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患者陈×女28岁工人住院号2005因右眼红,眼球突出,眼胀,伴有头痛1个多月入院。1个多月前,无明显诱因右眼红胀,眼球突出,伴同侧头痛。在基层医院按结膜炎治疗无效。经我科门诊检查怀疑右眼眶内炎性假瘤收入院。血压16/10.6KPa,胸腹及神经系统检查均正常,也未见其他异常。视力右0.5(矫正视力1.0),左0.4(矫正视力1.0)。左眼正常。右眼睑中度肿胀,眶周围轻度压痛。下部球结膜充血、水肿,球结膜及巩膜可见轻度血管扩张和纡曲。角膜及前房正常。瞳孔比健侧大1mm,对光反应稍迟顿。右眼视神经乳头边界清楚,色泽正常,C/D=0.3。视网膜正常,静脉略充盈。眼压右4.95KPa,左2.3KPa。房角为宽角,无粘连。右
Patient Chen × female 28-year-old worker hospital number 2005 due to the right eye red, prominent eyes, swollen eyes, accompanied by headache more than 1 month admission. More than a month ago, no obvious incentive to right eye bloating, prominence, with ipsilateral headache. In the primary hospital by conjunctivitis treatment ineffective. My department outpatient examination suspected right orbital inflammatory pseudotumor income hospital. Blood pressure 16 / 10.6KPa, chest and abdomen and nervous system tests were normal, nor other abnormalities. Right vision 0.5 (corrected visual acuity 1.0), left 0.4 (corrected visual acuity 1.0). Left eye is normal. Moderate swelling of the right eyelid, mild orbital tenderness. The lower part of the conjunctiva hyperemia, edema, conjunctival and sclera visible mild vasodilation and kyphosis. Cornea and anterior chamber normal. Pupil larger than the contralateral side 1mm, light reaction slightly later Dayton. Right optic nerve head clear boundary, normal color, C / D = 0.3. Retinal normal, slightly venous filling. Intraocular pressure right 4.95KPa, left 2.3KPa. Angle is wide angle, no adhesion. right