Department of Ophthalmology

Manila Doctors Hospital

667 United Nations Avenue, Manila
5243011 local 3720

April 20, 2019

MEDICAL CERTIFICATE & SUMMARY

This is to certify that patient Ali, Zeyad 23/M was admitted and treated at Manila Doctors Hospital
Department commencing from April 8, 2019.

Final Diagnosis is as follows:

1) Ruptured globe, right with scleral laceration and uveal prolapse s/p repair of scleral
laceration with repositioning of prolapsed uvea and anterior chamber wash out.

2) Comminuted zygomaticomaxillary complex fracture, right Le Fort I and II fracture, nasal

bone Fracture, complete, displaced; dehisced wound with unfavorable scar s/p Closed
nasal Bone fracture; open reduction with internal fixation of comminuted
zygomaticomaxillary complex fracture, right and Le Fort I and II fracture using titanium
plates and screws with Caldwell Luc approach with scar revision

3) Knee Laceration, left S/P wound exploration, debridement and repair.

Medical summary:

Patient was admitted at Manila Doctors Hospital (MDH) last April 8, 2019 after sustaining injuries
to the right eye and multiple fractures to the right side of the face along with injury to the left lower
leg after patient was involved in a motor vehicular accident in Pangasinan on April 7, 2019 at
0530H. He was allegedly riding his motorcycle without wearing a helmet when he hit the car in
front of him causing to lose balance and finally hit a lamp post thus sustaining multiple facial and
leg injuries. He lost consciousness for about 2 hours then he was brought and initially managed
emergently at hospitals in Pangasinan. Eye shield placed, knee laceration repair done. However,
patient opted to transfer to our institution due to unavailability of specialized ophthalmologic care.

When patient was seen at the emergency room at MDH, patient was conscious, coherent with
GCS 15. Visual Acuity was No Light Perception on right eye. There was noted periorbital soft
tissue swelling on the right eye, with serosanguinous discharge, diffuse subconjunctival
hemorrhage and chemosis, hazy cornea, uveal prolapse at the nasal limbal area, shallow anterior
chamber with hyphema, and with no visualization of lens and pupil. Left eye on the other hand
was unremarkable with visual acuity of 20/50. Extraocular motility was limited on the right eye
prominently on left and right gaze. Patient was started on moxifloxacin eye drops 1 drop to right
eye every hour and eye shield was maintained at all times. A few hours later, patient noted slight
improvement of vision on the right eye, now with light perception but with no light projection. Blood
work-up, imaging tests and pre-op clearance done. Referred to CVS, Ortho and ENT for co-
management.

Plain Head CT scan done 08 April 2019 showed 1) comminuted fractures of the right zygomatic
arch, coronoid process of the right mandibular bone, right side of the alveolar ridge of the maxillary
bone, right pterygoid plate, bilateral nasal bone, nasal septum and bilateral maxillary sinus walls
associated with hemosinuses and blood both nasal chambers 2) right orbital wall comminuted
fractures with associated globe rupture, orbital emphysema, herniation of orbital fat into the right
maxillary and ethmoid air cells, and thickening of the right lateral rectus muscle 3) polysinusitis
with obstruction of bilateral ostiomeatal units, fronto-nasal ducts and spheno-ethmoidal recesses
4) subgaleal hematoma, soft tissue swelling and irregularities, as well as subcutaneous
emphysema overlying superior parietal bone 4) soft tissue swelling and subcutaneous
emphysema involving the face, more in the right periorbital and both maxillary regions 5) no
intracranial hemorrhage at the time of the study.

Surgical management of the right eye was contemplated by Ophtha service at this point. ENT
service decided to wait for swelling to subside until repair of facial fractures could be performed.

On April 9, 2019, visual acuity was still light perception with no light projection. There was grade
4 hyphema, with moderate mucoid discharge, poor view of the pupils. The ophthalmic options
were discussed with the patient, including the poor prognosis for visual recovery and the expected
degree of ocular injury. Treatment options of primary enucleation vs. attempted repair along with
its risks and benefits were discussed. The future risks of sympathetic ophthalmia was likewise
discussed along with the other possibilities. The patient requested for repair. On intraoperative
exploration, the scleral laceration was measured approximately >4 cm extending from the equator
superonasally underneath the superior rectus insertion, going down alongside the nasal
corneoscleral limbus and extending inferonasally underneath the inferior rectus to reach the
inferior equatorial area. The prolapsed uvea was repositioned with no evidence of residual uveal
exposure. The entire scleral laceration was closed with nylon 9-0. Patient underwent anterior
chamber wash thru a paracentesis however the hyphema continued to recur.

Orthopedic service performed wound debridement and suture revision of left knee laceration.

The patient tolerated the surgery well. Post-operative meds included Prednisolone Acetate eye
drops, atropine eye drops, moxifloxacin eye drops, metoclopramide IV, paracetamol IV, tramadol
IV and dalacin c IV.

On April 11, 2019, patient was examined at the clinic and visual acuity on the right eye was no
light perception. There was still diffuse subconjunctival hemorrhage. The repaired lacerations
were well coaptated with the sutures intact. The anterior chamber had grade 4 hyphema and
evidence of corneal staining.
On April 12, 2019, the ENT service proceeded with closed nasal bone fracture; open reduction
with internal fixation of comminuted zygomaticomaxillary complex fracture, right and Le Fort I and
II fracture using titanium plates and screws with Caldwell Luc approach with scar revision. Patient
tolerated the surgery well and additional post-operative meds included pain medications,
methylprednisolone IV and chlorhexidine mouth wash. .

On April 15, 2019, the patient was cleared for discharge by Ophtha, Cardio and Orthopedics.

On April 16, 2019, patient was seen and examined. Wound cleaning of right eye done. There
was noted decreased periorbital swelling and hematoma. VA of right eye still No Light Perception,
(+) mild mucoid discharge, (+) diffuse subconjunctival hemorrhage; clear cornea, (+) 8 ball
hyphema, iris cannot be visualized. Eoms partially limited. Refraction OS:-0.75DS -1.50DCx158
20/30. Explained to patient poor visual prognosis for the right eye. IV Co-Amoxiclav antibiotics
completed and other eye drops and pain medications continued.

Currently we are awaiting plans of the ENT service for discharge.

This report is made purely for medical purposes only.

GARY JOHN V. MERCADO, MD

Oculoplastic, Lacrimal and Orbital Surgery
Ocular Oncology
Ophthalmology
MANILA DOCTORS HOSPITAL
UN AVENUE, MANILA PHILIPPINES
gvmercado@hotmail.com