Leonardo David Sales-Retinopathy and Optic Nerve Disease-(Argentina)
Name: Leonardo David Sales
Sex: Male
Nationality: Argentinean
Age: 32Y
Diagnosis: Retinopathy and Optic Nerve Disease
Discharge Date: 2018/06/04
Before treatment:
The patient was a six months preterm birth. His weight was 1 kg when he was born, he was put in incubator for 2 months and he was given high flow oxygen therapy. He wore high degree glasses and in 1998 he had surgery because of retinal detachment. He also had two surgeries in the years 1999 and 2000. He lost vision in his left eye but could see with his right eye with glasses. He had laser treatment in 2003 and 2004 and three surgical procedures because of retinal detachment in 2006. In 2007 he lost the vision function in his right eye. At present he has no vision but has light sense in both eyes. He has tears in both eyes under strong light so he wears sun glasses.
His spirit is good, his diet, sleep, urination and defecation functions are all normal.
Admission PE:
Bp: 116/80mmHg, Hr: 80/min, breathing rate: 19/min, body temperature: 36 degrees. Nutrition status is good with normal physical development. There is no injury or bleeding spots of his skin and mucosa, no blausucht, no throat congestion, and his tonsils do not have swelling. The respiratory sounds in both lungs were clear with no dry or moist rales. The heart beat is powerful with regular cardiac rhythm and no obvious murmur in the valves. The abdomen was flat and soft, with no masses or tenderness. The liver and spleen were normal and there is no edema of the legs
Nervous System Examination:
Patient was alert and had clear speech. His memory, orientation and calculation abilities were normal . Both eyeballs can move freely but he has blindness. The left pupil was irregular, diameter was 4mm and had light sensitivity. The right pupil could not be distinguished. Eyes fundus examination: left side partial retina detachment, slight yellow color, poor blood supply, A/V was 2:3. Papilledema is present. Doctors could not check his right side fundus because of the lens opacity. The bilateral forehead wrinkle and nasolabial fold are symmetrical, showing the teeth is normal and he could make his tongue extend out as normal. The neck could move freely. Muscle tone of his 4 limbs was normal, muscle power of the 4 limbs was basically 5 degrees. The abdominal reflex was normal, bilateral biceps reflex and triceps reflex were normal; patellar tendon reflex and Achilles tendon reflex were normal. The bilateral Hoffmann sign was negative, the pathological signs of the legs were negative, sensory system was normal and the coordinate movement was normal. Meningeal irritation sign was negative.
Treatment:
After the admission he received 3 nerve regeneration(neural stem cells and mesenchymal stem cells) treatments to active stem cells, repair his damaged retina and nerves, replace dead nerves, nourish retina and nerves, regulate his immune system and improve blood circulation. This was done with rehabilitation training.
Post-treatment:
After 14 days treatment the patient's right side pupil improved with the diameter 4mm. His left side pupil could respond to light much better than before and the pupil returned to normal size. He could feel light when there was light and he could sense some big objects in front of his eyes. The blood supply of his left fundus was better.
