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孙×男40岁住院号317912。左眼视力减退1年,眼球突出半年。于1988年3月9日入院,1年前,偶然左眼红,当即遮盖右眼,发现左眼视物不清。近半年来,左眼发胀,视力明显减退,眼球逐渐突出,但无复视、流泪、虹视、眼痛等不适。体检无异常。左眼视力0.2,近视力0.5,眼压2.3kPa外眼正常。屈光间质透明。眼底视盘色正常,边界欠清,生理凹陷消失。黄斑中心反射消失。视网膜静脉充盈、纡曲,后极部视网膜显放射状条纹。眼球向正前方突出,眼球突出度右眼17mm,左20mm,眶距99mm。
Sun × male 40-year-old hospital number 317912. Left eye vision loss for 1 year, prominent half a year. Admitted to hospital on March 9, 1988, a year ago, occasionally left jealous, immediately cover the right eye and found the left eye is not clear. The past six months, the left eye swollen, visual acuity was significantly diminished, the eye gradually prominent, but no diplopia, tearing, rainbow, eye pain and other discomfort. No abnormal medical examination. Left eye vision 0.2, near vision 0.5, intraocular pressure 2.3kPa normal eye. Refractive interstitial transparent. Fundus disc normal color, the border is not clear, the physiological depression disappeared. Macular center reflex disappeared. Retinal vein filling, song, the posterior pole retina showed radial stripes. Eye prominent in front of the eye highlight the right eye 17mm, left 20mm, orbital distance 99mm.