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Wednesday, March 21, 2012

March interesting eye cases

Hey there readers, I'm going to show a couple of interesting cases that I've had this month. You should know by now if wierd pictures of the eyeball bothers you. If that is you, you have been warned.

1. A 32 year old woman presented with a 2 month complaint of blurry vision in her left eye. She had been punched in that eye by her husband a few weeks prior. Vision in the left eye was counting fingers at 3 meters. Anterior segment exam was normal. An exterior photo of her is posted below.  Do you know what she had? I bet most of my collegues studying for their board exams know this one. Scroll down to the end of the post for the diagnosis and classic exam finding.
 2. I'm blessed here with a collegue, whom, as far as I know, is the only Angolan ophthalmologist who actually does significant amounts of surgery. He works in the central hospital here in Benguela, and has access to general anesthesia, in which we need to operate on most children.
I am starting to take children there who need surgery, such as our next case.
This child has retinoblastoma, at least i'm pretty sure he does. No pathology results yet, but it looks like RB. This tumor is fatal for many children, and he had an advanced tumor. It had actually grown outside of the eye, which is a bad sign. However, I was growing very tired of simply telling the mothers that their child would die, so I arranged to takethis child over to the General Hospital and do his surgery there. I hope I have saved his life, but only time will tell. I'm praying to God that he lives. He is in the hands of the almighty now, I have done what I can. Pictured is the child and the eye after removal.

Same day, working on a different patient. At the head of the bed is Dr Salomao.
 I'm to the right, operating.

3. This patient came in to be seen at Boa Vista several times by the eye nurses that we have. She had complaints of headaches. My nurses gave her eye drops and told her that she had dry eyes ( on 2 seperate visits) 3 months later when she was blind, she came back to Boa Vista and the nurses showed the patient to me. She had bilateral swelling of the optic nerve. I sent her to get a CT scan. Pictured below.

 Its a really big brain tumor. It represents a probable fatal condition for her because access to Neurosurgery here is equally poor and chemotherapy is almost non existent.
This represents a larger problem however, because even my nurses who are probably the best trained nurses in Angola, still make rather poor efforts at diagnosing complex problems and do not show me all of the cases of the day. I'm struggling with that idea. I simply don't have time to see all 80 + patients of the day and do 10-12 surgeries in the morning. I sure could use some more doctors here.

4. I think I posted this photo before. But I wanted to show the results of surgery. Briefly for review, she had some type of small growth removed by a nurse. She had lots of scarring, pain and double vision because of this growth afterward.

Below I am taking out some nylon sutures about 1 month post surgery. Her double vision and pain are completely gone. The symplepharon has been lysed and her conj autograft looks great, not a sign of recurrence yet. Will keep watching her.

5. Posterior Capsule Opacity - Capsulotomy with needle
With doing so many cataracts comes the usual complications; long term that includes clouding of the lens capsule behind the now clear lens implant. I had only ever used a LASER to clear this in the USA. But here I don't have that expensive piece of machinery.
SO I took the advice of Rainald Deurkson in Paraguay and cut it with a needle! I entered the eye 3mm behind the limbus with a 25 g needle. I used my very little experience with retina surgery to help with the placement of the needle, visualized the needle engaging the posterior capsule and then intentionally broke the bag! The patient could see well the next day, no infection and importantly a happy patient.

6. Answer to above unknown. Angioid streaks, with choroidal neovascular membrane in a patient with Pseudoxanthoma Elasticum.
-I'm presuming that the trauma she had from the domestic abuse (despicably common here), caused a break in Bruchs membrane and subsequent CNV. Other eye had same picture minus CNV.

Sunday, March 18, 2012

Day in and Day out

After living in Angola for 6 months life has finally settled in and I can say that the "honeymoon" stage on being a missionary is wearing off. Not that I don't love being here, but now I don't love all the sacrifices. Like when I got here, after every meal I would hand wash every dish and think how easy it was, and that I don't know why I ever thought I needed a washing machine. (I know our Boston friends can relate here) Then I'd go clean a used cloth diaper, and fill up our water filter. And every time I swept the mound of dust that comes in the house, I would just smile and think how satifying it was to sweep a lot of things out of the door. Ha, you know how it was when you first got married, and you thought you loved the quarky things about your spouse that turned out to be the things you despised after a few years. That kind of thing, I even thought I loved studying a new language at the begining. But now, after six months and I still get whole sentences in conversations that I totally don't understand, I'm getting fed up with it. This must be why my relationship with God is deepening, because I really need to rely on Him right now in these frustrating times. I just want to have a couple over for dinner and sit back and laugh about life. But I'm too focused on understanding every word that even when it's funny, I don't have the energy to laugh.
The kids on the other hand are really getting comfortable. They have a few friends on the street, and they love to play together. Oliver and Zeke are attending a daily tennis class taught by our neighbor. And Oliver is actully liking school a little bit. We are very happy about this. He goes to a Portuguese speaking school in the morning and I teach him and Zeke together in English in the afternoons.
Roman is very comfortable with people and I'm sure he will be communicating in both languages here someday.
John is starting to feel the weight on his sholders as being one of a very few eye surgeons in the country. People are always traveling hours to be seen at the Boa Vista  eye clinic and the types of complicted eye problems are numerous. It's a releif to know that God wants to carry this burdon for John, and John knows that God is pleased when he is giving his best, but at the same time it is overwhelming.
Yesterday, I was at the blind association and even though I tell them all the time that I'm not a doctor they continue to call me Dr. Lori, so this poor woman brought her three year old son, that is clearly mentally handicapped, to me to see what I can do to help him get better. And of course in my limited knowlede of medicine I don't think anything can be done,, so I told her what I know, then refered her to the general hospital. Unfortunately, they will not have good news for her. So this was my glimpse into John's day to day life. Everyday, he sees blind people that the Lord allows him to bring sight, but at the same time he has to tell many others that their particular problem cannot be fixed; and send them back on their 2 day journey home. Since the Lord cares more about our love for him than the things of the world, we can rest asurred that people who come to Boa Vista and don't get the result that they want, they at least heard the Gospel and know that the love of Jesus even reaches them.
It is a tremendous honor to be somewhere where we are so needed and appreciated. So please pray with us that we always remember that. We really miss everybody and are so thankful for this ability to stay in touch. Thanks again for reading.

From Angola with Love,