Navarro-Traumatic Retina Damage of right eye-(Venezuela)-Update on Mar. 14, 2016

Name: Navarro Montilla Jorge Enrique                 
Sex: Male
Country: Venezuela
Age: 42 years
Diagnosis: 1. Traumatic Retina Damage of right eye 2.  Absence of left eyeball
3. Hyperlipidaemia
Date: October 23, 2014
Days Admitted to Hospital: 21days

Before treatment:
One and a half years ago (March 2013), the contre coup injury by gunshot resulted in the injury of both eyes. He had surgery and his vision of right eye has declined sharply and the left eye had no eyeball. He was diagnosed with Traumatic Retina Damage. He had Vitamins but his vision did not improve. At present, the patient's right eye is solely able to distinguish black and white color and the visual field is only limited to bitemporal area. His right eye can perceive finger in 30cm away but cannot count the number of fingers. In 50cm away, he can only perceive the shape of big objects. Since the onset of disease, he had normal diet and does not have very good sleep. He has normal urination and defecation every day. He has no family history of this disease.

Admission PE: 
Bp: 121/80mmHg; Hr: 68/min. The nutrition was normal and body figure was symmetrical. For he suffered from gunshot wound, there was scar of contre coup injury from right bitamporal to left bitamporal, and from right middle cheek to left ear's ahead. The left eyeball was absent, and other part of the body's skin was intact, with no ecchymosis, petechia or yellow stains on skin. The thorax was symmetrical. The respiratory sounds in both lungs were clear, with no obvious dry or moist rales. The heart sounds were strong and the rhythm of his heartbeat was normal, with no obvious murmur in the valves. The abdomen was flat and there was no masses under palpation. The liver and spleen were normal under palpation. The legs were not swollen. The blood cholesterol level from laboratory examination was much higher than normal.

Nervous System Examination: 
Navarro Montilla Jorge Enrique was alert and his speech was clear. His memory, orientation and calculation ability were almost normal. Patient lost his left eyeball. The diameter of right pupil was 2.5mms and the pupil presented with grey white. The right eye had slow response to light stimulus. He was able to distinguish only black and white color. His right eye remained only temporal visual field. He could see fingers from 30cm distance but he was unable to distinguish the number of fingers. He could feel the outline of big objects from 50cm's distance. 
Under ophthalmoscope (right eye): eye fundus was dark red color. The optic nerve head was in a pale white color. The border of optic nerve head was clear. The macular could be observed but its border was unclear. The optic disc fiber became thinner and its border was clear. The veins were enlarged and presented with darker color. His right eyeball could move flexibly, with no nystagmus. The forehead wrinkle pattern was symmetrical, the nasolabial sulcus was equal in depth, the teeth were symmetrical and the tongue was centered in the oral cavity. There was flexible movement in the neck. The muscle strength and muscle tone of all four limbs were normal. The pathological signs of both sides were normal. The deep sensation and superficial sensation were normal. The coordinate movement was normal. There was no meningeal irritation.

Treatment:
We initially gave Navarro Montilla Jorge Enrique a complete examination and the diagnosis was confirmed. He received treatment for nerve regeneration for his retina optic nerves. He received treatment to activate his own stem cells. He also got treatment to improve the blood circulation in order to increase the blood supply and nutrition to the neurons. He also had treatment to dilate blood vessels and adjust his blood lipid.

Post-treatment: 
After 3 weeks of treatment, the patient's vision has improved. In 50cm's away, his right eye is able to perceive fingers. In one meter's away, he can distinguish the outline of small object. In 2 meters' away, he can perceive the outline of big objects. The color-distinguishing ability has improved. Now he can distinguish black, white, silver and etc.

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Date:2016-3-14