Ophthalmology


        

Case Discussion

permanent dry eyes and corneal ulcer scarring   Posted By maliha Naseem    Date : 17-Apr-04   11:45 AM     Reply

A CHALLENGE TO THE MODERN MEDICAL HISTORYA BRIEF OF THE CASE HISTORY OF MALIHA NASEEM

PATIENT SUFFERING FROM DRY EYES AND CORNEAL ULCER

Name of patient. Maliha Naseem Female/Bachelor Age 21 years

Mailing Address c/o Prof. Naseem Baluch Principal, Government Degree College Hasil Pur. District Bahawalpur E-Mail [email protected] Residential Address H.No.43-C Block –X Model Town –C Bahawalpur. Phone No. 0621-884666 880404, 0300-968-4820 Office 0696-41572 , _______________________________________________________________________ PAST HISTORY OF THE PATIENT

In November 1991 she was diagnosed as patient of Nephrotic Syndrome. She was placed on steroid { tab. Deltacortril (Prednisolone) 40 mg O.D. } for a prescribed period of six weeks. It relapsed twice after withdrawal. However it was cured in September 1992.

PRESENT HISTORY

After a mild dust storm on 22-5-2001 both the eyes became red with inflammation and over secretion of tears with temperature 103-104. Following treatment was given at 8 pm. 1: Tab. Soften (Loratadine) 10 mg 2: Isopto cetapred eye drops Only two doses were taken but there was no relief. On 23-5-2001. The situation became worse with the following symptoms. Ulceration, inflammation in both the eyes, lips, tongue, mouth with soaring throat. Temperature 104 . It was diagnosed as STOMOTITIS . How ever it was added that it might be an acute attack of unusual virus. . The treatment consisting of oral and inject able antibiotics, antiallegic etc was carried out for two days but no relief was observed. A Medical Board of B.V Hospital Bahawalpur consisting of three physicians and one skin specialist diagnosed as STEVEN JOHNSON SYNDROME. New combination of misc. medicines only through injectables was started with the following signs.. 1: All body from head to foot was full of ulcers and blisters. 2: All the face became black of blisters. 3: Temperature 101 to 103. 4: No sleep. 5: Thick Secretions of adhesive substance from esophagus through mouth. 6: No oral intake of medicines. 7: Eyes, nose, ears closed due to infection of ulcers. 8: Throat, tongue, lips full of ulcers and secretions.

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As the result of this treatment all the symptoms / signs started subsiding in a very slow mode. The treatment was carried out for one month. The patient became normal but eyes stood effected because of ulceration as such with the following problems.

1-Eyes could not be opened. 2- Ulceration in the both eyes 3- Pain, redness, irritation

EXCLUSIVE TREATMENT OF THE EYES STARTS

The exclusive treatment of eyes started on 20-06-2001.The treatment and the diagnosis of different Ophthalmologists with a detail of signs is given below.

A: (0phthalmologist ) B.V. Hospital BWP.

Diagnosis STEVEN JHONSON SYNDROME Prescription 1: Tears Natural II e/drops TDS 2: Cortisporin eye o/t TDS 3: Optolube eye o/t TDS used for 8 days but no significant relief was B: Dr.Raffat Ali Burq ( check up on 28-06-2001)

Diagnosis STEVEN JHONSON SYNDROME Signs Target lesions mucous membranes, symblepharon, ankyloblepharon dry eyes. Advised for PAROTID DUCT TRANSPLANT Prescription 1: Tears Natural II e/d TDS 2: Optolube o/t TDS 3: Echnochlore e/d TDS No significant relief.

C: Dr. Munzoor Ahmad Malik Firs visit on 30-6-2000 and subsequent weekly check ups regularly for about five months.

Diagnosis STEVEN JHONSON SYNDROME Signs 1: Bilateral dry eye. 2: Bilateral Symblepharon 3: Conjuntival Scaring 4: L/E Corneal Ulcer

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Prescriptions used time to time The following prescriptions were issued from time to time check ups. 1: Santodex Eye Drops 2: Cartisporine Eye Ointment 3: Maximitrol Eye Drops 4: Tears Natural II Eye Drops 5: Visco Tears Eye Gel 1 Tobrex Eye Ointment 2 Tears Natural II Eye Drops 3 Visco Tears Eye Gel 4 Vitamin C Tab 1 Salcoseryl eye gel left eye at night 2 Tobrex Eye Ointment 3 Tears Natural II Eye Drops 4 Visco Tears Eye Gel 5 Vitamin C Tab. ------------------------------------------------------------------------------------------------------------ As a result of the above mentioned prescriptions the patient felt a significant relief . The redness, inflammation and irritation in eyes and adhesions minimized. Occasional pain in left eye was experienced which was relieved by taking pain killer tablet or Inj. Corneal ulcer in L/E was minimized however bilateral dry eye became the permanent phenomenon. ________________________________________________________________________ D: Dr M. Afzal Bodla Multan (6-08-2001)

Diagnosis STEVEN JHONSON SYNDROME Signs Symblepharon formation Advised bandage contact lenses and conjunctival mucous membrane graft. Prescription 1: Viscotears eye gel BD 2: Blinkfresh e/d 4 hourly 3: Solcoseryl eye gel left eye at night 4: Tab. Rovigon o/d for three weeks

E: Dr.Latif Ch. Lahore ( check up on his visit to hospital at Hasilpur on 12-08-2001)

Diagnosis CITCATRICIAL OCULAR PEMPHIGUS Signs 1: Bilateral dry eye. 2: Corneal ulcer in left eye. 3: Conjunctiva adhesion formation With special direction, “No surgery at all”

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Prescription 1: Salcoseryl eye gel BD 2: Tears Natural II e/d 2 hourly 3: Echnoclore e/d 6 hourly

F: Dr. Nazir Ahmed Aasi Lahore. ( check up on 08-10-2001)

Diagnosis OCULAR PEMPHIGUS Signs 1: Dry eyes 2: Symblepharon / ankyloblepharon 3: Panalate keratits Prescription 1: Tears Natural II e/d 1 hourly 2: Salcoseryl eye gel 5 times a day 3: Mucosolvon Tab. 4 Time a day 25-03-2003 G- Dr. S.P.Mahr Consultant Agha Khan Hospital Karachi Diagnosis Not mentioned on prescription but supposedly diagnosed as S.J.S Tears Prescription !-Rovigon Tab. Once a day 2-Vitamin A Ointment 3- Artificial tears which suits 4-Salcoseryl eye gel 6 times a day 5-Ciloxan E/D twice a week Special advice. Patient herself should decide to adjust the medicines according to situation 04-12-2003 F- Dr.Muneer-ul-Haq (Retired professor of eye department of Mayo Hospital and M.S) Comments. God saved from more damage SJS has caused mild damage to the eyes Advised. Parotid duct transplant and then KarotomPlasty

Prescription used for Four months ( August to November2002) 1: Tears Natural II e/d 1 hourly 2: Salcoseryl eye gel 5 times a day 3: Mucosolvon Tab. 4 Time a day 4 Tobrex Eye Drps 5 Time a day 5 Visco Tears Eye Gel 3 Time a day 6-

After a prolonged use of the above mentioned prescription, there was a substantial relief of irritation, redness, pain and other infection. Both the eyes were normal to the extent that eyes could be opened easily through applying artificial tears. The corneal ulcer in the left eye was minimized to the extent of cure. Vision of both the eyes was safe and apparently there was no complication except being dry eyes. But in the 3rd week of November 2001 right eye became active and there was an acute attack of infection consisting of irritation, redness, inflammation. Subsequently L/E also became affected with the same symptoms with the enhancement of corneal ulcer with stromal tissue involvement and the sharp pain in the left eye. With the treatment by Dr. Ijaz Latif at Bahawalpur, the right eye became alright only being dry as before but corneal ulcer in the left eye became significant. Now cornea of Left Eye has scar tissue which is supposed not to be transparent thus the vision of this eye is badly affected.

Following medication was carried out for a reasonable time. 1-Ciloxan e/d one hourly 2-Blinkfresh e/ d when required 3- Tobrex o/t at night 4-Feldene cap. While pain in the left eye 5-Visco tears when required 6- Salcoseryl eye gel 3 times a day

Scar emerged in the cornea of right eye and the vision of this eye stands badly effected. The dry eyes is the permanent phenomenon and can not be opened w/o applying artificial tears and gel at bed time.

PRESENT SITUATION 1-Permanent dry eyes 2- Corneal scar in the whole cornea of left eye. Left eye almost dull with maximum poor vision 3- Usual burning ,irritation , redness in the right eye 4- Painful irritation in adhesions temporarily relieved by excessive use of tears and use of Salcoseryil eye gel

PRESCRIPTION UNDER USE

1-Blink Fresh ( excessive use) 120 Bottles monthly average 2- Optolube ointment at night ( 15 tubes per month ) 3-Dexoptic-C drops while burning 4-Ciloxan Eye drops Occasional 5- Tab.Rovigon O.D 5- Vitamin A Ointment

DILEMMA??? 1-Are the tears ducts are damaged permanently? 2-Can scar tissue be treated and vision may return. 3- Why the right eye is usually active causing burning , irritation etc. and L/E dull? 4-Whether grafting of Mucous Membrane by ocular plastic surgery can restore the tear gland or lacrimal system. 5-Is the parotid duct transplant successful and solves the problem to what extent and available in Pakistan. 6- Is this disease treatable to the extent of cure or leading normal life? 7-Any treatment available in Pakistan or abroad .or any research is underway any where? _____________________________________________________________________


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Replies to the above case discussion :

Re : permanent dry eyes and corneal ulcer scarring - dr. prashant bhatia 22-Apr-04    08:24 AM

Re : permanent dry eyes and corneal ulcer scarring - dr smita rane 23-Apr-04    07:17 AM

Re : permanent dry eyes and corneal ulcer scarring - Dr. Quresh B. Maskati 24-Apr-04    03:10 AM

Re : permanent dry eyes and corneal ulcer scarring - Prof .Dr Navneet Saxena 26-Apr-04    12:07 AM




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