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.