Yesterday, I was in the operating room with Jono when I was summoned by one of the nurses. There was a 13 year-old boy out in the pre-op area who had lost vision in his right eye secondary to trauma. They asked that I come evaluate.
When I went to examine the boy, it was clear he didn't speak any English, he only spoke siSwati. Luckily the room was full of patients who were waiting for their surgery (Jono did 20 surgeries yesterday in about 6 hours!). This really kind lady sitting next to the boy helped me translate.
Me: "What happened?!"
Boy: "I was hitting a cow with a stick when the stick broke and it hit me in the eye."
Me (thinking): "Why on Earth were you hitting a cow with a stick?!"
Me (saying): "Oh no. I am so sorry. When did it happen?"
Boy: "Two days ago."
Me: "Why did you wait until today to come to the doctor?"
Boy: "I thought it would heal on its own."
I quickly checked the vision in his right eye. It was hand motions at 1 meter.
Before I move on to what happened to the little boy, I must tell you about hitting cows. I went to tell Jono the basic exam and that I was going to take the boy down to clinic to examine him. He asked how it happened. I said, "he was apparently hitting a cow with a stick when the stick broke..." And before I could even finish Jono said, "Oh. This is so common in Swaziland. And the reason that it happens this time of year is that the kids are on break from school." He was totally unfazed. I suppose if you want to draw a similarity between Iowa eye trauma and Swazi eye trauma, this accident could be considered a "farming" accident.
Kids help out on the farm and they hit the cows with the sticks to drive them into the pasture. According to Jono, this is one of the most frequent causes of eye trauma in kids here in Swaziland.
I took the boy downstairs. He had perfect vision in the left eye. He had no RAPD in either eye, which was a great sign. There was no hypopyon in the anterior chamber, very mild cell and flare, and no cataract. He had about a 5mm full-thickness corneal laceration running obliquely from the limbus at 5:00 to the central visual axis (which is unfortunate), but it was Seidel negative! His anterior chamber was deep and formed. There was no vitreous cell and I could see the optic nerve and retina pretty well and there was no obvious pathology. I gently checked an eye pressure, and it was 10mmHg (low end of normal), which told me the eye was holding a pressure and again supported the idea that the wound was self-sealed.
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| Corneal laceration |
I went and conferred with Jono. We decided that since the eye was closed, it happened more than 48 hours prior to presentation, and there was absolutely NO sign of infection we would observe. If this had presented acutely, we would have definitely placed sutures in the cornea. Sutures hold the eye closed, but they can cause irregular astigmatism and furthermore, we don't like to put sutures right in the central visual axis.
I had the nurses give him a tetanus shot and I placed him on antibiotic eye drops and put a clear eye shield over his eye to protect it and remind him not to touch or rub the eye. The visual prognosis is still unknown, but as long as the eye does not become infected, he will only have to deal with the corneal scar.
I told the child and his mother that he needed to be a "couch potato" for at least this weekend. I asked them if they had T.V. (No). I asked them if they had some coloring books for him to use. (No). I asked them if they had any games or magazines or books. (No). I asked the translator to ask him what he liked to do besides play outside. (Answer: play outside). I realized this may be a losing battle.
So, this morning before I saw him back in clinic, I drove into Siteki and bought him some crayons, a coloring book, and a blank notebook (total cost was about 250 Emalangeni, or about $2.50). I just couldn't bear the though of this child sitting at home bored out of his mind. They were very excited with the "gifts" today and it brought a huge smile to his face.
I have noticed there isn't a lot for kids to do in the hospital here. I know in the peds ward they apparently do have some activities. But if the child is a teenager, they get put in the general ward. This was the case with my patient who had orbital cellulitis. She was in a room with 8 beds. She had no books, T.V., magazines, or toys. Her mother had to work days and did not live nearby, so she couldn't visit often. I remember asking my patient, "What do you do all day?" and she replied "I sleep". I think we could use some Swazi "Child Life Specialists" to help keep the kids entertained.
Kids in the U.S. probably are over-stimulated (T.V., iPad, loads of toys, etc), but kids here do not seem to have enough stimulation. We should probably meet in the middle somewhere.
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