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患者×××,男,36岁,住院号4953。河南孟县人,于92年4月9日以左眼球转动受限二年为主诉入院。患者二年前因骑摩托车跌到,当时昏迷,左眼睑严重肿胀,在当地按“脑震荡和左眼睑外伤”给以西药治疗。半月后发现左眼睑下垂、左眼球转动受限。91年4月到我院门诊求治,按“左眼动眼神经不全麻痹”给以维生素、激素、三磷酸腺苷和血管扩张剂口服,无效,故半年后入院要求手术治疗。患者否认有其它病史,否认遗传病史。体检:Vos:1.5,上睑下垂,眼球呈外斜位,瞳孔散大,光反应消失。角膜荧光法检查左眼外斜约15°,三
Patients × × ×, male, 36 years old, hospital number 4953. Meng County, Henan Province, on April 9, 92 to the left eye rotation restricted two years as the main complaint hospitalization. Patient fell to a motorcycle two years ago, was unconscious, severe swelling of the left eyelid, according to the local “concussion and left eyelid trauma” to Western medicine treatment. Half a month later found the left eyelid ptosis, left eye rotation limited. 91 years to our hospital for treatment in April 91, according to “left eye ophthalmoplegia paralysis” to give vitamins, hormones, adenosine triphosphate and vasodilator oral, invalid, so six months after admission to the hospital for surgery. Patients denied having other medical history, denied genetic history. Physical examination: Vos: 1.5, ptosis, eye was oblique outside, mydriasis, light reaction disappeared. Corneal fluoroscopy left oblique outside about 15 °, three