Benjiamin Juan Gomez-Retinal Dysplasia-(Argentina)

Name: Benjiamin Juan Gomez
Sex: Male
Nationality: Argentinean
Age: 18Y
Diagnosis: Retinal Dysplasia
Discharge Date: 2019/05/01

Before treatment:
The patient was born after premature rupture of amniotic fluid at 38 weeks of gestation. His birth weight was 1.7 kg and he was given oxygen inhalation for 4 days. Two months later he was taken to the hospital for a fundus examination and laser treatment. Five months later the family found that the patient had no eyesight. "Retinopathy of premature " was diagnosed by examination. At present he has growth and development retardation, poor balance function, cognitive dysfunction, is studying in a special school and can only do part of daily activities. He has no reaction to the light reflection, the left eye has no light sense, the right eye only has light sense at a distance of 10cm and can not accurately determine the light source position.
His spirit, sleep, diet, urination and defecation functions are normal.

Admission PE:
Bp: 115/73mmHg, Hr: 68/min, body temperature: 36.0 degrees. Height 167cm, weight 49Kg. Nutrition status is good with normal physical development. There is no injury or bleeding spots of his skin and mucosa, he has a symmetrical chest, clear respiratory sounds in both lungs and no dry or moist rales. He has a strong heart beat with irregular cardiac rhythm, no obvious murmur in the valves, a soft, flat abdomen with no masses or tenderness and a normal liver and spleen.

Nervous System Examination:
The patient is alert, has clear speech, good memory and orientation but bad intelligence and calculation. He has normal eyeball movement, is cloudy in front of his pupils, has no light reaction with pupils, no light sensation in the left eye and light sensation in the right eye within 10cm with no ability to locate the source accurately. Fundus examination: right eye, yellowish-white color in right fundus, pale optic papilla, arteriovenous ratio of 1:3, thin blood vessel, a large amount of surrounding osteoid deposits; left eye, blocked from view. He has a symmetrical forehead wrinkle and nasolabial fold, normal swallowing, normal hearing and a  normal neck. There is normal muscle power, muscle tone and active tendon reflex of the 4 limbs, normal abdominal reflex with a negative sucking and palm-jaw reflex. The Hoffmann sign, Rossolimo sign, and Babinski sign are all negative with normal deep and shallow sensation. The finger to finger movement test was completed, there was clumsy fast alternate movement and he  cannot stand on one leg. The  meningeal irritation sign was negative.

After the admission he received 3 nerve regeneration treatments (neural stem cells and mesenchymal stem cells) to develop his retina, repair his damaged retinal cells and optic nerves, replace dead cells, nourish optic nerves and retinal cells, improve body environment, improve blood circulation. This was combined with rehabilitation training.   

After 14 days treatment the light sensation of his right eye increased (around 20cm), he could see big objects within a short distance, light sensation came to left eye (about 10-15cm) and he  could now locate the light source.

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