Clinic photos

Photos from another busy week in the clinic:



Mass over the lacrimal sac in a 96 yo Swazi female. She is the oldest Swazi I have met!



Same patient as above



Squamous cell carcinoma in a 37 year old male.

The patient above is a sad case for me. He came in to report that he had noticed a new growth on his right eye (people are quite perceptive here, and readily pick up on these things). I took one look at it and it looked like a squamous cell carcinoma (SCC) to me (the electricity was out in clinic, so I improvised with my 20 diopter lens and my headlamp). I told the gentleman that I would like to excise the lesion in the coming weeks and that I would like him to have an HIV test (he said he was healthy and had last been tested one year ago and it was non-reactive). The siSwati translator explained this to him. He said he was not ready for an HIV test. I told him I was not going to force him to get tested, but I was concerned that he had HIV (based on the likely SCC). I told him that if I was to excise the lesion, I wanted him to be tested first. I feel that treating the SCC without treating the whole patient and the underlying disease, would be poor medical practice on my part. So, I had the translator take him to a private room and talk with him/counsel him. He agreed to be tested.

The rapid HIV test was done, and unfortunately came back as reactive. I think there was a part of me that thought it would be negative because I so desperately hoped he did not have HIV. I talked to him for awhile, and I told him that although this was not news he wanted to hear, it was really good that we found out he was positive, because now he can get on treatment. I explained that HIV is not a death-sentence here anymore. It was upsetting to me, however, to make this new diagnosis in this gentleman. You could tell he was devastated by the news.

In America, we often associate being HIV positive as a "choice"...a lifestyle choice. Which is not really true. But there is a stigma, and we assume people who are positive have chosen a certain lifestyle. We must get past that idea. Here, it can be seen as a "curse" from a higher power, so it is still stigmatized somewhat. There are many innocent children living with the disease. In fact, the Swaziland statistics show that 1 in 5 children is orphaned due to parents dying from HIV and that 1 in 4 children themselves are HIV positive. Many grandparents are now raising their grandchildren. It is a sad situation.
 



Viral conjunctivitis in a 13 month old female. It's everywhere, folks!



Old corneal scarring from previous corneal ulcer in the setting of vernal keratoconjunctivitis. Notice the "wispy" lines emanating toward the scar. These are "ghost" vessels (located in the corneal stroma).

Photo 1 of 4.  This is a 26 year old female with history of severe unilateral granulomatous uveitis. She was negative for TB and sarcoid. The eye is now blind and painful. You can see the dark area superiorly represents scleral thinning and uveal prolapse. We are recommending enucleation, but the patient and her husband are delaying because they need to talk to all their relatives and their community before proceeding with enucleation of the left eye.

Same patient as above (photo 2 of 4). Scleral thinning and uveal prolapse (dark spot).

Photo 3 of 4. External view. Notice the contour of the left eyelid. The eye is misshapen.
 

Photo 4 of 4. Slit lamp photo. Note the granulomatous keratic precipitates (white dots). There was also a Busacca nodule on the iris (unable to photograph).

 

Below is another sad case that I had this week. This was a 35 year-old gentleman who had known HIV. He had quit taking his ARVs earlier this year (when I asked why he said in perfect English, "Only out of sheer stupidity, doctor"). He was only off the ARVs about a month, but starting losing a significant amount of weight and becoming very ill during this time. He went to the hospital two weeks prior to seeing me, and his CD4 count at that time was 6.  As in, horribly low (the lowest CD4 count I have seen here).

 

His ocular complaint was new onset horizontal, binocular diplopia (double vision). He had his right eyelid closed, which was voluntary ptosis, to occlude the right eye so he wouldn't have double vision. I was also told by the technician that this patient had vomited multiple times in the waiting room.

 

Before I even examined him, I suspected  a sixth nerve palsy and intracranial pathology (history of vomiting multiple times a day and new diplopia).

 

On exam, he indeed had a new esotropia in primary gaze. Motility revealed that he had a right sixth nerve palsy (could not abduct the right eye). I suspected that when I dilated him and looked at his nerves he would have papilledema...

 

And, on dilated exam he did have bilateral papilledema (OS >> OD). I explained carefully to the mother and her son that he was very sick, and even without imaging of the head I could nearly guarantee intracranial pathology (such as cerebral toxoplasmosis or cryptococcosis) leading to a sixth nerve palsy, vomiting, and papilledema. This was not news he wanted to hear. I referred them to the government hospital, but they were not keen to go there. Instead, they were going to go try to get help at Raleigh Fitkin Memorial hospital in Manzini. I suspect that this patient will not have the head CT that I recommended and will die within the coming weeks. Sad, but true.

 

Subtle esotropia in primary gaze.



Right CN VI palsy (unable to abduct the right eye). The remainder of the motility exam was normal. Note the temporal wasting.