Name: Koh Pee Leong
Sex: Male
Nationality: Malaysian
Age: 71 Y
Diagnosis: . Retinopathy 2, Glaucoma 3. Hypertension
            4. Type2 diabetes 5. CHD post stent surgery 6. Hyperuricemia
Discharge Date: 2019/04/13

Before treatment:
In 1998 the patient's visual acuity suddenly decreased in the right eye and he immediately went to the hospital. He was diagnosed with "retinal detachment" by examination and was treated by operation. The patient's visual acuity recovered after the operation. In the following year there were two more retinal detachments which were repaired surgically but the visual acuity of the right eye decreased gradually and only a little visual acuity was retained in the temporal visual field of the right eye. Six years ago the patient was found to have high intraocular pressure in the left eye and was diagnosed with "left eye glaucoma". Intraocular pressure was controlled by eye drops. In the past two years the visual acuity of the left eye decreased gradually and the peripheral visual field of the left eye was defective.
His spirit, weight and diet are normal. He can’t sleep well and he has frequent urination and dry stools. He has a history of coronary heart disease, hypertension and has had type 2 diabetes for many years.

Admission PE:
Bp: 145/90mmHg, Hr: 56/min, breathing rate: 18/min, body temperature: 36 degrees. Height 177cm, weight 81Kg. Nutrition status is good with normal physical development. There is no injury or bleeding spots of his skin and mucosa, no blausucht and no throat congestion. Chest development was normal, the respiratory sounds in both lungs were clear and there was no dry or moist rales. The heart beat is powerful with regular cardiac rhythm and no obvious murmur in the valves. The abdomen was flat and soft with no masses or tenderness. The liver and spleen were normal and there was mild edema of the lower ankle joints.

Nervous System Examination:
Patient was alert, had clear speech, his memory, comprehension and calculation ability examinations were normal. Bilateral pupils were equal and round, diameter of 2.0mm. The right eye pupil did not have a direct or indirect reaction to light. The left eye can react to light slowly and the right eye had mild congestion. The eyeballs can move freely with no obvious nystagmus. Visual field check: left eye only kept central vision, he had visual field loss in other part. The corrected eyesight by 3m eyesight chart: 0.8. eyes fundus examination: right eye fundus color was pale yellow, reflective rate of optic nerve head was low, A:V =1:4, left eye macula area surrounding color was dark red, unclear border, A:V =1:4. The bilateral forehead wrinkle and nasolabial fold are symmetrical, showing teeth was normal, he could make his tongue extend out normally and his neck can move freely. The 4 limbs muscle tone were normal with muscle power of 5 degrees. The abdomen reflex was normal, the bilateral biceps reflex and radial periosteal reflex could not be induced and the bilateral triceps reflex was normal. The patellar tendon reflex  and ankle reflex of both sides could not be induced. The palm-jaw reflex was negative. The bilateral Hoffmann and Rossilimo signs were negative. The  pathological reflex of the legs was positive. His deep and superficial sensory was present and the coordinate movement was normal.

Treatment:
After the admission he received 3 nerve regeneration treatments (neural stem cells and mesenchymal stem cells) to repair his damaged optic nerves, replace dead nerves, nourish nerves, improve body environment, regulate his immune system and improve blood circulation. This was combined with rehabilitation training.   

Post-treatment:
After 14 days treatment the left eye nose side and bitamporal side visual field enlarged and the bitamporal visual field nearly recovered to be in the normal range. Right eye bitamporal side eyesight was much clearer than before, the left pupil reaction to light was much better and the right eye started to have a response to light while still being clumsy. Funduscopic examination:optic nerve head of the right side was light yellow，macular boundary was unclear; the left fundus was light red, some areas are orange, the optic nerve head was light yellow，macular boundary was unclear，arteriovenous ratio was 1:4. At 3 meters visual chart, his left CVA is 1.0.