Vitreous Haemorrhage: A Consequence of Herpes Simplex Acute Retinal Necrosis

@#Acute retinal necrosis (ARN) is a rare, blinding disease that typically affects adults. However, in this case report, we highlight the diagnosis, management and outcome of herpes simplex acute retinal necrosis in a 13-year-old healthy girl, who presented with painful right eye, redness and blurring of vision for one week. Examination of the right eye showed features of granulomatous panuveitis. Optic disc was swollen and retina appeared pale. There were multiple patches of retinitis and haemorrhages at mid-periphery of the fundus with inferior serous detachment observed. Rapidly progressive inflammation in just four days along with secondary cataract that obscured fundus view, imposed greater challenge to the diagnosis and management. Intravenous acyclovir 300mg, 3 times a day was initiated promptly while vitreous fluid was sent for polymerase chain reaction, which identified Herpes Simplex Virus-1. Inflammation improved, but she developed vitreous haemorrhage secondary to proliferative retinopathy, which required panretinal photocoagulation. ARN is therefore, principally a clinical diagnosis and high index of suspicion is crucial particularly, in children for prompt diagnosis and treatment. Complications should also be addressed timely to improve the chances of preserving vision.

Evaluation of Outer Retinal Layers in Diabetic Macula Edema Treated with Intravitreal Ranibizumab

Anti-vascular endothelial growth factor (VEGF) reduces choroidal thickness by choroidal hypoperfusion in diabetic macula oedema (DME) patients. Indirect effect of anti-VEGF towards outer retinal layers (ORL) which supplied by choroidal circulation has not been well described. We evaluate the ORL thickness between retinal pigment epithelium (RPE) with inner-segment-outer-segment photoreceptor junction (IS/OS) and RPE with external limiting membrane (ELM) in pre- and post-intravitreal Ranibizumab (IVR) treated eyes with central foveal diabetic macula edema. A total of 60 eyes (40 patients) were analysed. ORL thickness measured with optical coherence tomography at pre- and post-injection day 1, week 4 and week 6. Mean thickness of RPE-IS/OS was statistically significant over time (p=0.023) but not for RPE-ELM (p=0.216). Thickness ratio between RPE-IS/OS and RPE-ELM and central subfoveal thickness (CST) both showed statistically significant result over time with p=0.038 and p=0.000, respectively. We observed an initial reduction of ORL thickness at day 1 followed by increased in thickness at week 4 with subsequent reduction at week 6 was observed. ORL is an aspect that can be explore and emphasized further in patients considered for IVR injections. The long-term effects of IVR to the ORL however could not be concluded due to short follow up period.

Severe Orbital CellulitisSecondary to Chronic Sinusitis: Challenges in Saving the Eye

Orbital cellulitis is a relatively common disease affecting predominantly the paediatric population. Most cases occur as a result of spread from the nearby sinuses. Other causes include penetrating trauma or extension from infected adjacent structures.If left untreated, this condition may result in devastating sequelae such as orbital apex syndrome, cavernous sinus thrombosis, meningitis, cranial nerve palsies, intracranial abscess formation and even death.A 47 year old immunocompetent Burmese lady presented with left eyelid swelling of 2 days duration associated with eye redness, blurring of vision and diplopia. Previously, there was history of right maxillary sinusitis and parapharyngeal abscess 9 months prior to presentation. On examination, she was afebrile with vision of 1/60 for the left eye with positiverelative afferent pupillary defect (RAPD). The eye was proptosed and swollen with restricted extraocular movements in all gazes. Conjunctiva was injected with chemosis and there was corneal epithelial bedewing. Otherwise anterior chamber was quiet and intraocular pressure was 51mmHg. Bilateral fundus examination was normal. Computed tomography (CT) scan of the orbit and paranasal sinus showed dense sinusitis and periosteal abscess at the lateral orbital wall.She was started on intravenous (IV) Cefuroxime and Metronidazole and underwent Functional Endoscopic Sinus Surgery (FESS) and orbital decompression. Intra-operatively there was pus and debris at the left anterior ethmoid, maxillary and sphenoid air sinuses and cultures revealed Klebsiella pneumoniaewhich was sensitive to Cefuroxime. Despite medical and surgical treatment, left orbital swelling only reduced minimally. However after starting intravenous Dexamethasone the swelling dramatically improved. She completed 10 days of intravenous Dexamethasone. Upon discharge, she was given oral Dexamethasone 2mg daily for 2 weeks and completed 2 weeks of oral Cefuroxime and Metronidazole. Intraocular pressure normalised and vision recovered to 6/9. A repeat CT orbit 3 weeks later showed resolving preseptal and periorbital collection.

Lupus Nephritis with Visual Field Defect Secondary to Hypertensive Retinopathy: A Case Report

A 23-year-old lady presented with both eye progressive painless blurring of vision for two weeks in 2011. Prior to that she had malar rash, hair loss, photosensitivity and bilateral leg swelling. Ocular examination showed that visual acuity on the right was 6/60 and on the left was 6/24. Both optic disc were swollen with extensive peripapillary cotton wool spot (CWS), flame shape haemorrhages, dilated and tortuous vessels with macular oedema. Systemic examination revealed blood pressure of 176/111 mmHg, malar rash and alopecia. Diagnosis of grade 4 hypertensive retinopathy secondary to SLE was made. The diagnosis was confirmed by positive ANA/ dsDNA, low C3/ C4 and renal biopsy showed lupus nephritis. She was treated with oral prednisolone, hydroxychloroquine and cyclosporin A. Throughout the monitoring for hydroxychloroquine toxicity, vision over both eyes were 6/9, but serial visual fields showed non-progressive left superior and inferior scotoma while right eye showed inferior scotoma. The intraocular pressure was normal with pink optic disc and cup disc ratio of 0.3. Optical coherence tomography (OCT) showed temporal and nasal retinal nerve fiber layer thinning bilaterally. However, macula OCT, fundus fluorescein angiography and autofluorescence were normal. The visual field defect was concluded secondary to CWS indicating microinfarction of the retinal nerve fiber secondary to previous hypertensive retinopathy. Non-progressive visual field defects may occur after the appearance of CWS in hypertensive retinopathy and it should not be overlooked when diagnosing glaucoma or hydroxychloroquine toxicity.

Retinal Break Adjacent to the Optic Disc Causing Retinal Detachment in a Pathological Myopia

Retinal detachment is one of the common complications of pathological myopia due to presence of retinal break. However, retinal break commonly occurs in the peripheral retina. This case report illustrates the rare incidence of retinal break adjacent to the optic disc, highlights the possible causes of poor visual outcome following surgical repair as well as the possible measures to treat the complications.

Retinal Redetachment After Pneumatic Retinopexy – The Importance of Case Selection

Pneumatic retinopexy is known as one of the treatment options for a specific type of retinal detachment. It is done in an office setting and may be the most cost-effective means of retinal reattachment surgery. Location and size of the retinal break remain as the major criteria for a successful outcome. We describe a case that fulfilled all except one major criteria for pneumatic retinopexy and underwent multiple procedures but failed. Fluctuation in the resolution of the retinal detachment such as in this particular case suggested possibility of early treatment failure.

Choroidal Metastasis from Renal Cell Carcinoma Presenting with Exudative Retinal Detachment

A 42-year-old Chinese man, known case of renal cell carcinoma with lung metastasis, was referred to Universiti Kebangsaan Malaysia Medical Centre for left eye blurring of vision for one month duration, which was worse upon waking up in the morning and cleared up after 1-2 hours. On examination, visual acuities were 6/6 in both eyes. No relative afferent pupillary defect. Left fundus showed inferonasal retinal detachment without macular involvement. No retina break, no retinitis and no choroidal lesion seen. Right eye examination was normal. Optical coherence tomography (OCT) of left eye showed subretinal fluid temporal and inferior to optic disc. Fundus fluorescein angiography (FFA) left eye showed hypofluoresence in early phase but hyperfluorescence with pin point leakage in late phase over inferonasal quadrant. Indocyanine green (ICG) showed early hypofluoresence with late pin point hyperfluoresence in the same quadrant. A clinical diagnosis of exudative retinal detachment due to choroidal metastasis secondary to renal cell carcinoma was made. The patient was planned for cyber-knife radiotherapy of his left eye but unfortunately we lost the follow up. High index of suspicion and relevant investigation are needed for patients with visual complaints and history of renal cell carcinoma to diagnose choroidal metastasis.

Dislocated Posterior Chamber Intraocular Lens (PCIOL) in Patients with Retinitis Pigmentosa (RP)

Subluxation or dislocation of PCIOL is one of the complications of cataract operation in RP patients. This paper reports the presentation of PCIOL dislocation and subluxation and the management and outcome in 3 eyes of 2 RP patients. Two medical records of patients with RP who developed dislocated or subluxated PCIOL and subsequently underwent explantation of the dropped IOL were evaluated. Two patients had bilateral eye cataract operation done and had PCIOL implanted. Patient 1 developed left eye subluxated PCIOL inferiorly after 2 years of the cataract operation and right eye dislocated PCIOL anteriorly 4 years after cataract operation. Patient 2 develop right eye subluxated PCIOL inferiorly after 12 years of the cataract operation. Patient 1 with right eye dislocated PCIOL underwent intraocular lens (IOL) explantation and was left aphakic as her visual prognosis was poor due to advanced RP. The left IOL remained within the visual axis despite subluxation and no intervention has been done. Patient 2 with right eye subluxated PCIOL underwent IOL explantation and anterior chamber intraocular lens (ACIOL) implantation. ACIOL remained stable and visual acuity improved post-operation. Both the operations were uneventful. Post-operatively, there was no elevated intraocular pressure and no prolonged ocular inflammation, which required prolonged anti-inflammatory and no retinal detachment was seen. Both patient and surgeon should be aware of potential PCIOL subluxation or dislocation in RP. The presentation may be as late as more than a decade after the cataract operation.

Bilateral Compressive Optic Neuropathy Secondary to Tuberculum Sella Meningioma in Pregnancy

A 37-year-old primigravida in her second trimester presented with bilateral painless progressive visual loss. Her vision was hand motion in both eyes. Both pupils were dilated with sluggish reaction to light. Both fundus appeared myopic with bilateral optic atrophy. Magnetic resonance imaging (MRI) of the brain revealed a suprasellar mass with optic chiasm compression and bilateral optic nerve atrophy. As the mass has compromised her vision, a semiemergency craniotomy and excision of tumour was performed. Histopathological examination confirmed the diagnosis of low grade meningothelial meningioma. Both mother and foetus were well after the surgery. However, post-operatively her vision remained poor due to optic nerve atrophy.

Retinal Nerve Fibre Layer Thickness Changes after Pan-Retinal Photocoagulation in Diabetic Retinopathy

Diabetic retinopathy is a disease involving microangiopathic changes in response to chronic hyperglycaemia and pan retinal photocoagulation (PRP) is currently the mainstay of treatment for proliferative retinopathy. In the present study, we evaluated the effect of pan retinal photocoagulation (PRP) on retinal nerve fibre layer (RNFL) thickness in patients with diabetic retinopathy using optical coherence tomography (OCT). This was a prospective longitudinal study. Patients with Type 2 diabetes mellitus with proliferative diabetic retinopathy (PDR) or very severe non- (N)PDR requiring laser treatment were included in the study. PRP was performed by a single trained personnel. Peripapillary RNFL located 3.4 mm around the optic disc was evaluated using time-domain OCT. Examination was performed before treatment, and 2 and 4 months after laser treatment. In total, 39 subjects (39 eyes) were recruited into this study. Twenty-nine patients had PDR and 10 had very severe NPDR. Mean age was 54.97 ± 8.38 years. Male and female genders were almost equally distributed with 18 males and 21 females. Median thickness of average RNFL at baseline was 108.8 um (interquartile range [IQR] 35.3). At two months post-procedure, average RNFL thickness significantly increased to 117.4 (IQR 28.6; P = 0.006). Although, other quadrants revealed a similar trend of increasing thickness at two months but it was not significant. At 4 months post-laser treatment, RNFL thickness in all quadrants reduced to baseline levels with insignificant changes of thickness compared to prior to laser treatment. There was also no significant association between changes in RNFL thickness and HbA1c levels (P = 0.77). In conclusion, PRP causes transient thickening of the RNFL which recovers within 4 months post-laser treatment. At the same time, poor sugar control has no direct influence on the RNFL changes after PRP.

Patterns of Polypoidal Choroidal Vasculopathy among a Multiracial Population in a Malaysian Hospital

Polypoidal choroidal vasculopathy (PCV) is a retinal disorder characterized by aneurismal polypoidal lesions in choroidal vasculature. PCV appears to preferentially affect pigmented individuals and is considerably high among Asians. Most reports on patterns of PCV around Asia are based on a homogenous race (e.g. Chinese, Japanese) and very few descriptions from a multiracial population like those seen in Malaysia. The present study aimed to describe the demographic features, clinical and investigative characteristics of PCV in a multiracial group at Universiti Kebangsaaan Malaysia Medical Centre (UKMMC). Ninety one eyes of 86 PCV patients, comprising of Chinese (65.1%), Malays (31.4%), Indians (2.3%) and Eurasian (1.2%) were retrospectively reviewed. All underwent complete ophthalmic examination and investigations. Mean patient age was 70.4 years with a male preponderance (59.3%), and mostly unilateral presentation (94.1%). The logMAR mean presenting visual acuity was 0.78 ± 0.64. Polypoidal vascular lesions were located generally within the macula area (86.8%), manifesting mainly as submacular hemorrhage (59.3%). Interestingly a number of eyes (43.9%) had associated drusen. Optical coherence tomography largely demonstrated exudative changes (75.9%) and almost all patients (97.7%) had loss of external limiting membrane (ELM) and IS/OS interface. On indocyanine green angiography, majority of eyes had multiple polyps (82.4%) with ‘cluster’ (58.2%) being the commonest configuration. In conclusion, although the patterns of PCV in UKMMC were mainly similar to other Asian patients, a number of our patients had associated drusen. This indicates that PCV in our population could be a variant of neovascular age related macular degeneration and not solely idiopathic in nature.

Relationship between Central Corneal Thickness and Severity of Open Angle Glaucoma using Optical Coherence Tomography

Central corneal thickness plays a major role in the management of many types of glaucoma. Therefore, our aim is to determine the relationship between the severity of glaucoma measured by optical coherence tomography (OCT) and central corneal thickness (CCT) among normal tension and high tension glaucoma patients. This is an observational cross sectional study on 190 patients carried out in Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Three groups of patients were identified; 60 normal tension glaucoma (NTG), 61 primary open angle glaucoma (POAG) and 69 control. Patients were identified based on the glaucomatous visual field changes and previous record of intraocular pressure before treatment. Visual acuity and intraocular pressure measurements were recorded. Specular microscope was used to measure the CCT and the severity of glaucoma was evaluated objectively based on the retinal nerve fibre layer (RNFL) thickness using optical coherence tomography. Results showed NTG patients had significantly thinner cornea, 503.07±32.27μm compared to the control group, 517.45±31.74 μm (p=0.012). However, there was no significant difference between the CCT of POAG and NTG groups (p=0.386).Retinal nerve fibre layer (RNFL) thickness was significantly different between the glaucoma and the control groups (p<0.05 in all quadrant). However, correlation between CCT and severity of RNFL thinning was only found for the POAG group but not for the NTG group. (mean RNFL and superior quadrant RNFL; r=0.251,0.401) . This study demonstrated the correlation between CCT and severity of glaucoma in POAG patients but not for the NTG group. Therefore, CCT is related to the severity of POAG-related visual loss.