Manuel Ignacio Paez Moreno-Retinitis pigmentosa-Type 2 diabetes-(Venezuela)

Patient Name: Manuel Ignacio Paez Moreno
Gender: Male
Age: 51 years old
Nationality: Venezuela
Diagnosis: 1. Retinitis pigmentosa 2. Type 2 diabetes

Admission condition:
The patient was admitted with the chief complaint of "progressive vision loss for over 7 years, worsening in the past 6 months" due to retinitis pigmentosa. He has a history of diabetes and hypertension. He underwent artificial lens replacement surgery for cataracts two years ago.

Physical examination on admission:
The patient's blood pressure is 134/86 mmHg, his heart rate is 78 beats per minute. He has normal development and good nutrition. There is no cyanosis in his lips and no congestion in the throat. Clear breath sounds are heard in his both lungs without any crackles or wheezing. His heart sounds are strong, regular, and without any murmurs. His abdomen is soft and flat, and his liver and spleen are not palpable below the rib cage. There is no edema in the lower extremities.

Neurological examination:
The patient is alert and oriented, with normal calculation, memory, and orientation. The pupil size is 3mm in his both eyes, with delayed light reflex in his left eye and absent light reflex in his right eye. He could see objects within 10 centimeters with blurred vision in the left eye. Full range of his eye movements was observed without nystagmus. Fundoscopy reveals yellow-white retina, wax-yellow optic disc, grade 3 arteriosclerosis, arteriovenous ratio of 1:3, and bone-like pigment deposition in his retinal equator and surrounding areas. Facial symmetry, equal nasolabial folds, symmetric showing of teeth, and centered tongue protrusion are observed. There is normal range of motion in his neck. Muscle tone is normal in his all four limbs, with muscle strength of grade 5. Bilateral tendon reflexes are slightly decreased, and pathological reflexes are negative. Deep and superficial sensations are present, and coordination movements are normal. There are no signs of meningeal irritation.

Treatment process:
The patient was diagnosed with retinitis pigmentosa upon admission. He received treatment with mesenchymal stem cells, neural stem cells, and CAST therapy to increase the number of retinal cells, repair retinal lesions, improve retinal blood circulation, regulate immunity, and nourish the retina and optic nerve. Rehabilitation therapy was also provided.

Post-treatment:
The patient's visual function has significantly improved. Pupillary light reflex has appeared and gradually become more sensitive. He can recognize faces and perform tasks such as pouring water and using utensils independently. Using a 3-meter visual acuity chart, his naked eye visual acuity reached 4.6-4.7 (lines 9 to 10 on the chart). His blood sugar control is stable and well-maintained, with a significant reduction in the dosage of oral hypoglycemic medications.