Traumatic Orbital Emphysema Following Blunt Trauma and Nose Blowing.

Orbital emphysema commonly resolves with no morbidity. However, sight-threatening complications, such as central retinal artery occlusion and ischemic optic neuropathy, may occur, which can result in poor visual outcomes. Plain skull X-ray, which is widely available, is a useful tool in identifying orbital emphysema. We report a case of a 29-year-old gentleman with underlying allergic rhinitis who presented with a painless, progressively increasing periorbital swelling of the right eye, which was aggravated by nose blowing. He had a history of blunt trauma one day prior to the presentation. Visual acuity was unaffected and optic nerve function tests were unremarkable. There was right upper lid swelling with crepitations, right hypoglobus with restricted upward gaze movement, and right conjunctival injection. Intraocular pressure was within normal limits. The posterior segment examination was unremarkable. A plain skull radiograph revealed a "black eyebrow sign" over the right orbit with no obvious orbital wall fracture. Computed tomography of the orbit showed focal indentation over the right lamina papyracea with superior orbito-palpebral emphysema. Systemic antibiotics, steroid nasal spray, and oral antihistamines were initiated with the prohibition of nose blowing. On post-trauma day five, he made an uneventful recovery. High clinical suspicion and thorough clinical examination with the aid of a plain skull radiograph can diagnose orbital emphysema in order for prompt referral to be undertaken to prevent morbidity. Clinicians should consider orbital emphysema as a differential diagnosis for periorbital swelling, especially if there was a preceding trauma.

Preferred cataract surgery practices in Malaysia: a survey based study.

BACKGROUND: To describe the preferred cataract surgery practices among Malaysian ophthalmologists and medical officers in comparison with the recommended practices. METHODS: An online questionnaire was sent out in April 2021, to Malaysian Ophthalmologists and medical officers who perform cataract surgeries. The questions were focused on the preferred cataract surgery practices of the participants. All data obtained were collected, tabulated and analysed. RESULTS: A total of 173 participants responded to the online questionnaire. 55% of the participants were within 31-40 years of age. 56.1% preferred peristaltic pump over venturi system. 91.3% of participants practised povidone iodine instillation to the conjunctival sac. With regards to the main wound incision, more than half of the surgeons (50.3%) preferred fixed superior incision and 72.3% of them preferred 2.75 mm microkeratome blade. Most of the participants (63%) were inclined towards C-Loop clear intraocular lens (IOL) with a single-handed push preloaded system. 78.6% of the surgeons routinely use carbachol in their cataract surgery. CONCLUSIONS: This survey provides some insight into the current practices among Malaysian ophthalmologists. Most of the practices are in line with international guidelines for preventing postoperative endophthalmitis. This article could help trainees and ophthalmologists benchmark and observe the common cataract surgery practices among their seniors and peers in Malaysia.

Eight-and-a-half syndrome as the first presentation of multiple sclerosis in an Asian male: a case report.

BACKGROUND: Multiple sclerosis is a diffuse chronic demyelinating disease of the central nervous system. It is relatively uncommon in the Asian population and even more so in males. Despite the usual involvement of the brainstem, eight-and-a-half syndrome remains a rare first presentation in multiple sclerosis. Only a few cases have been reported previously, but none involving the Asian population. Eight-and-a-half syndrome, a neuro-ophthalmological condition, is characterized by one-and-a-half syndrome with ipsilateral lower facial nerve palsy, which localizes lesions to the pontine tegmentum. This case report demonstrates the first case of eight-and-a-half syndrome as the first presentation of multiple sclerosis in an Asian male. CASE PRESENTATION: A healthy 23-year-old Asian man presented with sudden onset of diplopia followed by left-sided facial asymmetry for 3 days. Assessment of extraocular movement revealed left conjugate horizontal gaze palsy. On right gaze, there was limited left eye adduction and horizontal nystagmus of the right eye. These findings were consistent with a left-sided one-and-a-half syndrome. Prism cover test revealed left esotropia of 30 prism diopters. Cranial nerve examination showed left lower motor neuron facial nerve palsy, while other neurological examination was normal. Magnetic resonance imaging brain showed multifocal T2 fluid attenuated inversion recovery hyperintense lesions, involving bilateral periventricular, juxtacortical, and infratentorial regions. A focal gadolinium contrast-enhanced lesion with open ring sign on T1 sequence was seen at the left frontal juxtacortical region. Multiple sclerosis was diagnosed on the basis of the clinical and radiological evidence, which fulfilled the 2017 McDonald criteria. Positive oligoclonal bands in cerebrospinal fluid analysis further confirmed our diagnosis. He had a complete resolution of symptoms 1 month after a course of pulsed corticosteroid therapy, and was subsequently placed on maintenance therapy with interferon beta-1a. CONCLUSION: This case illustrates eight-and-a-half syndrome as the first presentation of a diffuse central nervous system pathology. A wide range of differential diagnoses needs to be considered in such a presentation as based on the patient's demographics and risk factors.

Enriching traditional didactic teaching in undergraduate ophthalmology with lateral thinking method: a prospective study.

PURPOSE: To evaluate undergraduate medical students' perspective on lateral thinking pedagogy in teaching clinical ocular anatomy in correlation to developing differential diagnoses and recognising red flags in managing common eye conditions. METHODS: The prospective study compared the lateral thinking method (LTM) versus the traditional didactic method in teaching clinical ocular anatomy. Two hundred seventy-two medical students who underwent ophthalmology clerkships were recruited over 3 years. They were randomised into two groups, the LTM and regular didactic groups. Students participated in pre and post-tests to assess their theoretical clinical ophthalmic knowledge, and their responses to respective teaching methods were measured via the self-assessment questionnaire (SAQ), which incorporated a five-point Likert-type scale. RESULTS: Overall, the LTM group scored significantly higher than the control group, and they found the innovative teaching method improved their confidence and awareness in theoretical knowledge in generating differential diagnoses, managing common eye conditions and recognising potential signs that could be sight and/or life-threatening compared to the regular teaching group (P < 0.05). However, all students were neutral towards both lectures regarding changing their negative perception of the current ophthalmic curriculum. CONCLUSION: From the student's perspective, LTM is an effective tool in enriching regular teaching. The method encouraged versatile thinking patterns while enhancing the effectiveness of learning experience in time and resource-limited undergraduate ophthalmic teaching.

Familial exudative vitreoretinopathy in a 4 generations family of South-East Asian Descendent with FZD4 mutation (c.1501_1502del).

BACKGROUND: Familial Exudative Vitreoretinopathy (FEVR) is a hereditary disorder characterized by peripheral avascular retina with neovascularization. Although FEVR has been thoroughly described in multiple literature publications from different countries, there are currently limited articles describing the phenotypes of FEVR among South-East Asian Descendent. This paper describes the clinical phenotype of the FZD4 gene with c.1501_1502 deletion in a 4-generation case series of a South East Asian family. METHODS: We reviewed a 4-generation case series of a South-East Asian descendent family consisting of 27 family members with 10 members diagnosed with FEVR. We observed the clinical phenotype of these series of patients, including some of the family members who underwent whole-exome sequencing, PCR amplification and DNA sequencing techniques to identify the mutated gene. RESULTS: Frameshift mutation (c.1501_1502del) were found in FZD4 gene in this series of patients with the age ranging from 1 month old to 69 years old. There was a 100% (4/4) of our paediatric patients being diagnosed within 21 days of life. It was also found that 75% of patients (6/8) less than 40 years old exhibited disease asymmetry of 2 stages or more and 80% (8/10) had a history of vitreoretinal surgery or diode laser photocoagulation, with a further 50% of the adult patients identified as legally blind; the mean age of blindness was 18-years-old. CONCLUSIONS: Phenotypic manifestation of FZD4 gene with c.1501_1502del mutation can be identified within the neonatal period. They have relatively greater clinical asymmetry of 2 stages or more compared to other mutations. Without treatment, most of them will have bilateral severe visual impairment around the adolescent age group.

Godtfredsen syndrome - recurrent clival chondrosarcoma with 6 years follow up: a case report and literature review.

BACKGROUND: We report a rare case of Godtfredsen syndrome caused by clival chondrosarcoma and perform a review of literatures. This article also explains the clinico-anatomical correlation of this rare neurological syndrome. CASE PRESENTATION: A 22-year-old gentleman presented with binocular diplopia. Clinical examination revealed an isolated right abducent nerve and right hypoglossal nerve palsy, with other cranial nerves intact. Neuroimaging revealed a right clival mass. Supraorbital craniotomy and tumour debulking were done in the same year. Histopathological examination showed low-grade chondrosarcoma. After 5-years of default, he came back with the tumour enlarged. He underwent a right orbitozygomatic craniotomy and tumour excision with 33 cycles of radiotherapy. Despite two surgeries and radiotherapy, the abducent nerve and hypoglossal nerve did not improve throughout 6 years of follow-up. Cranial nerve VI palsy is not always a false localizing sign, in Godtfredsen syndrome it serves as a localizing sign. CONCLUSION: To the best of our knowledge, this is the first case report of Godtfredsen Syndrome secondary to clival chondrosarcoma. Cranial nerve VI and XII palsy with no involvement of other cranial nerves, most likely the pathology is located at the clivus.

Update on surgical management of complex macular holes: a review.

Modern surgical interventions effectively treat macular holes (MHs) more than 90%. Current surgical treatment for MHs is pars plana vitrectomy with epiretinal membrane, internal limiting membrane (ILM) peeling, gas endotamponade, and prone posturing postoperatively. However, a small subset of MHs imposes challenges to surgeons and frustrations on patients. A narrative review was performed on the surgical treatment of challenging MHs including large and extra-large MHs, myopic MHs with or without retinal detachment, and chronic and refractory MHs. There are robust data supporting inverted ILM flap as the first-line treatment for large idiopathic MHs and certain secondary MHs including myopic MHs. In addition, several studies had shown that ILM flap manipulations in combination with surgical adjuncts increase surgical success, especially in difficult MHs. Even in eyes with limited ILM, surgical options included autologous retinal graft, human amniotic membrane, and creation of a distal ILM flap that can assist in MH closure even though the functional outcome may be affected by the MH chronicity. Despite relative success anatomically and visually after each technique, most techniques require a long-term study to analyze their safety profile and to establish any morphological changes of the MH plug in the closed MHs.

A rare case of unilateral Cogan's anterior internuclear ophthalmoplegia, upgaze palsy and ataxia caused by dorsal tegmentum lesion at pontomesencephalic junction.

BACKGROUND: Cogan's anterior internuclear ophthalmoplegia (INO) is characterized by INO with inability to converge and commonly thought to be due to rostral midbrain lesion. A lesion outside midbrain that causes unilateral Cogan's anterior INO combined with upgaze palsy and ataxia are rarely described. CASE PRESENTATION: A 67-year old male presented with left Cogan's anterior internuclear ophthalmoplegia (INO), left appendicular ataxia and bilateral upgaze palsy. A Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA) brain showed a left dorsal tegmental infarct at the level of pontomesencephalic junction. CONCLUSIONS: This case highlights the clinical importance of Cogan's anterior INO in combination with upgaze palsy and ataxia, and report possible site of lesion in patients with such constellation. Clinicians should consider looking for cerebellar signs in cases of Cogan's anterior INO, apart from just considering localizing the lesion at the midbrain.

Human coronaviruses: ophthalmic manifestations.

The 2019 novel coronavirus which causes severe acute respiratory syndrome (SARS) known as SARS-CoV-2 still remains as a global pandemic since its discovery and continues to spread across the world, given how highly contagious the virus is. We reviewed various articles that explore eye involvement in COVID-19 and other human coronaviruses, its human manifestations in comparison to animal studies and potential mechanism of viral entry into the eye surface. Evidence of animal studies depicted various complications of coronaviruses infection into the eyes, in both anterior and posterior segments of the eye. Conjunctival inflammation remains uncommon in association with COVID-19, with other ophthalmic findings. The risk of transmission via the ocular surface remains likely low, though it is inarguably present based on preliminary finding of viral load in ocular samples and expression of ACE2 on the ocular surface. Testing the tears sample for diagnosing SARS-CoV-2 was unreliable due to limitations of the testing kits and conflicting evidence of the viral titre in the ocular samples. Further larger, more precise and specific studies are required to allow us to better understand the pattern of virulence underlying the associations of SARS-CoV-2 in the eye despite its rare occurrence. This review article aims to enhance better awareness among clinicians regarding ocular manifestations associated with COVID-19 and necessary precautions should be implemented to minimise the risk of person-to-person especially in the nosocomial setting.

Factors predicting screen time related to physical and behavioural complaints in primary school children

@#problems from extended usage of electronic devices areissues among primary school children. This study is aimedto investigate the prevalence of physical and behaviouralcomplaints arising from the electronic device usage and toidentify the potential factors that predicted the complaints.Methods: This was a primary school-based cross-sectionalstudy using multistage cluster sampling, conducted at Baudistrict in Sarawak, Malaysia in 40 primary schools. Aquestionnaire was used to collect information of usagepattern in insufficient lighting, timing and position. Thephysical and behavioural complaints were traced. Dataanalysis was performed using SPSS version 22. A p-value <0.05 with 95% CI was considered as statistically significant. Results: About 52.8% of the 569 students used digitaldevices in a bright room, 69.8% in the day time and 54.4% insitting position. The physical complaints were headache(32.9%), neck, shoulder and back pain (32.9%) followed by byeye strain (31.8%). Regarding behavioural problems, 25.7% ofthe students had loss of interest in study and outdooractivities (20.7%), skipped meals (19.0%) andarguments/disagreements with parents (17.9%). After logisticregression analysis, the lying position (OR=1.71, 95% CI:1.096, 2.688) and darkroom lighting (OR=2.323 95% CI: 1.138,4.744) appeared to be potential predictors of the complaint.Conclusion: One-quarter of the students studiedexperienced physical complaints, and one-fifth hadbehavioural problems associated with the use of electronicdevices. Lying position and darkroom lighting are thepotential predictors of complaints. Therefore, we suggestthat the children should use electronic devices in the sittingposition with adequate room lighting.

Comparison of Icare Rebound Tonometer and Perkins Applanation Tonometer in Community Eye Screening.

PURPOSE: To compare the measurement of intraocular pressure (IOP) of Icare rebound tonometer and Perkins applanation tonometer (PAT) during community eye screening and to assess the agreement between these 2 instruments. DESIGN: A cross-sectional, non-interventional study. METHODS: The IOP measurements by handheld Icare rebound tonometer (Finland) were first performed by a primary care physician. Then the IOP was measured using Perkins Mk3 applanation tonometer (Haag-Streit, UK) by an ophthalmologist who was masked to previous readings from the Icare rebound tonometer. The mean IOP measured by each tonometer was compared. Pearson correlation coefficient was used to explore the correlation between the IOP measurements of the 2 instruments. The level of agreement between them was assessed using the Bland and Altman method. RESULTS: A total of 420 left eyes were examined. The mean age of subjects was 38.6 ± 18.2 years. Approximately 67% of subjects were female. The mean IOP was 16.3 ± 4.0 mm Hg using Icare and 13.4 ± 2.3 mm Hg using PAT. Pearson correlation coefficient showed a moderate positive correlation between the 2 methods (r = +0.524, P < 0.001). Linear regression analysis revealed a slope of 0.28 with R² of 0.255. The mean difference between the 2 methods was 2.90 ± 3.5 mm Hg and the sample t-test revealed a statistically significant mean difference from 0 (P < 0.001). The 95% limits of agreement between the 2 methods were between -9.73 and 3.93 mm Hg. CONCLUSIONS: The handheld Icare rebound tonometer is a reasonably acceptable screening tool in community practices. However, Icare overestimated IOP with a mean of 2.90 mm Hg higher than the PAT. Thus, using Goldmann applanation tonometer as a confirmatory measurement tool of IOP is suggested.

Iatrogenic intralenticular broken steroid implant: a case report.

BACKGROUND: This is a case report of an iatrogenic intralenticular broken steroid (Ozurdex™) implant in a patient with uveitis. There are only a few case reports on broken Ozurdex™ implants in the vitreous cavity, with none of them involving the crystalline lens. A few authors have described the accidental injection of an Ozurdex™ implant into the crystalline lens, but all of the implants remained in one piece in the lens and none of them were broken. We report an unusual case of an Ozurdex™ implant which was injected inadvertently into the crystalline lens, resulting in a broken Ozurdex™ implant with an entry and exit wound through the posterior capsule of the lens. CASE PRESENTATION: An ophthalmic trainee performed an Ozurdex™ intravitreal injection into a 48-year-old Asian man's right eye under aseptic conditions. This patient was then followed up for further management. On day 7 post-procedure, a slit lamp examination revealed that the Ozurdex™ implant was injected into the intralenticular structure of his right eye and had fractured into two pieces. The posterior capsule of the right lens was breached, with one half of the Ozurdex™ implant stuck at the entry and the other stuck at the exit wound of the posterior capsule. This patient underwent right eye cataract extraction and repositioning of the fractured implant; he made an uneventful recovery. CONCLUSIONS: Ophthalmologists should be aware of the potential risk of injecting an Ozurdex™ implant into an anatomical structure other than the vitreous cavity. Adequate training and careful administration of the Ozurdex™ implant are necessary to avoid such a complication, which fortunately is rare.

Systematic Review of the Effect of Reflective Materials Around a Phototherapy Unit on Bilirubin Reduction Among Neonates With Physiologic Jaundice in Developing Countries.

OBJECTIVE: To identify the efficacy and safety of the use of various cost-effective reflective materials around phototherapy units to reduce the duration of phototherapy and hasten the reduction of bilirubin among neonates with physiologic jaundice. DATA SOURCES: A systematic review of randomized controlled trials identified from searches in the Cumulative Index to Nursing and Allied Health Literature, ScienceDirect, Embase, and the Cochrane Library with the use of keywords, MeSH terms, operators, and the review of reference lists of retrieved articles. STUDY SELECTION: From a total of 186 studies initially screened, five were eventually included in this analysis. DATA EXTRACTION: Two authors independently reviewed each study with a standard template. Review parameters included the quality of each study based on the Physiotherapy Evidence Database scale and the Consolidated Standards of Reporting Trials guidelines. DATA SYNTHESIS: All studies were generalizable and were rated as high quality on the Physiotherapy Evidence Database scale; one study scored 8 points, and the other four scored 6 points each. The reflective materials used in these studies included the following: white 100% cotton cloths (one study), white plastic covers (two studies), underpads (one study), and silver fabric cloth (one study). Pooled analysis of three studies indicated that reflective materials significantly reduced the duration of phototherapy with a large effect size of 0.82 (p = .04). Pooled analysis of another three studies indicated that the mean decrease of the total serum bilirubin 4 hours after the initiation of phototherapy was significantly greater when reflective materials were added (mean difference of 11.39 µmol/L, 95% confidence interval [2.26, 20.52 µmol/L], p = .01). CONCLUSION: The addition of reflective materials to phototherapy units may be therapeutic for neonates with physiologic jaundice.

A Review on the Extraction of Quantitative Retinal Microvascular Image Feature.

Digital image processing is one of the most widely used computer vision technologies in biomedical engineering. In the present modern ophthalmological practice, biomarkers analysis through digital fundus image processing analysis greatly contributes to vision science. This further facilitates developments in medical imaging, enabling this robust technology to attain extensive scopes in biomedical engineering platform. Various diagnostic techniques are used to analyze retinal microvasculature image to enable geometric features measurements such as vessel tortuosity, branching angles, branching coefficient, vessel diameter, and fractal dimension. These extracted markers or characterized fundus digital image features provide insights and relates quantitative retinal vascular topography abnormalities to various pathologies such as diabetic retinopathy, macular degeneration, hypertensive retinopathy, transient ischemic attack, neovascular glaucoma, and cardiovascular diseases. Apart from that, this noninvasive research tool is automated, allowing it to be used in large-scale screening programs, and all are described in this present review paper. This paper will also review recent research on the image processing-based extraction techniques of the quantitative retinal microvascular feature. It mainly focuses on features associated with the early symptom of transient ischemic attack or sharp stroke.

The incidence of acute angle closure in Scotland: a prospective surveillance study.

PURPOSE: To estimate the incidence, and describe the clinical features and short-term clinical outcomes of acute angle closure (AAC). METHODS: Patients with newly diagnosed AAC were identified prospectively over a 12-month period (November 2011 to October 2012) by active surveillance through the Scottish Ophthalmic Surveillance Unit reporting system. Data were collected at case identification and at 6 months follow-up. RESULTS: There were 114 cases (108 patients) reported, giving an annual incidence of 2.2 cases (95% CI 1.8 to 2.6) or 2 patients (95% CI 1.7 to 2.4) per 1 00 000 in the whole population in Scotland. Precipitating factors were identified in 40% of cases. Almost one in five cases was associated with topical dilating drops. Best-corrected visual acuity (BCVA) at presentation ranged from 6/6 to perception of light. The mean presenting intraocular pressure (IOP) was 52 mm Hg (SD 11). Almost 30% cases had a delayed presentation of 3 or more days. At 6 months follow-up, 75% had BCVA of 6/12 or better and 30% were found to have glaucoma at follow-up. Delayed presentation (≥3 days) was associated with higher rate of glaucoma at follow-up (22.6% vs 60.8%, p<0.001), worse VA (0.34 vs 0.74 LogMAR, p<0.0001) and need for more topical medication (0.52 vs 1.2, p=0.003) to control IOP. CONCLUSION: The incidence of AAC in Scotland is relatively low compared with the Far East countries, but in line with previous European data. Almost one in five cases were associated with pupil dilation for retinal examination.

MACULA RETINAL VASCULITIS AND CHOROIDITIS ASSOCIATED WITH GRANULOMATOSIS WITH POLYANGIITIS.

PURPOSE: To report a case series of two cases of granulomatosis with polyangiitis, previously known as Wegener granulomatosis, which developed macular necrosis, not previously associated with granulomatosis with polyangiitis, healed with fibrosis, despite aggressive immune-modulating therapy and good control of systemic disease. METHODS: Case series of two cases with observation of treatment progress. RESULTS: The results reported the progress of response to treatment in the two cases, which resulted in the final outcome of fibrosis in the macula region, despite being on aggressive immune-modulating therapy and good systemic control. CONCLUSION: Granulomatosis with polyangiitis can be associated with macular necrosis leading to fibrosis, unresponsive to immune-modulating therapy.

WIDESPREAD MACULAR NEUROSENSORY DETACHMENT AFTER OCRIPLASMIN INTRAVITREAL INJECTION.

PURPOSE: To present the case of a patient with vitreomacular traction who experienced immediate severe acute complications after ocriplasmin intravitreal injection. METHODS: Case report. RESULTS: A 61-year-old woman with vitreomacular traction underwent ocriplasmin treatment. Within 24 hours after injection, she noticed severe reduction in visual acuity. Spectral domain optical coherence tomography revealed release of vitreous traction, together with widespread subretinal fluid and decreased reflectivity in the outer retina. Ten weeks after treatment, visual acuity improved, although below pretreatment levels, with partial reduction in subretinal fluid. CONCLUSION: Intravitreal ocriplasmin can produce acute visual acuity changes with widespread subretinal fluid and outer retinal ellipsoid zone hyporeflectivity on spectral domain optical coherence tomography. The overall acute and long-term safety profile of ocriplasmin remains unknown.