We (the Cropsey gang) had just arrived at Tenwek Hospital. I (John) wasn't officially starting work until the following week, but I was anxious to see the Eye Unit. It was a "slow" Friday afternoon around 4 pm, so Ben Roberts (the ophthalmologist I'm joining) said to stop in for a quick tour. There were exactly three patients left to be seen on my arrival.
The first was a six year old girl. She had bilateral, pan-uveitic, neuro-retinitis. Even if you don't know what that means, you know it can't be good, right? Well, our testing is limited and some Western tests are nearly useless. So, based on her elevated ESR (a blood marker for inflammation in the body) and history, we thought she most likely had tuberculosis in the eyes. We sent her to peds for a late Friday afternoon lumbar puncture to rule out further central nervous system involvement and systemic treatment. The peds department is loving me right out of the gate, I'm sure of it.
The next patient Ben runs by me was also a six year old girl presenting with a V-pattern esotropia (eyes turned out and make a V pattern when she looks up and down). She had swollen optic nerves suggesting possible increased intracranial pressure. Also, not good. Imaging with an MRI scan, or at minimum a CT scan is needed. We don't have either. The family will have to take the girl over a 100 miles away to find a scanner. The cost will be an enormous burden for this rural family. And if the scan confirms an intracranial mass, it will be extremely difficult for them to find a neurosurgeon, let alone pay for one.
To finish my orientation, I finally get to meet an adult. She is a pleasant 40 y.o. lady who says, "I was sitting under a tree and a fly hit me in the eye. About five days later I began to lose vision in my right eye." She is following up several months over due. Below are pictures of the back of her eye on initial presentation.
For the non-eye folks out there, the pink structure with the white hole in the middle and all the vessels coming out of it is the tip of the brain entering the back of the eye, the optic nerve. All of the little white "trails" on the nice orange retina are not normal. It almost looks like worm tracks, doesn't it? Do you see the larvae next to the right of the optic nerve? That's right! He's the white outline chewing away under the retina. This disease is called "ophthalmomyiasis." The treatment: cook the bugger with laser! The problem: he is munching next to the tip of the brain, the part that does the seeing. Also, not good. By the time Ben got her to the laser, this is where he had eaten to:
It is clear at the edge of the retina, far away from the optic nerve and central vision! This is good. The white patch is from the laser burn which marks the worm's grave. The woman had done so well after the laser that she did not follow-up as asked. This was a bummer for Ben because he presented a case series of ophthalmomyiasis x 3 at a retina conference the week before in New York City.
This ends my first hour in the Tenwek Eye Unit. Needless to say, I have many more stories, many of them deeply moving, from my first month here. I daily find myself seeing things I've never seen before. I often ask God for wisdom and compassion in clinic and the O.R. I try to categorize things: Really BAD, bad, probably not bad, no big deal. If it's towards the badness end of the spectrum, I might grab a book and look for its ugly cousin in the pictures section, and then figure out if it needs to be cut out, treated or just watched. You can read and see more in Part 2 to come shortly. Note: all photos were taken with the patient's permission, and this post is being sent before Jessica proof reads it. This is always a regrettable choice in my experience, but I'm posting it anyways.