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李××女57岁住院号302822 就诊日1988年4月12日。主诉:右眼视力障碍二年。现病史:自1986年起右眼视力逐渐下降,无眼胀疼及头疼,近半年来,右眼仅能辨光。既往史无特殊。检查:视力右光感,定位确,左0.9,右眼结膜充血(一),角膜透明,垂直径11mm、水平径12mm;前房深度正常,瞳孔4mm、光反应正常,晶体呈均一灰白混浊;眼底不可窥;眼压Tn。左眼晶状体皮质部分混浊,余无异常所见。诊断:老年性白内障右成熟期,左初发期。治疗经过:4月18日在手术显微镜下行右眼白内障现代囊外摘除术。做以穹窿都为基底
Lee × × Female 57 years old Hospital No. 302822 Treatment Date April 12, 1988. Chief complaint: Right eye dysfunction for two years. Current history: since 1986, the visual acuity decreased gradually, no eye pain and headache, the past six months, the right eye can only distinguish light. No previous history. Right eye light perception, right positioning, left 0.9, right conjunctival hyperemia (a), corneal transparency, diameter 11mm, horizontal diameter 12mm; anterior chamber depth normal, pupil 4mm, light reaction was normal, the crystal was uniform gray turbidity; Eye can not glimpse; Ia Tn. Part of the left lens cortex cloudy, I found no abnormalities. Diagnosis: Right cataract right-mature, left early onset. After treatment: April 18 surgery under the right eye cataract surgery extracapsular cataract extraction. Do domes are based on the dome