Tuesday clinic

Today we had St. Theresa's clinic in Manzini. I stayed overnight last night in the Malkerns, so I didn't have far to drive this morning. On my way to work, I drove by the "Swazi Candles" shop, where several weeks ago, I saw they were selling Sukumani (sewing ladies) products. They had cards for sale, but only had two left.

So I went in the store and asked to speak to the owner or manager. I spoke with Audrey, the manager, and she said she loves the Sukumani cards and would love to sell more! I was so excited.

I then made it to clinic and jumped head-first into the long day. I was feeling very lousy, but Jono had several meetings lined up, and so I had to handle the majority of the patients. Jono was absolutely willing to cancel the patients, but I told him I could make it! I hate cancelling clinics...in the States or here, so I pressed on.

Once again, we had some interesting patients... (these are actually a compilation of patients from the entire week... I am catching up on my blogging).

Patient one: 56 year old HIV positive male with long history of right sided "facial droop", inability to close right eyelid, and diplopia. On exam, vision was 6/6 (20/20 in the U.S.) in each eye and there was no RAPD. He had a large esotropia on primary gaze, and assumed an alternate head position to fuse. Vertical gazes were preserved, but he couldn't ABduct or ADduct the right eye and he couldn't ADduct the left eye (he could, however ABduct). He also had a right facial palsy and had complete right lagophthalmos as a result. The palsies had actually been present for quite some time (difficult to ascertain whether it was progressing or not). His real reason for the visit was right eye pain. With his clinical findings, I told him he likely had brainstem pathology (pons), and he needed an MRI.  (I believe he had "one-and-a-half syndrome" and with the seventh nerve palsy, one could consider it an "eight-and-a-half" syndrome"). Apparently he had a prior MRI that was "clean". Of note, we have NO MRI in Swaziland, but he had obtained one in South Africa several years ago. He had exposure keratopathy on the right, and given he can't move that eye anyway, I suggested we do a 70% tarsorrhaphy, which should protect the eye and still allow him to see out of the right eye.

Primary gaze
 

Attempted right gaze.

Left gaze

Eyelid closure

Alternate head position adopted by patient to fuse images

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Patient two: 36 year old HIV positive male with a new "growth" on his right eye. This "growth" had already been excised once in South Africa, several years ago, and recurred. The vision was 6/6 in each eye (perfect vision). We told him this is a very large squamous cell carcinoma and it is VERY dangerous. We offered one more excision with application of mitomycin C and we told him if there is any sign of recurrence, we will need to enucleate (remove) the eye. We will excise on Thursday. We also plan to give him 5-fluorouracil drops in the coming weeks to try to further rid him of the squamous cell carcinoma.

Large squamous cell carcinoma in HIV positive patient.
 

Same patient as above. This, however, is the "surgeon's view" through the operating microscope. The SCC is located nasally on the right eye.

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Patient three: Female in her mid thirties, HIV positive, with new growth on her left eye. Any guesses as to the diagnosis??!

Another squamous cell carcinoma.
 

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Patient four: Male in his late twenties who was diagnosed with HIV after the onset of herpes zoster in the V1 distribution. He not only has corneal involvement, but he has the acute onset of a CN VI palsy on the left, which can also be seen in herpes zoster infections.

Patient with herpes zoster (Shingles) in the V1 distribution. Notice the subtle esotropia (left eye has a new CN VI palsy).

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Patient five: 9 month old female whose mother reports that her "eyes are running, running all the time" (by "running" she meant moving very fast back and forth, or nystagmus). She has had this since she was born. There was no family history of eye problems. The child could fix and follow and her pupil reaction was equal and seemed brisk in both eyes.

The mother wanted the child's eyes to quit "running". The child had a small bracelet on her wrist with a button. I had never seen a small bracelet on a child, and inquired about it. The mother said, "her granny made it for her so that her eyes would stop running, running". Then she carried on, "but it no work". This is part of their belief in traditional medicine/healing. Dr. Pons said the "button" is what they put on the bracelet when there are eye problems. I explained the mother in a gentle way that I didn't think the bracelet would ever stop the child's eyes from moving, but I think the mom had already realized that...

She is scheduled for an exam under anesthesia (EUA) later this week.

Child with congenital nystagmus

The bracelet with the button, from the child's granny. The bracelet is supposed to stop the nystagmus.

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 Patient six: My absolute favorite patient of the week. A man in his late eighties who was hilarious. He kept the staff laughing. He was making jokes (that I couldn't understand) in siSwati. Jono and I gave him a top ("once a man, twice a child", as they say) and he put it on his head!! He underwent successful cataract surgery!

Top on his head. I guess he thought you were supposed to put a "top" on the "top" of your head? I am not sure...he was a very rural 88 year old Swazi who spoke no English, except to say "no English!"