Osvaldo Rafael Acuna-Retinal and Optic Nerve Damage-(Argentina)

Name: Osvaldo Rafael Acuna
Sex: Male
Nationality: Argentinean
Age: 34Y
Diagnosis: 1. Retinal and Optic Nerve Damage  2. Glaucoma
Discharge Date: 2019/07/17

Before treatment:
The patient was normal at birth and at the age of 5 his parents found that his eyesight was poor. They took him to the local hospital and he was diagnosed as having "retinal optic neuropathy". After that, his visual acuity gradually decreased and seven operations were performed on both eyes in 2002. After the first operation his visual acuity was improved and maintained for about 10 years and then the visual acuity decreased again. The last operation was one year ago. Due to an increase of intraocular pressure after an implantation it was removed.The right eye implant was placed again 15 days later. At present the patient's left eye vision is completely lost, the right eye only retains a small part of the vision and color discrimination. He walks on crutches, can only see objects within 60cm, has a fear of light, tears, regular eye pain and he needs  oral pain medication.
His spirit is good, diet and sleep are normal. His urination and defecation functions are normal.

Admission PE:
Bp: 117/73mmHg, pulse rate: 76/min, breathing rate 18/min, height 191cm, weight 84kg, body temperature: 36.2 degrees. The patient had good nutrition status and normal physical development. There were no bleeding spots or yellow  stains of the skin or mucosa, a symmetrical chest, clear respiratory sounds of both lungs and no moist rales were heard. He had regular heart sounds, regular heart rhythm and no obvious murmur was heard in valves. He had a flat and soft abdomen without masses felt by touch, a normal liver and spleen.

Nervous System Examination:
The patient was alert, had good spirit, fluent speech, normal memory,  calculation and orientation. Only 2 mm was seen of the left pupil with the rest covered and it did not react to light. The right pupil was 4mm with irregular shape and reacting weakly to light. Bilateral conjunctivas were bright red. The intraocular pressure was slightly higher than normal. The color discerning ability was reduced. Fingers can be discerned at 1.5m for both eyes, he is totally blind in the left eye and has tubular visual field of the right eye. Visual field range: up, 5.5cm; down, 7.5cm; left, 9cm; right, 7.5cm. Bilateral eyesight: 0.06 (the first line) at 1.4m; 0.1 (the third line) at 1.0m. Fundus examination: right eye, light yellow, 1:3 (arteriovenous ratio), relatively thin artery, pale optic papilla, reduced macular area (1/5 of normal area); left eye, light yellow, others unseen. There was free eyeball movement, symmetrical forehead wrinkle and nasolabial fold, symmetrical teeth, tongue in the middle when sticking out and free neck movement.  There was normal muscle tone of  the 4 limbs, grade 5 muscle power and normal tendon reflexes of the 4 limbs with normal abdominal reflex. Negative sucking reflex, palm-jaw reflex, Hoffmann sign, Rossolimo sign, and Babinski sign bilaterally. Normal deep and shallow sensation with normal coordination and a negative meningeal irritation sign.

Treatment:
After the admission he received 3 nerve regeneration treatments (neural stem cells and mesenchymal stem cells) to repair his damaged retina and optic nerves, replace dead nerves and cells, nourish nerves and retina, improve body environment, regulate his immune system and improve blood circulation. This was combined with rehabilitation training.   

Post-treatment:
After 14 days treatment his visual ability got better than before. He had 20% improvement, can see objects in the 1.6m range, his vision field was enlarged and the central visual field radius was doubled. Bilateral eyesight examination after the treatment was 0.3 (the sixth line) at 1.6m. The pain in his eyes disappeared and he now didn’t fear  sunlight.

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