Recurrent Retrobulbar Optic Neuritis in Seronegative Rheumatoid Arthritis

@#Rheumatoid arthritis (RA) is a multisystemic autoimmune disease which can be associated with visual threatening ocular manifestations. Common ocular associations with RA include necrotising scleritis and peripheral ulcerative keratitis (PUK). Optic nerve involvement otherwise is uncommon, especially as a presenting feature of RA. We report a rare case of recurrent bilateral retrobulbar optic neuritis (ON) with progressive visual deterioration as an early manifestation of seronegative RA. This case posed diagnostic and management challenges due to its unusual presentation and initially inconclusive investigations. The patient was diagnosed with seronegative RA three years after the first eye presentation. Her RA disease activity score (DAS-28) improved after treatment with a disease-modifying anti-rheumatic drugs (DMARDs), and her ON attacks have been controlled since then. However, her visual acuity, visual field and colour vision remained poor after multiple ON attacks. Multidisciplinary care is key to managing such a patient’s condition and its potential disease complications.

Optic Neuritis in Herpes Zoster Ophthalmicus: A Rare Manifestation of a Common Malady

@#Herpes zoster optic neuropathy (HZON) is a rare manifestation of herpes zoster ophthalmicus (HZO). It is a potentially blinding condition. We report a case of an immunocompetent patient with HZON following keratouveitis during the course of treatment. A 33-year-old gentleman presented with left eye (LE) worsening of visual acuity (6/9 reduced to 6/24) despite on treatment for HZO keratouveitis. It was associated with pain on ocular movement and central scotoma. He was on systemic acyclovir and topical corticosteroids prior to current complaint. Fundoscopy showed left optic disc swelling with impaired optic nerve functions. Diagnosis of left optic neuritis secondary to HZO was established in view of close temporal relationship with occurrence of cutaneous herpes zoster. Systemic corticosteroids was commenced. The patient had obtained good visual outcome at two months. Early referral for ophthalmology assessment is crucial to establish diagnosis of HZON and prompt initiation of treatment may preserve vision.

Diagnosis of Ankylosing Spondylitis: Do not let the spine bites the eye

@#Background: A diagnosis of ankylosing spondylitis (AS) is challenging and often delayed despitebpatients being symptomatic. Low back pain is the most common initial symptom, appearing in the second and third decades of life. Acute anterior uveitis (AAU) occurs much later in the course of the disease, often when the destruction of the spine is already debilitating. Objective: Here, we report three cases of AS that were diagnosed after the patients developed AAU. Methods: A case series illustrated AAU leading to the diagnosis of AS years after the initial episode of low back pain. A comparison of the clinical presentation, diagnosis, and outcomes was also illustrated. Result: We report three cases of acute anterior uveitis (AAU)-associated AS diagnosed only after many visits to the primary health care provider with the complaint of chronic low back pain. All three patients had irreversible radiological changes upon diagnosis of AS. The AAU resolved with topical steroids, and one patient developed cataract. Conclusion: A high index of suspicion of AS in a young adult with chronic back pain before the development of AAU may prevent further functional loss and provide a better prognosis. Diagnosis of AS following AAU is not only associated with dependency but also may rob the vision of a young adult.

Commemorating the 40-Year Journey of the School of Medical Sciences, Universiti Sains Malaysia

@#The School of Medical Sciences of Universiti Sains Malaysia (USM) is the launching pad for this journal. From the school’s humble beginning at the USM Main Campus in Pulau Pinang, Malaysia, it has grown in stature at its current location in the USM Health Campus, Kubang Kerian, Kelantan, Malaysia. Commemorating its 40th anniversary, this editorial aims to recollect, although not exhaustively, the wealth of returns for the USM, as well as for the nation, which the school has managed to deliver in that period. Resolute to its vision and mission, this article highlights the outstanding accomplishments in various core aspects of the school’s academic, research and professional growth as we continually strive to train globally competitive and compassionate medical graduates, medical specialists and scientists, skilled to serve nation’s needs and broader markets worldwide. Currently guided by the Malaysian Higher Education Blueprint (2015–2025), the school shall remain ingenious in its duties in the many more years to come, as we head for a world-class trajectory.

Factors predicting visual improvement post pars plana vitrectomy for proliferative diabetic retinopathy / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To identify factors predicting visual improvement post vitrectomy for sequelae of proliferative diabetic retinopathy (PDR).METHODS: This was a retrospective analysis of pars plana vitrectomy indicated for sequelae of PDR from Jan.to Dec.2014 in Hospital Sultanah Bahiyah,Alor Star,Kedah,Malaysia.Data collected included patient demographics,baseline visual acuity (VA) and post-operative logMAR best corrected VA at 1y.Data analysis was performed with IBM SPSS Statistics Version 22.0.RESULTS: A total of 103 patients were included.The mean age was 51.2y.On multivariable analysis,each pre-operative positive deviation of 1 logMAR from a baseline VA of 0 logMAR was associated with a post-operative improvement of 0.859 logMAR (P<0.001).Likewise,an attached macula pre-operatively was associated with a 0.374 (P=0.003) logMAR improvement post vitrectomy.Absence of iris neovascularisation and absence of post-operative complications were associated with a post vitrectomy improvement in logMAR by 1.126 (P=0.001) and 0.377 (P=0.005) respectively.Absence of long-acting intraocular tamponade was associated with a 0.302 (P=0.010) improvement of logMAR post vitrectomy.CONCLUSION: Factors associated with visual improvement after vitrectomy are poor pre-operative VA,an attached macula,absence of iris neovascularisation,absence of post-operative complications and abstaining from use of long-acting intraocular tamponade.A thorough understanding of the factors predicting visual improvement will facilitate decision-making in vitreoretinal surgery.

Visual electrophy siological tests in obstructive sleep apnoea / 国际眼科杂志(Guoji Yanke Zazhi)

AIM:To compare the pattern electroretinogram (PERG) and pattern visual evoked potential (PVEP) between obstructive sleep apnoea (OSA) patients and controls.METHODS: This was a prospective cross-sectional study involving 40 OSA patients and 31 control subjects in Hospital Universiti Sains Malaysia.Patients with a confirmed diagnosis of OSA who had no ocular pathology were randomly selected to participate in the study.The apnoea-hypopnoea index (AHI) was obtained from their records and used for stratification of OSA severity.Electrophysiological tests (PVEP and PERG) were performed on each patient by a trained technician in the electrophysiology laboratory of the Department of Ophthalmology, USM.The results obtained were recorded as median values.Data analysis was done using IBM Statistics Version 21.0.RESULTS: Among OSA patients, we observed a significant reduction of the PERG amplitude P50 (P<0.001) and the PVEP amplitude P100 (P<0.001) compared to the control group.OSA patients also had a significant increase in PVEP time to peak P100 (P=0.003) and time to peak N75 (P=0.004).However, no significant differences were detected in PERG time to peak between OSA patients and controls.There were likewise no significant differences in PVEP or PERG between OSA patients with different disease severity.CONCLUSION: OSA patients have significant abnormalities in PVEP amplitude and time to peak, as well as PERG amplitude.This may reflect subclinical optic nerve dysfunction in OSA.Further research is needed to determine the association between the severity of OSA and the degree of optic nerve dysfunction.

Thymectomy in Myasthenia Gravis at Hospital Unversiti Sains Malaysia - A 10 Years Review of Cases at the Hospital Universiti Sains Malaysia

Background: A thymectomy is considered effective for patients with myasthenia gravis (MG). Although a few studies have described the role of a thymectomy in the treatment of MG in Asians countries, there are no published data on the application of this surgical approach for MG in Malaysia. We aimed to describe the clinical outcomes of MG patients who underwent a thymectomy and the factors affecting these outcomes. Methods: This was a retrospective study involving 16 patients with MG who underwent a thymectomy at the Hospital Universiti Sains Malaysia (HUSM) from January 2002 until December 2012, with a follow-up period ranging from 3–120 months. Results: The study consisted of 16 patients aged 22–78 years, 10 of whom were males. The overall remission/improvement rate was 87.5%, and the rate of clinical outcomes classified as unchanged/ worsened was 12.5%. Thymomamatous or non-thymomamatous MG, histology features, Osserman stage and the duration of follow-up were not significant prognostic factors. Post-operative mortality was 6.2% (1 of 16 patients died of septic shock). Conclusion: A thymectomy seems to be an effective treatment for MG, with low surgical morbidity. Patients with a lower Osserman stage and those with/without thymomas had favourable outcomes.

Migraine with aura complicated by “migraine triggered seizures” and “occipital lobe infarction”: A case report

Migraine with aura is one of the major subtypes of migraine, and can be associated with ischaemic brain infarction. Use of oral contraceptive pills (OCPs) increases the risk of infarction in this type of migraine. Seizures and migraine also have a complex relationship, one element of which is migrainetriggered seizures. We report a case of bilateral occipital lobe infarction and migraine-triggered seizures, most likely precipitated by oral contraceptive pills (OCPs) in a patient with migraine with visual aura. OCPs, triptans and ergotamines should be used cautiously in these patients. Methods of birth control other than OCPs should be considered.

Ultrasonographic Findings in Eyes with Retinopathy of Prematurity in Malaysia

RetCam is an excellent screening tool for the detection of retinopathy of prematurity (ROP). However, affordability is a barrier when adopting the use of RetCam in developing countries. We aimed to describe different stages of ROP using ultrasonographic B-scan and to evaluate the association between funduscopic examinations and ultrasonographic B-scan findings in premature neonates with ROP in Malaysia. A descriptive cross sectional study was conducted in 90 eyes of 47 premature neonates with different stages of ROP in three tertiary hospitals in Malaysia. Experienced ophthalmologists performed detailed funduscopic examinations using binocular indirect ophthalmoscopy (BIO). A masked examiner performed a 10 MHz ultrasonographic B-scan evaluation with 12 meridian position images within 48 hours of clinical diagnosis. Data from the clinical examination and ultrasonographic findings were collected and analysed. We recruited 37 eyes (41.1%) with stage 1 ROP, 29 eyes (32.3%) with stage 2, 18 eyes (20.0%) with stage 3, and 3 eyes (3.3%) with stages 4 and 5 based on the clinical assessment. Ultrasonography correctly identified 3 (8.1%) stage 1 eyes, 17 (58.6%) stage 2 eyes, 13 (72.2%) stage 3 eyes, and 3 each (100%) of the stage 4 and 5 eyes. There was a significant association between the funduscopic signs and the ultrasound findings for stage 2 ROP and above (Fisher’s exact test, p <0.001). In conclusion, all stages of ROP were detected and described with a 10 MHz ultrasonic B-scan system. A significant association was observed between funduscopic signs and ultrasonographic findings in premature Malaysian neonates with stage 2 ROP and above.

Clinical Profile and Aetiology of Optic Neuritis in Hospital Universiti Sains Malaysia – 5 Years Review

Although few studies concerning optic neuritis (ON) in Asian countries have been reported, there is no report about ON in Malaysia particularly within the Malay population. We aimed to determine the clinical manifestation, visual outcome and aetiology of ON in Malays, and discussed the literature of ON studies in other Asian populations. This was a retrospective study involving 31 consecutive patients (41 eyes) with ON treated at Hospital Universiti Sains Malaysia commencing from July 2005 till January 2010 with a period of follow-up ranging from 18-60 months. The clinical features, laboratory results, possible aetiology, and visual acuity after one year were analysed. Females were the predominant group. The age of the patients ranged between 3-55 years and peaked between 21-30 years old. 67.7% of the patients had unilateral involvement. Pain on ocular movement was observed in 31.7% of the affected eyes. 73.3% of 41 involved eyes showed visual acuity equal 6/60 or worse on presentation. Paracentral scotoma was the most common visual field defect noted. Optic disc papillitis proved more widespread compared to the retrobulbar type of ON. The aetiology was idiopathic in more than 50%, while the risk of multiple sclerosis was extremely low (3.2%) in our series. 66.0% demonstrating visual acuity improved to 6/12 or better at one year after the attack. 16.1% showed evidence of recurrence during follow-up. In conclusion, the clinical profile and aetiology of ON in Malay patients are comparable to other ON studies reported by other Asian countries.

Isolated Optic Neuritis Secondary to Presumed Tuberculosis In An Immunocompetent Child

Isolated optic neuritis as a presenting sign of tuberculosis in children is uncommon. We report a case of an immunocompetent child who displayed features of bilateral optic neuritis secondary to presumed tuberculosis. It is essential to highlight this alarming presentation in a child, as the presence of tuberculosis has re-emerged as a serious public health problem especially in developing countries.

Large full thickness medial canthal reconstruction: a report of two cases and review of literature

The reconstruction of the upper eyelid with medial canthal involvement post extensive removal of malignant tumour remains a challenge. Proper eyelid reconstruction is necessary to re-establish anatomic integrity, restoration of its functions and to maintain the best cosmetic appearance. These case reports illustrate an alternative reconstructive technique for large upper eyelid full thickness defect with medial canthal involvement. Two cases of upper eyelid tumours involving medial canthal region underwent staged reconstruction by glabellar flap advancement and reconstruction of the posterior lamellar with autologous graft using buccal mucosa and ear cartilage. The posterior lamellar graft and flap survived without any complication except for mild eyelid margin notching in one of the two cases. The staged reconstruction with glabellar flap advancement provides adequate defect coverage, excellent blood supply, maintains eyebrow contour and function of the eyelid. The flap also perfectly matches the surrounding tissue with minimal donor site morbidity.

Sudden visual loss after football game: a case report / 国际眼科杂志(Guoji Yanke Zazhi)

We describe a 27-year-old gentleman who presented with sudden loss of left vision after a football match. As there was no improvement with previous treatment, he was referred to us for second opinion three weeks after initial presentation. Examination showed a quiet left eye with large whitish lesion with fluid level in the macula. It posed a dilemma in diagnosis as possibility of infectious cause could not be ruled out.Pars plana vitrectomy with vitreous biopsy was done and it showed old organised blood from premacular haemorrhage resulted from valsalva retinopathy.

Excellent outcome of primary Neisseria meningitidis keratoconjunctivitis

Infectious conjunctivitis is a very common presentation to medical professional and ophthalmologist all over the world. Although its typically self-limiting and treatable in almost all of the cases, but we need to be aware of the rare and potentially life threatening if the cause is not promptly identified and treated accordingly. In our case report, we highlighted the rare case of Neisseria meningitidis as a primary cause of keratoconjunctivitis. Neisseria meningitidis is a rare etiology of keratoconjunctivitis and its ocular presentations are quite similar with other bacterial or viral infection. The infection may potentially fatal if systemic invasion occurred, however with immediate and proper treatment the outcome is satisfactory. Early diagnosis and proper antibiotic treatment are critical to prevent systemic spread of the infection. Public health intervention is needed to prevent outbreak of the disease.

Devastating ocular injury by a rice black bug: a case report / 国际眼科杂志(Guoji Yanke Zazhi)

A 59-year-old female farmer presented with left painful swollen eye for 1 week after being stung by a rice black bug ( Scotinophara sp. ). It was associated with acute progressive blurring of vision. On examination of the left eye, there was a marked periorbital swelling with proptosis and complete ptosis. The extraocular movements were restricted in all the directions. The cornea was hazy with large epithelial defect. Fundoscopy showed combined features of both central retinal vein and artery occlusions with swollen optic disc and ischaemia of the macular area. CT scan and MRI of orbit and brain showed evidence of orbital soft tissue inflammation. Patient was diagnosed with left orbital cellulitis, keratouveitis and central retinal vein and artery occlusions. The periorbital swelling and proptosis were improved after treatment with systemic and topical antibiotics. However, the vision remained no perception of light(NPL)and limitation of ocular movements persisted. The potential ophthalmic insults by Scotinophara sp. Can be severe and permanent. Awareness of the debilitating insults by Scotinophara sp. To human eye should be instilled timely especially in its prone areas.

Acute onset of proptosis secondary to subcutaneous panniculitis-like T cell lymphoma / 国际眼科杂志(Guoji Yanke Zazhi)

To report a rare case of acute onset of proptosis secondary to subcutaneous panniculitis-like T cell lymphoma (SPTCL). METHODS: A case report. RESULTS: A 27-year-old Malay man presented with history of acute onset of proptosis in the left eye for 2 weeks. It was associated with history of prolonged high fever. He also developed multiple erythematous swelling on his body and both thighs during this period. On examination, visual acuity in both eyes was 6/6. The left eye was proptosed and chemotic.The extraocular move-ment was limited in all directions.The cornea and the anterior segment were normal. Fundoscopy showed normal optic disc and retina.The examination of the right eye was unremarkable.His body temperature was 40.0℃.There was presence of multiple erythematous subcu-taneous lesions over the body mainly in the left axillary, right hypochondriac, both thighs and the suprapubic area.The inguinal lympnodes were also palpable.MRI of orbit and brain revealed generalized soft tissue swelling in the left extraconal and retro-orbital space suggesting of inflammatory reaction.The cavernous sinus and brain were normal.Skin biopsy from the erythematous lesion revealed as SPTCL.He was referred to the haematologist and was started on chemotherapy-CHOP regime. The patient responded well to the chemotherapy and the proptosis reduced. CONCLUSION: Proptosis secondary to SPTCL is very rare. This is a variant of a peripheral T cell lymphoma characterised by multiple subcutaneous nodules presented with proptosis and fever.

Traumatic optic neuropathy: a review of 24 patients / 国际眼科杂志(Guoji Yanke Zazhi)

·AIM: To evaluate the clinical presentations of traumatic optic neuropathy and to assess the visual outcome of three groups of patients managed differently (conservative, intravenous corticosteroids only and combination of intravenous and oral corticosteroids) at an academic tertiary care referral centre.·METHODS: A retrospective study was conducted involv-ing 24 consecutive patients (27 eyes) with traumatic optic neuropathy attending Hospital Universiti Sains Malaysia from January 2007 till December 2009.·RESULTS: Twenty-four patients (27 eyes) were included. All cases involved were male. Mean age was 33 years old. Motor vehicle accident was the major cause (83%). Both eyes were equally involved. Most of the eyes had poor vision on presentation (HM-NPL, 82%) with associated periorbital haematoma (22 eyes) and subcon-junctival haemorrhage (20 eyes). Majority of patients (19 patients, 79%) presented with more than one bony fracture of skull or orbit and 5 patients (21%) had no fractures. None of the patients had evidence of optic nerve compression on CT scans or MRI done. Eleven patients (46%) had been treated with intravenous and oral corticosteroids. The other 7 patients (29%) were treated conservatively and the third group (6 patients, 25%) was on intravenous corticosteroids only. Eleven of 12 eyes (92%) treated with intravenous and oral corticosteroids had showed 1 line improvement of visual acuity. Those eyes treated conservatively (78%) had showed 1 line improvement of visual acuity. As for patients treated with intravenous corticosteroids only, four patients remained NPL, one patient had mild visual improvement and the other one's vision remained the same. The visual improvement in patients treated with conservative management was not significant (P=0.386). Patients treated with intravenous corticosteroids alone have shown no statistical visual improvement (P<0.05). Patients treated with intravenous followed by oral corticosteroids had significant visual improvement (P<0.05). There was no statistically significant difference in visual outcome between patients treated with corticoster-oids and patients treated conservatively (P=0.368). No patient underwent surgical decompression of the optic nerve. In this series, the follow-up ranged from 6 months to 3 years.·CONCLUSION: Most of the traumatic optic neuropathy patients are presented with periorbital haematoma, subconjunctival haemorrhage and orbital wall fractures. Patients treated with intravenous followed by oral corti-costeroids have better visual outcome compared to conservative management.

Syphilitic uveitis: 3 cases report / 国际眼科杂志(Guoji Yanke Zazhi)

·AIM: To evaluate the clinical manifestations and visual outcome of syphilitic uveitis patients. ·METHODS: Case series of three patients with syphilitic uveitis were managed in Hospital USM.·RESULTS: Three patients were diagnosed to have uveitis secondary to syphilis. All three patients were not known to have syphilis prior to presentation but had positive history of sexual promiscuity.Allpatients presented with progressive blurring of vision for average of one-month duration. Two of them had association with fever,ocularpainandfloaters.Visualacuityat presentation ranged from 6/12 to hand movement. Mild anterioruveitis( non-granulomatous),vitritisand papillitis were present in all the patients. First patient had multifocal chorioretinitis with exudative retinal detachment. The second patient presented with exudative retinaldetachmentwhilethethirdpatienthad chorioretinitis only. All the patients were treated with intramuscular benzyl-penicillin 2.4 MU weekly for 4 weeks and two of them received oral doxycycline 200mg twice daily for 3 months. The uveitis responded well to the treatment and two of them showed dramatic visual improvement from 6/120 to 6/21 and 6/12 to 6/6. The one with worse outcome was confirmed to have positive retroviral.·CONCLUSION: Ocular syphilis presented here as non granulomatous inflammation associated with exudative retinal detachment, Final visual outcome is generally good despite slow improvement after treatment.

Case series and Variants of ocular injury Secondary to firecrackers / 国际眼科杂志(Guoji Yanke Zazhi)

·Acquired uniocular blindness in pediatric group deserves an urgent attention. The blindness usually results from mechanical injury to the globe. It is one of the leading causes of acquired blindness in this group. Most of the ocular injuries were accidental and resulted from mechanical trauma. Firecracker is one of the potential causes for acquired uniocular blindness. The nature of injury varies from mild to severe, penetrating or blunt trauma, chemical or thermal. The irreversible nature of the visual loss is preventable. Public awareness will be one of the main contributors in preventing the ocular morbidity.

Syphilitic optic perineuritis: a case report of a rare presentation / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To report a rare case of optic perineuritis secondary to syphilis infection with severe visual loss showing a dramatic improvement following treatment with corticosteroids.METHODS: Case report.RESULTS: A 66-year-old Malay lady presented to us with sudden onset of unilateral loss of vision and pain on eye movement. Her vision had no perception of light and marked relative afferent pupillary defect (RAPD) was present over the right eye. Serological and radiological investigation showed evidence of syphilitic optic perineuritis. She was treated with intramuscular benzathine penicillin and intravenous methyl prednisolone, followed by oral steroid with tapering dose for long period. Her visual acuity improved remarkably after the treatment. She regained the vision of 6/18 and there was no sign of recurrence or steroid related side effects during 4 months follow-up.CONCLUSION: Accurate diagnosis and prompt treatment of this case has converted a poor vision to a better visual outcome.