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Richard Lee - Optic nerve injury

Author Julia Views Posted at 2014/01/14

Name:Richard Lee


Age:47 years old

Country: Korea

Diagnose: Optic nerve injury

Admission Date: 2013-11-12

Days Admitted to the Hospital:28

Before treatment:
The patient received an operation to treat cataract 9 years ago. After the operation, the patient had high intraocular tension of the right eye. He looked at object in a vaporific manner. He was diagnosed with right glaucoma. The patient received medication to reduce the intraocular pressure. Then the intraocular pressure fluctuated and the vaporific sign still persisted. The visual field shrank gradually. The patient's right eye received implanted operation for the treatment of glaucoma 8 years ago. The vision and visual field did not improve. He was diagnosed with optic atrophy. From the onset of disease, the patient's weight remained the same. The diet and sleep were almost normal. The defecation was normal. There was no history of familial hereditary disease.

Admission PE:
Bp: 132/86mmHg; Hr: 64/min, Br: 18/min. Richard's development and appetite were normal. The skin mucosa was normal. There was no hemorrhaging spots or yellow stains on the skin. The thorax was symmetrical; the respiratory sounds of both lungs were clear, with no moist rales. The heart sounds were strong, the rhythm was regular, and there was no obvious murmur in the valve area. The abdomen was smooth and soft, with no mass. Through palpation, the liver and spleen were found to be normal.

Nervous System Examination:
Richard was alert and his speech was clear. His memory, orientation and calculation ability were almost normal. Left eye had lost its sight. The right eye's vision with reading glasses was 0.4 from 3 meters distance. Right eye's upper vision was 30 degree, the nasal side and lower vision was 10 degree, the temporal visual field was 60 degree. The diameter of the left pupil was 4.0mms, and the diameter of the right pupil was 3.5mms. The direct light reflex and consensual reflex of left eye had disappeared. The direct light reflex of the right eye was obviously slow. The consensual reflex of the right eye had disappeared. The intraocular pressure of the left eye was higher than normal. The eyeball of the left was protruded. The intraocular pressure of the right eye was normal. There was an uneven white attachment in the left crystalline lens. The fundus of the left eye was unable to see. The fundus of the right eye was normal. The optic nerve head presented yellow. The retina was dark red. The artery was slim. Both eyes could move flexibly to each side. There was no obvious 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 tone of all the four limbs was almost normal; the muscle strength of all four limbs was about level 5. The abdominal reflex was not elicited; the tendon reflex of the four limbs was normal. The sucking reflex, palm and jaw reflex were negative. The pathological reflex of both lower limbs was negative. The deep sensation and superficial sensation were normal. The coordinated examination conducted was normal.

The patient started receiving treatment from November 12, 2013. We gave the patient a complete examination. The patient received nerve regeneration treatment and stem cell activating treatment. He received treatment to improve the blood circulation in order to increase the blood supply to the damaged nerves and to nourish the neurons. He also received treatment to adjust his immune.

The right eye's vision with reading glasses is 0.6 from 3 meters distance. Both pupil diameters are 3.0mm. Left eye had direct light reflex. Right eye has gained obvious sensitive with direct light reflex and the consensual reflex has appeared. The intraocular pressure of the left eye has reduced. The protrusion of left the eyeball has been alleviated. The uneven white attachment on left crystalline lens has also been alleviated. The color of right fundus is better than before, it presented with orange-red. The color of head of the optic nerve is light red. The arterial blood circulation is improved. The pipe diameter of artery is normal.



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