DIAGNOSIS:  Retinitis Pigmentosa.

CHIEF COMPLAINT: Patient is known case of retinitis Pigmentosa. He has been observed for visual impairment since 2008. He has c/o poor vision in both eyes initially since 2004-2005 but it appeared to be worse in 2008. Vision in daylight is good but its difficult vision in both eyes at night/darkness. Central vision is good as of now but peripheral vision is affected in both eyes. Due to dimness of vision, he has inability to read, glare at night/darkness.

PRESENTING ILLNESS:  A 44 years old male presented with history of difficulties of vision in both eyes since 2008. But initially his vision in both eyes was normal with good day vision till 2004-2005. Later on he developed difficulties in both eyes during night vision/darkness.  He has got loss of vision in both eyes during night time and unable to figure out object and colours in darkness. His central vision is good with poor vision in peripheral region. Patient’s overall health is good but his eyesight is not so good.

PAST MEDICAL HISTORY: He has h/o covid-19 infection in 2021 and got recovered from the same. Also he has taken 2 covaxin doses.

FAMILY HISTORY: h/o RP in elder brother.

ON EXAMINATION:  conscious and well-oriented

B: P:  130/90 mm of Hg

Pulse: 78 b/m

Temp.: 98.6^o F

RR: 22

SpO2: 96% 

INVESTIGATION:

• All blood reports, ECG reports, chest X-ray report attached with discharge summery.

PLAN OF ACTION:

• UC-MSC cellular therapy
• Bilateral Retro bulbar injection of MSCs.
• Exosome Inj
• MVI injections
• Inj Vit C
• monocef 1gm & Inj. Pan40mg

OPERATION UNDER TAKEN / PROCEDURE:

1. Umbilical cord derived Mesenchymal stem cells (100Millions) + Exosome growth proteins (50µgm) given through intravenous route.
2. Bilateral Retro bulbar injection of MSCs (30M each eye) + Exosome protein (50µgm) given in both eye under LA by Ophthalmologist with NO any adverse event.
3. MVI injection given in 100cc NS for 1 hrs slow infusion.
4. monocef-o 1gm & Inj Pan 40mg –IV / stat
5. Vit C injection given in 100cc NS for 1 hrs slow infusion.

IN COURSE OF HOSPITAL AND COMPLICATION IF ANY:  Patient was clinically examined and thoroughly investigated, physician opinion taken and informed written consent taken. After examination, his GC was stable and he was afebrile.

On day 1^st, he was given inj.monocef-O 1gm & inj. Pan 40mg stat, IV dose. Later in afternoon, he was taken to OT for retroblubar stem cell procedure. Under LA, retroblubar inj of 30millions UC-MSCs + Exosome (50µgm) was given in both eyes by Ophthalmologist. Post procedure was uneventful (no headache or vomiting). Slight pain at inj site was present in both eyes, for which eye drop has been administered once. He was given I/v MSCs (100millions) cells + Exosome (50µgm) by taking aseptic precautions. Post procedure was uneventful. At evening, later on Patient was stable & well oriented.

On day 2^nd, GC is stable and afebrile. There was no pain in both eyes and no headache. He was given 5cc Inj of MVI via 100cc NS slowly. Later on he was given Inj Vit C via 100cc NS slowly.  now at time of discharge he is clinically stable.

AT THE TIME OF DISCHARGE:

B: P:  120/80 mm of Hg

Pulse: 72b/m

Temp.: 98.6 F

RR: 22

Spo2: 99% 

DISCHARGE MEDICATION:

1. Ophthacare eye Drops….OD for 3 months.
2. Boslin….OD…. for 3 months.
   
   

NOTE:

1. Kindly visit nearby Ophthalmologist for retinal evaluation after 3 months.
2. Kindly visit to nearby Hospital emergency ward, if you observe fever, headache, seizures, severe vomiting, severe abdominal discomfort and decreased appetite.
   
   

SIGNATURE AND STAMP OF DOCTOR / AUTHORITY DEPARTMENT

All reports received by, ——————————————–, patient/attendant, dated on 26/06/2023