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@#Endogenous endophthalmitis accounts for approximately 5 – 10% of all endophthalmitis cases. We report a case of a middle-aged gentleman with underlying uncontrolled diabetes mellitus who presented with fever and generalised body weakness for one week. He was diagnosed with invasive Klebsiella syndrome based on blood culture with presence of bilateral pleural effusion, liver abscess, renal impairment and sphenoidal sinusitis. The patient developed sudden bilateral painless reduced vision on day two of admission. Ocular examination revealed bilateral severe anterior chamber reaction and severe vitritis that obscured the view of the fundus. Ocular B-scan ultrasonography showed multiple loculations in the posterior segment in both eyes. There was soft tissue density with calcification in the left sphenoid sinus on computed tomography of the orbit. He was treated for bilateral endogenous endophthalmitis with multiple intravitreal antibiotic injections, but showed no improvement. Functional endoscopic sinus surgery was performed and revealed that the left sphenoid sinus was filled with fungal balls. Following drainage of sphenoidal pus, there was resolution of vitritis and fundus examination showed features of underlying fungal infection with a “string of pearls” present along the vascular arcade of both eyes. The patient was diagnosed with bilateral endogenous endophthalmitis secondary to invasive Klebsiella syndrome with coexisting fungal endophthalmitis secondary to sphenoid mycetoma. In addition to repeated intravitreal antibiotic injections, he was also treated with systemic and topical antifungal therapy. At three months post treatment, the infection resolved and his vision improved from counting fingers to 6/36 bilaterally.
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@#This a case report on a rare case of denial of visual perception termed as inverse Anton syndrome. It is a rare extension of perception without awareness in which, specific brain lesions affected a patient’s visual abilities. A 66-year-old Malay gentleman presented with sudden onset of the painless bilateral total loss of vision with expressive aphasia for 2 days. His visual acuity was 6/12 in the right eye and 6/48 in the left eye. However, he was insistent that he could not see but did not request any form of assistance for his blindness. He also had neurological signs suggestive of parietal lobe syndrome. Brain imaging showed subacute left middle cerebral artery territorial infarct with no occipital lobe involvement. The denial of visual perception by this patient may be explained by a disconnection of parietal lobe attentional systems from visual perception
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Objectives: diabetic eye disease is the most common cause of visual loss in adults, and proliferative diabetic retinopathy [PDR] is the main cause of blindness. This study aimed to determine the predisposing factors for PDR that were identified by fundus photography among patients with type 2 diabetes mellitus [DM] at the Diabetic Clinic at Hospital Universiti Sains Malaysia
Methods: in this retrospective study, fundus photo review was performed on patients with type 2 DM who had undergone diabetic retinopathy screening using a nonmydriatic fundus camera from January 2008 until December 2012. Fundus photos were classified into 2 groups, PDR and no apparent diabetic retinopathy [no DR]. Socio-demographic data and clinical and metabolic profiles were obtained from the medical records. Logistic regression was used to determine the factors associated with PDR
Results: a total of 120 patients were selected, with 30 patients in the PDR group and 90 patients in the no DR group. The mean age of patients with PDR was 52 [7.94] years and was 58 [12.31] years in the no DR group. Hypertension and hyperlipidaemia were the most common comorbidities identified in this study. The HbA1c level >6.5% and LDL level >2.6 mmol/L were higher in the PDR group. Age [p = 0.032], duration of DM [p = 0.022], nephropathy [p = 0.002] and peripheral neuropathy [p= 0.001] were significantly associated with PDR
Conclusion: the significant predictors of PDR among patients with type 2 DM as detected by fundus photography were age, duration of DM, nephropathy and peripheral neuropathy
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A 58-year-old Malay lady, presented with gradual loss of vision in the right eye for 1 month duration. It was associated with right sided headache, nausea and vomiting. Patient had a history of contact with tuberculosis patient. On examination, visual acuity in right eye was no perception of light with presence of relative afferent pupillary defect. The left eye visual acuity was 6.0/7.5. There was a total restriction of extraocular movement in all direction (frozen eye) in the right eye. Both anterior segments were unremarkable. Fundoscopy in both eyes showed normal appearance of optic disc and retinal vessels. Other cranial nerves were normal. Lungs were clear and had no lymphadenopathy. Chest radiograph was normal. Erythrocyte sedimentation rate was elevated by 35 mm/h and Mantoux test was positive (20 mm). MRI of brain and orbit demonstrated thickening and irregularity of the right optic nerve on axial view with doughnut sign on coronal view. Patient was diagnosed to have optic perineuritis secondary to tuberculosis. She was treated with anti-TB drugs. Systemic corticosteroid was commenced after 2 weeks. The visual acuity was improved to hand motion after 1 month with almost complete resolution of extraocular movement.
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A 32-year-old lady, diagnosed with anaplastic large cell non-Hodgkin's lymphoma of the mediastinum, presented with bilateral floaters and reduced right eye vision 3 years post chemotherapy. Ophthalmic examination revealed bilateral panuveitis with multiple deep seated choroidal lesions in the left eye. Computed tomography scanning of the orbit showed enhancing and bulky optic nerve sheath at the retrobulbar part of both optic nerves. The patient was treated with involved field radiation therapy of the orbit, with cumulative dose of 30Gy. Eight months post radiation therapy, she developed retinal pigment epithelial detachment at the macula and deep chorioretinal degeneration at superotemporal and inferonasal regions of the right fundus. There was evidence of vitreoretinal traction at the margin of chorioretinal degeneration areas, thus barricade lasers were performed in the affected eye. Her visual acuity remains 6/6 in both eyes. Retinal pigment epithelial detachment is a possible complication of radiation therapy in non-Hodgkin's lymphoma with intraocular metastasis. It is essential to alert the managing ophthalmologists about this rare complication.
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·AIM: To present a case of Coats' disease in adult and to illustrate the retinal findings.·METHODS: A case report.·RESULTS: A 63 years old Malay man, a known case of diabetes mellitus, presented with one year history of painless and progressive reduced vision in the right eye. Right eye visual acuity was counting finger 2 feet while left eye best corrected visual acuity was 6/12. Right fundus showed presence of extensive subretinal exudates at the temporal part of the posterior pole involving the macular area and nasal to the optic disc. It was associated with multiple areas of abnormal blood vessels temporal to the macula with attenuated vessels. Fundus fluorescein angiography(FFA) showed presence of telangiectatic vessels at the area of subretinal exudates and leakage of fluorescein from the telangiectatic vessels. The left eye was normal. Based on clinical and FFA findings, he was diagnosed to have adult Coats' disease. The right eye was treated with argon laser photocoagulation. Six months post laser, his visual acuity remained at 6/120 and there was minimal regression of the disease seen in the retina. ·CONCLUSION: The clinical and angiographic findings are important in diagnosing retinal telangiectasia. Treatment by laser photocoagulation in area of leakages may be beneficial in preventing visual loss.
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·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.
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A 42-year-old Malay lady presented with a 2-year history of painless and progressive right upper lid swelling. There was no history of trauma or similar lesion elsewhere. An excisional biopsy of the mass was performed and the histopathological findings of the excised lesion were consistent with those for a trichilemmal cyst. Trichilemmal cyst, although rare should be considered in any case of eye lid lesion.
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A 25-year man presented with symptom of photophobia and tearing in the right eye for 2 months duration. It was associated with painless gradual reduced vision. There was a history of hammering on a metal object prior to that. Ocular examination revealed signs of mild anterior uveitis due to a retained metallic intralenticular foreign body. Conjunctiva was white. Computed Tomography (CT) scan of the orbit confirmed presence of a single intraocular foreign body. The condition is misleading and can be easily overlooked. A detailed history and clinical examination are mandatory in this misleading situation.
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AIM: To study the association between lipid profile and retinal hard exudates in diabetic retinopathy (DR) and the association between oxidized-LDL with systemic diseases among type 2 diabetic patients.another 40 patients without DR. Demographic data was collected and comprehensive ocular examination was performed. Nine mL venous blood was taken for fasting serum cholesterol, triglycerides, HDL, LDL, ox-LDL, and for HbA1C. Compared to patients without retinopathy 5.0±1.03mmol/L (P=0.001). The mean serum LDL was 3.6±1.69mmol/L in retinopathy group compared to 3.0±1.02mmol/L in the contol group (P=0.005). There was a higher concentration of serum cholesterol, triglyceride and LDL in patients with severe retinal hard exudates compared to those with mild and moderate, however it was not statistically significant (P=0.082, 0.116, 0.218) respectively. The mean serum oxidized-LDL concentration was higher in DR with severe retinal hard exudates compared to mild and moderate. There was no statistically significant difference in the mean oxidized LDL with other systemic diseases or duration of diabetes.and LDL with DR. However there was no association between serum lipid profile with the severity of retinal hard exudates. Serum ox-LDL was also not associated with DR and other systemic co-morbidities in our study.
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A 67-year-old man presented with right sided temporal headache and sudden onset of painless loss of vision in the right eye. It was associated with total ophthalmoplegia with swollen optic disc. ESR and C-reactive protein were elevated. Magnetic resonance imaging demonstrated features of optic perineuritis. The right temporal artery biopsy was normal. The extraocular movements improved with systemic steroids. Unfortunately the patient developed central retinal artery occlusion in the right eye. Total ophthalmoplegia is a rare presentation of giant cell arteritis and initiation of corticosteroids is required for a satisfactory outcome and to prevent blindness of the fellow eye.
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AIM: To describe a case of diffuse conjunctival calcinosis in hyperpararthyroidism and end stage renal failure patient.METHODS: A case report.RESULTS: A 35-year-old gentleman, known case of hyperparathyroidism with subtotal parathyroidectomy done and end stage renal failure, presented with one month history of foreign body sensation of both eyes associated with redness and tearing. On examination, vision was 6/6 OU with diffuse conjunctival deposits and congestion. Conjunctival histopathological examination showed multiple foci of calcium deposits in the subepithelial stroma. Serum calcium was markedly raised and serum phosphorus was normal. His eye symptoms was reduced with topical steroid (betamethasone) and intramuscular calcitonin. CONCLUSION: Diffuse and symptomatic conjunctival calcinosis is uncommon condition of ocular calcium deposition. Hyperparathyroidism and renal failure are the contributing factors for the development of it.
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·AIM: To report cases of carotid cavernous fistula in post traumatic patients successfully treated with coil embolization.·METHODS: Two cases of direct carotid cavernous fistula (CCF) underwent successful coil embolization. Both patients presented with clinical features of CCF following motor vehicle accident at two weeks and four months. One patient had good visual acuity with raised intraocular pressure (IOP) and the other had poor vision with borderline IOP. The diagnosis was confirmed with cerebral angiography. Coil embolization were performed in both cases.·RESULTS; After the procedure the vision was back to normal and IOP came down to normal range without anti-glaucoma. The features of CCF were also resolved, which included proptosis, ophthalmoplegia, chemotic conjunctiva, orbital bruit and fundus changes.·CONCLUSION: Carotid cavernous fistula should be diagnosed and treated early to prevent serious ocular complication of vision loss. Endovascular embolization is the current treatment of choice.
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A 43 year-old man presented with pain on the right tooth for three days duration. Computed tomography showed left orbital cellulitis and right parapharyngeal abscess. There was also evidence suggestive of a dental abscess over right upper alveolar region. Magnetic resonance imaging revealed left superior ophthalmic vein thrombosis. Emergency drainage of the right parapharyngeal abscess was performed. Right maxillary molar extraction revealed periapical abscess. Left eye proptosis markedly reduced after initiating heparin.