Concurrent hyphema and orbital apex syndrome following herpes zoster ophthalmicus in a middle aged lady.

INTRODUCTION: Hyphema and orbital apex syndrome occurring concurrently in a patient with herpes zoster ophthalmicus have not been reported previously. We present a case with these unique findings and discuss the pathogenesis of these conditions and their management. PRESENTATION OF CASE: A 59-year-old Malay lady with underlying diabetes mellitus presented with manifestations of zoster ophthalmicus in the left eye. Two weeks later, she developed total hyphema, and complete ophthalmoplegia suggestive of orbital apex syndrome. She was treated with combination of intravenous acyclovir and oral corticosteroids, and regained full recovery of ocular motility. Total hyphema persisted, and she required surgical intervention. DISCUSSION: Hyphema is postulated to occur due to an immune vasculitis affecting the iris vessels. Orbital apex syndrome is probably due to an occlusive vasculitis affecting the vasculature of the extraocular muscles and optic nerve, resulting from a direct invasion by varicella zoster virus or infiltration of perivascular inflammatory cells. Magnetic Resonance Imaging of the brain is essential to exclude possibility of local causes at the orbital apex area. CONCLUSION: Herpes zoster ophthalmicus is an uncommon ocular presentation. Managing two concurrent complications; persistent total hyphema and orbital apex syndrome is a challenging clinical situation. Early diagnosis and prompt treatment are essential to prevent potential blinding situation.

Evaluation of anatomical and visual function for early detection of ethambutol toxicity among tuberculosis patients / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM:To evaluate if early ethambutol toxicity can be detected by comparing pre-and post-treatment anatomical and visual function using retinal nerve fiber thickness,pattern visual evoked potentials and conventional optic nerve function tests.METHODS:This was a prospective study involving 72 eyes of 36 patients treated with ethambutol according to directly observed treatment short-course(DOTS) strategy in Hospital Universiti Sains Malaysia,Kelantan,Malaysia.The visual acuity and optic nerve function tests were performed by a single investigator.Likewise,Humphrey automated perimetry,optical coherence tomography (OCT) measurement of the retinal nerve fibre layer (RNFL) and pattern visual evoked potential (PVEP) were performed by a single technician.The examinations were performed before initiating ethambutol treatment and 3mo after that.RESULTS:There was no change in visual acuity,colour vision,light brightness,red saturation and fundus findings pre and post ethambutol.However,there was a statistically significant deterioration in the mean deviation of the visual field post treatment (P=0.010).There were also significant changes on OCT and PVEP,with increased RNFL thickness in all quadrants (P＜ 0.05) and PVEP delayed P100 peak latency and amplitude (P＜0.001).CONCLUSION:Ethambutol toxicity is a known complication of tuberculosis treatment.Early detection of this toxicity may prevent severe irreversible visual loss.The use of OCT to detect RNFL thickness and PVEP to assess P100 latency and amplitude can assist in the detection of subclinical anatomical and visual function changes prior to development of abnormalities on conventional optic nerve function tests.

Successful Resolution of Preretinal Haemorrhage with Intravitreal Ranibizumab.

We would like to report two cases of preretinal haemorrhage from two different aetiology courses of bleeding being treated with intravitreal ranibizumab and its outcome. Our first case was a 39-year-old man with a diagnosis of severe aplastic anaemia that presented with bilateral premacular haemorrhages in both eyes. His right eye vision was 6/45 and it was counting finger in the left eye. He was treated with intravitreal ranibizumab once to the right eye and twice to the left eye. Right eye showed complete resolution of premacular haemorrhage and minimal residual premacular haemorrhage in the left eye at 3 months after initial presentation. Our second case was a 32-year-old healthy teacher that presented with preretinal haemorrhage at superotemporal region extending to macular area in left eye secondary to valsalva retinopathy. Her left vision was counting finger. She was treated with single intravitreal ranibizumab to the left eye. There was significant reduction of premacular haemorrhage and her left eye vision improved to 6/6 at 10 weeks after injection. Both cases had favourable outcome with intravitreal ranibizumab and can be considered as nonsurgical treatment option in treating premacular haemorrhage.

Intravitreal ranibizumab in treating extensive traumatic submacular hemorrhage.

Herein, we report our experience in treating extensive traumatic submacular hemorrhage with a single dose of intravitreal ranibizumab. A 23-year-old healthy Malay man presented with a progressive reduction of central vision in the left eye of 2 days' duration following a history of blunt trauma. Visual acuity was reduced to counting fingers. Examination revealed infero-temporal subconjunctival hemorrhage, traumatic anterior uveitis, and an extensive sub-macular hemorrhage with suspicion of a choroidal rupture in the affected eye. He was initially treated conservatively with topical prednisolone acetate 1%. The subconjunctival hemorrhage and anterior uveitis resolved but his vision remained poor with minimal resolution of the submacular hemorrhage at 1 week follow-up (day 12 post-trauma). In view of the poor resolution of submacular hemorrhage, he was treated with a single dose of 0.5 mg intravitreal ranibizumab at day 20 post-trauma. At 4 weeks post-intravitreal ranibizumab, there was an improvement in visual acuity (from counting fingers to 6/45) and complete resolution of the submacular hemorrhage with presence of a choroidal rupture scar temporal to the fovea, which was not seen clearly at presentation due to obscuration by blood. His visual acuity further improved to 6/18 at 3 months post-trauma. Although this single case had a favorable outcome, a large population cohort study is needed to establish the effectiveness of intravitreal ranibizumab in treating extensive traumatic submacular hemorrhage.

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.

Diffuse unilateral subacute neuroretinitis in a young boy: a case report.

We report a case of diffuse unilateral subacute neuroretinitis in a young boy with no clinical visualization of nematode. The diagnosis was made based on clinical findings and detection of Toxocara immunoglobulin G by Western blot test. An 11-year-old Malay boy presented with progressive blurring of vision in the left eye for a duration of 1 year. It was associated with intermittent floaters. Visual acuity in the left eye was 6/45 and improved to 6/24 with pinhole. There was positive relative afferent pupillary defect, impaired color vision, and presence of red desaturation in the left eye. There were occasional cells in the anterior chamber with no conjunctiva injection. Posterior segment examination revealed mild-to-moderate vitritis and generalized pigmentary changes of the retina with attenuated vessels. The optic disk was slightly hyperemic with mild edema. There was presence of multiple, focal, gray-white subretinal lesions at the inferior part of the retina. Full blood picture results showed eosinophilia with detection of Toxocara immunoglobulin G by Western blot test. Investigations for other infective causes and connective tissue diseases were negative. The diagnosis of diffuse unilateral subacute neuroretinitis secondary to Toxocara was made based on clinical findings and laboratory results. He was treated with oral albendazole 400 mg daily for 5 days and oral prednisolone 1 mg/kg with tapering doses over 6 weeks. At 1 month follow-up, the inflammation had reduced, and multiple, focal, gray-white subretinal lesions were resolved; however there was no improvement of vision.

Involvement of superior rectus muscles in pansinusitis, a case report / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To report the involvement of extraocular muscles in a patient with for a month. Ocular examination revealed right sided superior oblique and inferior rectus palsy or superior rectus restriction. Investigation with CT however revealed superior rectus thickening with surrounding pansinusitis. Drainage of ethmoid sinus and superior rectus recession was done to relieve the diplopia.required to relieve residual diplopia following surgical drainage.

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.

Fibrin glue for sealing early bleb leak :a case report / 国际眼科杂志(Guoji Yanke Zazhi)

A 63-year-old male presented with sudden diminution of vision, eye discomfort, redness and watering in his left eye. He had undergone glaucoma valve filtering surgery for refractive secondary glaucoma one week back. He also had a history of failed augmented trabeculectomy one year earlier in the same eye. Ocular examination showed best corrected visual acuity(BCVA) of 6/18 and there was a bleb leak, shallow anterior chamber and intraocular pression(IOP) of 6mmHg. Successful sealing of bleb leak was performed using fibrin glue resulted in deepening of anterior chamber with IOP of 13mmHg. This case demonstrates that, fibrin glue is an effective method for management of early filtering bleb leak.