Tis the season for cornea problems (Merry Christmas to John)

From time to time my (John) medical friends want pictures of the interesting cases I see. This is one of those blog posts. I'm going to show the photos from patients I saw this week. We are technically closed for the holidays this week, but since I'm the only cornea specialist in Angola, I stay busy.

I'll start with some happy photos of Zeke and oliver making a Ginger bread house, and cute kids of Angola. This is so all you folks who don't like gross looking eyeballs can stop right here and not be offended.

This is your last chance to not see the eyeballs (or what was once an eyeball...) Pictures are first followed by caption

1. Still see lots of trauma. This is a Chinese immigrant worker, who was seen by the "International Ophthalmology Clinic" here in town run by Cubans, it is Government funded and has lots of nice new equipment. They sent him to me for surgery. Lori didn't think it was funny, but I found it ironic that the Cubans and Chinese go to an American for help... Anyway, I took out the traumatic/dislocated cataract and sutured the cornea. Quickly becoming one of my favorite surgeries.  (No FB or RD seen on Bscan)

 2. Endophthalmitis/Perforated Corneal ulcer after cataract surgery
- He had surgery less than 1 week previously at another location, another doctor sent him like this to me. I'm not sure how this problem started exactly. But I know how it ended, I took out the eye. If you look closely you can see the haptic of the IOL has extruded through the cornea (what was once cornea, now just necrotic)


3. Keratoconjunctivitis with Perforation
-60 yr old woman w/ history of 1 year of red painful eyes. Was seen in Capital city of Luanda and sent to see me. Other eye looks similar minus perforation.
Unclear on the exact mecanism here, but appears to be rosacea/blepharitis related, lid margins are terrible. I'm treating her with steroids/tetracycline. In just a few days both eyes are calm and she has no more pain. Now what to do with those perforations? Still not sure. I could patch graft them, but she really has thinning 360, you can see near descemetocele at 12 oclock. Also, central cornea is edematous and opaque. Could be related to longstanding hypotony. Right now my main focus is on the other eye. Hopefully I can maintain her vision there. As I mentioned she lives in the capital city, 8hrs by car from here, but she has to take the bus which is less reliable and almost $200 round trip. She doesn't have that money, so frequent follow up will not be possible. Not an ideal transplant candidate. I'm open to suggestions if any reader wants to help me out.



4. 23 yr old Angolan man with painful, red right eye for 4 months, Unilateral.

Begin watering profusely last week. Waited until it really, really hurt to go see the other clinic in town. They sent him to me with the specific note, that he would need to be seen daily. Ahhh, good memories, just like fellowship.

Anyway, you are looking at pictures of the same eye, large perforation superiorly seen in gross photo. Couldn't capture the perf in the slit lamp photo, like I said he is in a lot of pain. He has thinning for 270 degrees of his cornea, looks like I could simply lift his cornea off with a 0.12, it is all just so unhealthy peripherally.

You have probably guessed Mooren's Ulcer by now. That is what I am calling it. Hooray, I have a name for this, now if only I had something to make it better.... Well I have started antibiotics/steroids, orally and topically. Once again, I hesitate to do a cornea transplant here because all I have are glycerol corneas that are not optically clear, he would need a very large PK graft into sclera. I can't really do a normal  circular patch graft because of size, it is all necrotic. I am going to try a crescentic patch, we shall see how it goes.

5. 75 yr old man with bilateral corneal opacification in band distribution. Left eye had this yellow brown, raised lesion.Vision 6/60. Did not appear inflammatory/infectious. I'm calling it spheroidal degeneration/climactic keratopathy. I did superficial keratectomy of both eyes. Had a calcified bowmans that I removed with some difficulty with a crescent blade. Really would have loved some EDTA but I don't have it. Fortunately I did have some BCL's (donated by someone who had extra CL), so I placed those. He was very happy POD#1, he could already see more 6/36.

6. 20 yr old woman from Luanda. Had vision 6/5 as of May 2011. Had a small lesion, not sure what, removed then from her conj. Things have not been good since that time. I would have really like to see this before a local health nurse decided it was a good idea to cut on this eye. Now her vision is HM, there is a vascular infiltrative process with what I think is lipid or sclerotic keratitis. Also she has an ulcerated appearing area adjacent to the robust inflamed nasal conj, which I think is dellen formation. But I'm really not sure. I'm treating her with lots of acyclovir ointment to treat dellen. Steroid/antibiotics.  After a week of treatment and a lab work up ( I want to know HIV status), I plan to take biopsies and send to the only pathology lab in the country.

7. 3 yr old girl. Febrile for last week per parents. Went to "another" clinic was given eye drops for this condition and sent home. Presumably she could see at that point. When she came to me like this, there was a large APD OS, fixed motility, near cornea perforation from exposure. Also motility was limited OD. Given appearance of probable nasal abscess, I'm presuming this is orbital cellulitis. I started oral antibiotics and got her in to the hospital in Benguela for CT scan and IV antibiotics. Also needs orbital surgery/sinus surgery most likely to drain abscess, but only time will tell if her family has enough money to pay for the "free" care at the hospital for anesthesia, etc... I really want general anesthesia for children at Boa Vista. It kills me to let someone else decide the fate of these kids. Below: Same story with probable Burkitts Lymphoma.

OK...lets look at happy patients after cataract surgery

 These two men are brothers. I did surgery on their same eyes on two seperate days (first I did both OD, 5 days later, both OS).

Man on left would be happier if he didn't have post op ptosis. Nuts. He is the first patient that I was able to give mini-monovision to. He is 20/happy with +0.25 OD, and -1.25 OS ,uncorrected and happy. It has taken me 3 months to work on getting these post op results. I was getting large myopia my first two months, I modified many things trying to figure it out, recorded post op refractions of 50 consecutive cases. Finally it came down to the fact that the IOL calculations were being done on an SRK II formula and not accounting for lens position, I switched to Holladay formula and now am much happier with post op refractions.

Thanks for reading. I'm happy to get any feedback or suggestions for managment.

-John

Blinde Assotiation Christmas Party

I was officially given the reins of the Blind Association at the Christmas party this weekend. (taking a deep breath) My Portuguese is coming along, but my Umbundo is not. I can get by this way, but I am starting now to tackle the local dialect of Umbundo.

Anyway, every year, the Blind Association finds donations to be able to give 100 families a big sac full of food to cook. We give the staple food: corn flour, plus rice, beans, oil, sugar, baking soda, noodles, sausage, and margarine. Then we give a Christmas party, which is like a church service and worship together. These Angolans love to sing. Then we hand out the bags as they leave.

This is Geisa and me getting the bags ready the give out

I'm not sure why, but it turned out to just be us distributing all the food into the bags.

This young man read the Christmas Story with Brail

Giving the bags out

Remember the blind brothers?

The governor's wife really came through for this family. The brother who was wasting away, is now gaining weight, and walking and talking. We were very encouraged at our last visit. She gave him a bed, and boxes and boxes of food.

Here is a picture of Geisa giving him a radio for Christmas.

That's the other brother on the right with all the cousins

Just love this picture

Well, thanks for reading again, as always I love hearing from you.

Have a Merry Christmas!

With Love From Angola,

Lori

Great Weekend

We had a great weekend. It started Friday night with the graduation party of my first class of Eye health nurses. Boa Vista has a basic training course for nurses 2 or 3 times a year. This round we had 4 students. They all passed and received their certificates, now we are sending them out to practice basic eye health (think optometrists in the USA). They can prescribe medications and glasses. They also diagnose cataract blindness and refer the patients back to us for surgery. It's an important part of our strategic plan to erradicating cataract blindness in Angola.

Congratulations to Raquel, Zacharias, Oswaldo, and Ricardo (from left to right, Dr Afonso is at far left)

Lori made a great cake for the reception. All the people loved trying the "American" cake.

Then, like all good trauma cases should start, this one began at our graduation ceremony.
A family arrived at Boa Vista after driving more than 8 hours with their 10-year-old son who had suffered a terrible injury to his left eye at 6 o'clock that morning. He was walking on the side of the road with his father near a construction sight, a split rock flew out from the work site and struck him in the left eye. The family lives in the Bie province, they first went to their local hospital only to be told that nothing could be done for them there; he should drive to Benguela, 8 hours away. The family arrived in Benguela at the unfortunate hour of 4pm on Friday and the Central Hospital of Benguela turned them away saying they could do nothing for him because it was Friday. The Family was crushed, they had driven all that way only to be denied the help their son needed. Unfortunately, this is reality here, there are government hospitals for "free" with good equipment, but often they're unable or unwilling to help people when they need it most.
 Fortunately one of the nurses at the hospital was trained at Boa Vista and said that they should come and see us.
After one look at the eye I could tell that it likely could not see again. He had a large laceration of his cornea, sclera, and already had a cataract, plus the retina and vitreous were coming out of the wound (see photo).

I could tell that the family was really desparate and I felt moved to do something. So after our graduation ceremony I took him to the operating room. We don't have denveral anesthesia here (the central hospital does and would be ideally suited for this type of case), and you can imagine how a 10-year-old child would behave when trying to do surgery on his eye while awake. But, through God's mercy, I succeded in giving him an anesthesia shot behind the eye, so he calmed down after the first 5 minutes and things went smoothly after that.  I closed the cut, took out his cataract and did my best to make the eye whole again. He actually could see shadows the next day, so we will wait and see how it turns out. 

The look of deep gratitude from the family, desperate to help their child, was all the thanks I needed for spending my Friday night in the operating room.  I'm grateful that God has allowed me to be in this place and show compassion on his people.

After a night of excitment for me, Lori decided that we as a family should have some fun. We drove out 30 miles from Benguela along the coast to a ridge called the "Sombrero"

We don't have true mountains here in Angola so climbing here is as close as it gets. We had beautiful views of the coastal cliffs, cool ocean breeze to help beat the 90 degree heat (that's for you midwest/northeast folks). You can see the rock formation in the background, the pyramid like structure with the flat top is the Sombrero. We hiked up to the base, then I free climbed up to the top as the staircase had been destroyed.

 

Finally, we finished the weekend with a church service celebrating the anniversary of an association of Evangelical Churches working in partnership. It is the group of churches that work with us at Boa Vista providing the devotions daily to the patients. Having a group of different churches work together through their differences is something beautiful to behold. We have been to all 6 of the different churches, and they definitely have different styles of worship, but they all want the same thing: to reach their nation with the Love that God has for all of his creation. I'm happy to be a small part of this effort.

Church services are long here and without an actual nursery for babies. Fortunately, Roman has lots of Angolan mothers  ;)
With Love From Angola,
John