫克，每天2次，溴莫尼定每天2次在左眼，多佐胺左眼每天2次,左眼每天服用两次噻吗洛尔。患者有假定的类固醇反应史；然而，由于最近的DSEK，她的角膜外科医生要求在接下来的几个月内继续使用类固醇。自DSEK以来，左眼的IOP范围从20多岁到30多岁。多年来，在没有局部抗高血压药物的情况下，右眼在青少年及以下的人群中一直承受着压力。检查显示右眼和左眼在20/30和20/40时视力稳定，分别,通过Goldman掌图，右眼IOP为12mmHg，左眼IOP为25mmHg，不规则但无传入缺陷的反应性瞳孔，和完全对抗的视野。纵火灯检查显示上低位无血管泡，中度到重度，右眼后房IOL。左眼显示上低弥漫性气泡，清除DSEK移植物，安静的房间,鼻上虹膜切除术,后房型人工晶状体后囊开放。结膜中度瘢痕，但可能重复小梁切除术或XenGel支架（Abbvie）。每只眼睛的角度都是敞开的。除了近视外，眼底检查正常，异常出现的神经，两只眼睛的杯盘比约为0.90。Humphrey视野显示左眼右侧和中度鼻缺损的非特异性变化，稳定到2018年以前的检查（图1JOURNAL/jcrs/04.03/02158034-202407000-00018/图1/v/2024-07-10T174240Z/r/image-tiff和图2JOURNAL/jcrs/04.03/02158034-202407000-00018/图2/v/4240Z-T102024视网膜神经纤维层（RNFL）的光学相干断层扫描（OCT）显示，两只眼睛的变薄程度适中，对先前的检查也很稳定（图3JOURNAL/jcrs/04.03/02158034-202407000-00018/图3/v/2024-07-10T174240Z/r/image-tiff）。她的左右眼轴长度分别为25.23和26.34毫米，分别。在进行DSEK手术之前，右眼中央角膜厚度为553μm，左眼中央角膜厚度为563μm。你对这个病人左眼的管理方法是什么，解决以下问题：您选择手术的理由？您是否会过度限制角膜外科医生并停止使用类固醇以避免青光眼手术的需要？青光眼的发病年龄会影响您的手术决策吗？请注意，小梁切除术时的患者年龄为22岁。有些手术更适合DSEK手术后的患者吗？
