Vision Loss as a Presenting Symptom of Vitamin B12 Deficiency.

Nutritional optic neuropathy is a rare and often overlooked factor leading to bilateral, symmetrical, and gradual visual impairment. This condition falls within the category of metabolic neuropathies. We documented a case involving bilateral nutritional optic neuropathy attributed to pancytopenia associated with vitamin B12 deficiency. A healthy 65-year-old Indian woman reported a bilateral, progressive, painless decline in vision over the past six months. She had a history of reduced oral intake for the preceding year and denied experiencing any gastrointestinal or constitutional symptoms. Bilateral visual acuity was 1/60. Examination revealed pale optic discs with attenuated vessels in both eyes and a cup-disc ratio of 0.3. The blood analysis showed low indices and a deficiency in serum vitamin B12. Despite undergoing treatment, her vision remained impaired due to the chronic nature of the condition. This case highlights the importance of identifying visual symptoms in an elderly woman experiencing malnutrition caused by inadequate dietary habits, which leads to bilateral nutritional optic neuropathy.

Endogenous Endophthalmitis: A 10-Year Review of Cases on the East Coast of Malaysia.

Purpose Our study aimed to describe the clinical profile of endogenous endophthalmitis, focusing on patient demographics, infection sources, microbial profiles, clinical outcomes, and factors affecting the final visual outcome. Methods A retrospective review was performed on data from 68 eyes of 60 patients diagnosed with endogenous endophthalmitis and hospitalized in two tertiary hospitals on the East Coast of Peninsular Malaysia from January 2011 to December 2020. The analysis encompassed evaluating patient age, gender, laterality, risk factors, infection origins, presenting and final visual acuity, microbial results, treatment responses, and factors affecting final visual outcomes. Results The average age of the patient cohort was 54.9 ± 13.3 years. Females were more likely to have endogenous endophthalmitis than males (33, 55.0% vs. 27, 45.0%). Twenty-seven patients (45.0%) presented with endogenous endophthalmitis in the left eye, while 25 patients (41.7%) had it in the right eye, and eight patients (13.3%) had bilateral involvement. Most patients had underlying predisposing conditions, predominantly diabetes mellitus (53, 88.3%). Infection sources were identified in 42 patients (70.0%), out of which urinary tract infections account for the majority (11, 18.3%). Klebsiella species(14, 22.7%) were the leading pathogens and were significantly associated with liver abscess cases. In this series, the majority of patients had poor presenting and final visual acuity of worse than 3/60 (56, 82.4% and 53, 77.9%, respectively). Thirty-six eyes (52.9%) underwent vitrectomy, resulting in only four eyes (11.11%) achieving final visual acuity better than 6/12. Presenting visual acuity was identified as the factor contributing to the blind final visual outcome (r = 0.707, p < 0.001). Conclusion Females were found to be more commonly affected by endogenous endophthalmitis than males. Klebsiella species were the most commonly isolated microorganisms and were typically associated with liver abscesses. Urinary tract infection was the most common predisposing factor. A majority of the patients had poor presenting and final visual acuity, in which poor visual acuity is a significant indicator of blind visual outcomes.

Bilateral Eyelid Polyposis Due to Eccrine Hidrocystoma.

This case report discusses a diagnosis of eccrine hidrocystoma in a female patient aged 65 years who presented with bilateral, painless eyelid masses.

Evaluation of Visual Acuity, Macular Thickness, and Level of Proteinuria in Children with Nephrotic Syndrome.

PURPOSE: Macular edema, serous retinal detachment, and retinal pigment epithelial detachment have been reported in patients with nephrotic syndrome. However, there is limited data about macular thickness in children with nephrotic syndrome. The aim of this study was to compare the mean macular thickness in children with nephrotic syndrome and in a control group and to correlate it with visual acuity and level of proteinuria. METHODS: The comparative cross-sectional study included 66 children aged 6 to 17 years with nephrotic syndrome and healthy control seen in two tertiary centers in Malaysia. We recorded demographic data, as well as visual acuity, level of proteinuria, and the mean macular thicknesses in both groups. The mean macular thickness was measured using Stratus optical coherence tomography according to nine areas of the Early Treatment Diabetic Retinopathy Study map. RESULTS: The mean foveal thickness was 238.15 ± 22.98 µm for children with nephrotic syndrome and 237.01 ± 22.60 µm for the control group. There was no significant difference in the mean macular thickness between the groups (p = 0.843). A significant correlation with visual acuity was observed in the superior outer macula (r = -0.41, p = 0.019), the nasal outer macula (r = -0.41, p = 0.019), and the inferior outer macula (r = -0.40, p = 0.021). There was no significant correlation between the mean macular thickness and level of proteinuria (p = 0.338), although those with higher levels of proteinuria demonstrated a trend towards increased macular thickness. CONCLUSIONS: The mean macular thickness in children with nephrotic syndrome was similar to that of healthy children. A significant correlation between the mean thickness of the outer macular layer and the presenting visual acuity was observed. There was no correlation between the mean macular thickness and the level of proteinuria.

Staphylococcus aureus Orbital Abscess With Impending Compressive Optic Neuropathy in an Immunocompetent Individual With Subclinical Bacteriuria: A Case Report.

This is a case of an orbital abscess evidenced radiologically in a 41-year-old female with no comorbidities. She was healthy and had no history of trauma or infection of the adjacent structures. She denied having symptoms of upper or lower respiratory and urinary tract infections. The decision for surgical drainage was made following a slow response to antimicrobial agents after 24 hours, a progressive painful erythematous eyelid swelling, and further deterioration of vision. Her clinical condition and visual acuity improved following cutaneous incision and drainage. Culture and sensitivity results for urine and orbital abscess were positive for Staphylococcus (S.) aureus. The patient regained full visual recovery without any sequelae. In conclusion, an orbital abscess is a blinding and life-threatening condition that rarely occurs in immunocompetent individuals and uncommonly arises from distant sources. A high index of suspicion, early institution of appropriate diagnostic imaging, and aggressive medical and surgical treatment are necessary for a favorable visual outcome in orbital abscess cases.

Bilateral Primary Non-Hodgkin's Lymphoma of the Lacrimal Sac: A Case Report.

Primary non-Hodgkin's lymphoma of the lacrimal sac is extremely rare, usually representing secondary involvement of systemic malignancy. We report a case of bilateral primary non-Hodgkin's lymphoma of the lacrimal sac presenting with bilateral medial canthal swelling for one month which was preceded by a history of chronic bilateral epiphora and a recurrent history of dacryocystitis. The symptoms partially responded to systemic antibiotics for the past three years. Clinical examination revealed bilateral diffuse erythematous medial canthal swelling extending to the upper cheeks. CT of the orbits and paranasal sinuses demonstrated soft tissue masses involving bilateral lacrimal sacs and ducts. Endoscopic dacryocystorhinostomy (DCR) with excision biopsy of both lacrimal sac was performed and histopathologically confirmed the diagnosis of extranodal marginal zone B-cell lymphoma. She completed six cycles of chemotherapy. The symptoms subsided and radiologically showed a significant reduction of soft tissue mass at bilateral nasolacrimal sacs and ducts after completion of chemotherapy. Recurrent atypical presentation of dacryocystitis with suboptimal response to standard treatment should raise a suspicion of secondary cause. Histopathological examination is therefore crucial to avoid delays in diagnosis and treatment.

The Effect of Binaural Beat Audio on Operative Pain and Anxiety in Cataract Surgery under Topical Anaesthesia: A Randomized Controlled Trial.

Background: The aim of this paper was to examine the analgesic and anxiolytic effects of binaural beat audio in patients undergoing cataract surgery under topical anaesthesia. Methods: This was a prospective, randomized controlled trial of 61 patients undergoing cataract surgery under topical anaesthesia. They were divided into two research conditions; the binaural beat audio group, and a sham-control group (ear phones with no music). Patients completed the State-Trait Anxiety Inventory questionnaire (STAI), and their blood pressure (BP) and heart rate (HR) were measured pre- and post-intervention. Intraoperative pain levels were ascertained using a visual analog scale (VAS) completed immediately after the surgery. Results: The binaural beat group had significantly lower pain scores (p < 0.001), HR (p < 0.001), diastolic BP (p = 0.003), mean arterial pressure (p = 0.007) and anxiety (p = 0.009) than the control group. Within the binaural beat group, subjects experienced a statistically significant reduction in HR (p = 0.004) and anxiety (p < 0.001) levels compared to baseline values, while all parameters, except anxiety, increased significantly in the control group. Conclusions: Binaural beat audio decreases operative pain and anxiety in cataract surgery under topical anaesthesia. It may have additional benefits in modulating the tachycardic response to stress.

Retained Metallic Intraocular Foreign Body With Excellent Visual Outcome.

A healthy 25-year-old gentleman sustained a left eye perforating injury involving a metallic intraocular foreign body. Upon examination, his best-corrected visual acuity was 6/6 in the right eye and 1/60 in the left eye. There was a full thickness cornea-scleral laceration wound with uveal tissue prolapse at 7 o'clock. The pupil was peaked inferonasally. The anterior chamber was deep with cells grade 4+ and a hyphema level. The posterior segment could not be visualized due to a vitreous haemorrhage. The computed tomography scan revealed a high-density foreign body embedded in the posterior wall of the globe. He underwent primary toilet and suturing of the left eye cornea-scleral laceration, followed by pars plana vitrectomy with an endolaser and gas tamponade. However, the foreign body could not be identified intraoperatively. Post-operation, the left eye vision improved, achieving his premorbid best-corrected visual acuity of 6/6 by six months post-op. The intraocular foreign body was managed conservatively in view of the excellent visual acuity and the risk of further surgery. The patient has remained asymptomatic since then until his last follow-up at 30 months post-operation.

Acute Proptosis in a Diabetic Patient: Diagnostic and Therapeutic Dilemmas.

An elderly diabetic lady presented with a painful swollen right eye and blurred vision for one week, preceded by right eye redness for six months. Her right eye best-corrected visual acuity was finger counting at 1 m. There was right eye proptosis, limited extraocular muscle movements, corkscrew vessels, chemosis and elevated intraocular pressure, but no bruit. Fever was absent. Computed tomography of the brain and orbit showed thickened extraocular muscles and intraconal fat streakiness, with normal superior ophthalmic vein and concavity of the cavernous sinus. Intravenous antibiotics resulted in limited clinical improvement. The subsequent response to oral prednisolone was dramatic, with the improvement of visual acuity to 20/60 after three doses. In cases of atypical orbital cellulitis where antibiotics fail, one should consider differential diagnoses such as orbital inflammatory disease, vascular anomalies and masqueraders. We discuss the approach to the diagnosis of acute proptosis in a diabetic patient and highlight the role of corticosteroids in idiopathic orbital inflammatory disease.

Evaluation of Macular and Retinal Nerve Fiber Layer Thickness in Children with Type 1 Diabetes Mellitus without Retinopathy.

PURPOSE: There are limited data from Asian countries regarding retinal thickness in children with type 1 diabetes mellitus (T1DM). This study aimed to compare the macular and retinal nerve fiber layer (RNFL) parameters between diabetic children without retinopathy and non-diabetic healthy children. We also evaluated the factors associated with RNFL thickness in children with T1DM. METHODS: A comparative cross-sectional study was conducted among children with T1DM and healthy children aged 7 to 17 years old in Hospital Universiti Sains Malaysia from 2017 to 2019. Children with retinal disease or glaucoma were excluded. Macular and RNFL thicknesses were measured using spectral-domain optical coherence tomography. Demographic information, duration of diabetes, blood pressure, body mass index, visual acuity, and retinal examination findings were documented. Glycosylated hemoglobin levels, renal function, and blood lipid levels were also collected. RESULTS: Forty-one children with T1DM and 80 age- and sex-matched children were enrolled. Both sexes were affected. Mean duration of diabetes mellitus was 3.66 years. The mean glycated hemoglobin levels in the T1DM group was 9.99%. The mean macular and RNFL thicknesses in children with T1DM were 277.56 (15.82) µm and 98.85 (12.05) µm, respectively. Children with T1DM had a significantly thinner average macula, superior outer macula, nasal outer macula, mean RNFL, and inferior RNFL thickness compared to controls (p < 0.05). There was a significant association between nephropathy and the mean RNFL thickness. CONCLUSIONS: Children with T1DM had significantly decreased mean macular and RNFL thicknesses. Nephropathy is associated with an increased RNFL thickness.

Corticosteroid Therapy in Optic Neuropathy Secondary to Nasopharyngeal Carcinoma.

INTRODUCTION: Nasopharyngeal carcinoma (NPC) is a tumor arising from the epithelial cells of the nasopharynx. NPC can spread and invade the base of skull, nasal cavity, paranasal sinuses, pterygopalatine fossa, and apex of the orbit. However, the involvement of the optic nerve in NPC is rare. The purpose of this case report is to report the efficacy of corticosteroid therapy in optic neuropathy secondary to NPC. CLINICAL CASE: A 56-year-old Chinese woman, an active smoker, presented with a hearing deficit, persistent tinnitus and nasal congestion. Examination and investigations revealed the presence of a mass in the nasopharynx. Tissue biopsy revealed nasopharyngeal carcinoma. However, the Epstein-Barr virus was not tested. She was counseled for chemotherapy, but refused and was subsequently lost to follow up. She presented one year later with right eye ptosis associated with progressive worsening of diplopia and blurring of vision. Examination revealed multiple (second, third, fourth and sixth) cranial nerve involvement. Systemic examination and investigations revealed cervical lymphadenopathy and liver metastasis. Repeated imaging showed that the mass had invaded the base of the skull, cavernous sinus and orbital apices. Pulse dosing of corticosteroid therapy was commenced, resulting in dramatic improvement of vision. CONCLUSION: Optic neuropathy may be the presenting sign of NPC. Corticosteroid therapy can offer immediate visual improvement.

Heterogeneous bone-marrow stromal progenitors drive myelofibrosis via a druggable alarmin axis.

Functional contributions of individual cellular components of the bone-marrow microenvironment to myelofibrosis (MF) in patients with myeloproliferative neoplasms (MPNs) are incompletely understood. We aimed to generate a comprehensive map of the stroma in MPNs/MFs on a single-cell level in murine models and patient samples. Our analysis revealed two distinct mesenchymal stromal cell (MSC) subsets as pro-fibrotic cells. MSCs were functionally reprogrammed in a stage-dependent manner with loss of their progenitor status and initiation of differentiation in the pre-fibrotic and acquisition of a pro-fibrotic and inflammatory phenotype in the fibrotic stage. The expression of the alarmin complex S100A8/S100A9 in MSC marked disease progression toward the fibrotic phase in murine models and in patient stroma and plasma. Tasquinimod, a small-molecule inhibiting S100A8/S100A9 signaling, significantly ameliorated the MPN phenotype and fibrosis in JAK2V617F-mutated murine models, highlighting that S100A8/S100A9 is an attractive therapeutic target in MPNs.

Efficacy of WINROP as a Screening Tool for Retinopathy of Prematurity in the East Coast of Malaysia.

PURPOSE: To evaluate the efficacy of the "weight, insulin-like growth factor 1, neonatal retinopathy of prematurity" (WINROP) algorithm in predicting retinopathy of prematurity (ROP) requiring treatment in Malaysia. PARTICIPANTS: This was a retrospective study involving premature infants with gestational age less than 32 weeks treated from September 2016 to March 2019 in Hospital Universiti Sains Malaysia. Clinical diagnosis was made based on Early Treatment Retinopathy of Prematurity study. Participants' weekly weight gain since birth was entered in the website (http://winrop.com), along with date of birth, gestational age and final clinical examination outcome. WINROP software signals an alarm if an infant is at high risk of developing ROP requiring treatment during weight data entry. By using the alarm status, the sensitivity and specificity of this algorithm for predicting ROP requiring treatment were obtained. RESULTS: Ninety-two infants were included in this study. An alarm was detected in 67 infants (72.8%). There were a total of 53 infants (54.6%) with no ROP, 15 (16.3%) of whom developed stage 1 ROP, 10 (10.8%) who developed stage 2 ROP and 14 infants (15.2%) who developed stage 3 ROP. In our study, WINROP sensitivity was 95.2% and specificity was 33.8%. CONCLUSION: WINROP is recommended as an initial screening tool for premature infants at risk of developing treatment-requiring ROP in Malaysia. It may help to alert clinicians managing severely ill infants when clinical examinations are less possible.

Juxtacrine signalling via Notch and ErbB receptors in the switch to fate commitment of bone marrow-derived Schwann cells.

The phenotypic instability of adult tissue-derived Schwann cell-like cells (SCLCs) as revealed upon withdrawal of glia-inducing culture supplements limits their clinical utility for cell therapy and disease modelling. We previously overcame this limitation by co-culturing bone marrow-derived SCLCs with neurons purified from developing rat and subsequently human sensory neurons such that direct contact between cell types accomplished the cell-intrinsic switch to the Schwann cell fate. Here, our search for juxtacrine instructive signals found both Notch ligands and neuregulin-1 type III localized on the surface of DRG neurons via live cell immunocytochemistry. Bypassing ligand-induced release of the Notch intracellular domain (NICD) by transient transfection of SCLCs with the pAdlox/V5-His-NICD construct was shown to upregulate ErbB2/3. Interaction of ErbB2/3 with neuregulin-1 type III (NRG1 type III) as presented on neurons then mediated the switch to the Schwann cell fate as demonstrated by expression of S100ß/p75/ Sox10/Krox20. In contrast, treatment of cocultures with γ-secretase inhibitor perturbed Notch signalling in SCLCs and consequently deterred both upregulation of ErbB2/3 and the transition to the Schwann cell fate. Taken together, juxtacrine signalling via Notch is key to the upregulation of ErbB receptors for neuregulin-driven commitment of SCLCs to the Schwann cell fate.

The Use of Stents in Children with Nasolacrimal Duct Obstruction Requiring Surgical Intervention: A Systematic Review.

Nasolacrimal duct obstruction (NLDO) is the most common cause of childhood epiphora. It is managed conservatively in the first year of life, after which surgical treatment is classically based on a stepwise paradigm of probing, intubation, and dacryocystorhinostomy. This systematic review aims to present the current role of intubation in the management of children with NLDO requiring surgical intervention. A search for English-language articles from the electronic databases PubMed, SCOPUS, and the COCHRANE library was conducted over a period of five months in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane Handbook. The following keywords were used to aid retrieval: stents, children, lacrimal intubation, endoscopic dacryocystorhinostomy, external dacryocystorhinostomy, NLDO, dacryocystitis, congenital, acquired. The primary outcome was defined as the success of the intervention, determined by resolution of symptoms and patency of the lacrimal anatomy confirmed by the fluorescein dye disappearance test or syringing. Secondary outcomes included the presence of complications. A total of 144 articles were identified; of these, 35 fulfilled the study criteria. The majority of the included studies involved lacrimal intubation alone, followed by intubation as an adjunctive procedure to balloon dacryoplasty and dacryocystorhinostomy. The overall success rate of these procedures ranged from 41.1% to 100%. Post-operative complications were reported in 65.7% of the included studies. Lacrimal intubation was most commonly performed as a primary procedure in children with NLDO, with high success rates. The main complication was stent dislodgement. There is lack of evidence regarding the benefit of intubation over probing as primary treatment of congenital NLDO. In the absence of high-quality evidence, the decision of whether to perform lacrimal intubation in children with NLDO requiring surgical intervention depends on clinical judgement and other low-level evidence, such as observational non-randomised trials.

Survival Time of Visual Gains after Diabetic Vitrectomy and Its Relationship with Ischemic Heart Disease.

Vitrectomy surgery in proliferative diabetic retinopathy improves the vision-related quality of life. However, there is lack of data on the duration of maintenance of visual gains post vitrectomy. This study thus aimed to determine the survival time of visual gains and the prognostic factors of vision loss after vitrectomy surgery for complications of proliferative diabetic retinopathy. A retrospective cohort study was conducted in an ophthalmology clinic in Malaysia. We included 134 patients with type 2 diabetes mellitus on follow-up after vitrectomy for proliferative diabetic retinopathy. Visual acuity was measured using the log of minimum angle of resolution (LogMar). A gain of ≥0.3 LogMar sustained on two subsequent visits was considered evidence of visual improvement post vitrectomy. Subjects were considered to have vision loss when their post-operative visual acuity subsequently dropped by ≥0.3 LogMar. Kaplan-Meier analysis was used to determine the survival time of visual gains. Cox Proportional Hazard regression was used to determine the prognostic factors of vision loss. The median age of patients was 56.00 years (IQR ± 10.00). The median duration of diabetes mellitus was 14.00 years (IQR ± 10.00). Approximately 50% of patients with initial improvement post vitrectomy subsequently experienced vision loss. The survival time, i.e., the median time from surgery until the number of patients with vision loss formed half of the original cohort, was 14.63 months (95% CI: 9.95, 19.32). Ischemic heart disease was a significant prognostic factor of vision loss. Patients with underlying ischemic heart disease (adjusted HR: 1.97, 95% CI: 1.18, 3.33) had a higher risk of vision loss post vitrectomy, after adjusting for other factors. Approximately half the patients with initial visual gains post vitrectomy maintained their vision for at least one year. Ischemic heart disease was a poor prognostic factor for preservation of visual gains post vitrectomy.

Visual outcome and factors influencing surgical outcome of horizontal strabismus surgery in a teaching hospital in Malaysia: A 5-year experience.

PURPOSE: The available data on strabismus surgery in South East Asian countries are scarce. This study aimed to identify visual outcome and factors influencing surgical outcome of horizontal strabismus surgery in a Southeast Asian cohort. MATERIALS AND METHODS: A retrospective review of patients who underwent horizontal strabismus surgery between 2013 and 2017 in Hospital Universiti Sains Malaysia was conducted. Surgery was considered successful if the post-operative deviation was within 10 prism diopters at 6 months' postoperative period. Factors influencing the outcome of surgery at 6 months were identified. Chi-square and Fisher's exact tests were used in data analysis. RESULTS: Ninety-eight patients were included. Both genders were equally affected. Exotropia (58.2%) was the most common type. About 65.3% of patients had alternating strabismus, while 51% had an angle of deviation of more than 45 prism diopters. Amblyopia was documented in 14.3% of patients. Those operated on below 10 years of age comprised 64.3%. Ninety-four patients completed follow-ups at 6 months after the surgery. The success rate was 81.6%. Approximately 92% of the patients had best-corrected visual acuities of 6/12 and better at 6 months' postoperative period. There was no significant association between age of onset, gender, presence of amblyopia, type of deviation, amount of deviation, and postoperative best-corrected visual acuity with surgical outcome at 6 months' postoperative period (P > 0.05). CONCLUSION: The success rate was good. Postoperative best-corrected visual acuity was promising. Age of onset, gender, presence of amblyopia, type of deviation, amount of deviation, and postoperative best-corrected visual acuity did not influence the outcome of horizontal strabismus surgery in our review.

Mycotic Keratitis in a Tertiary Hospital in Northeastern Malaysia

Objectives: To identify the clinical profile, etiology, and outcome of culture-positive mycotic keratitis in a tertiary referral centre in the Northeastern part of Malaysia. Materials and Methods: A retrospective review of all patients with culture-positive mycotic keratitis in Hospital Universiti Sains Malaysia over a 3-year period, from January 2015 to December 2017. Results: This study included 27 eyes of 27 patients treated for mycotic keratitis based on a positive fungal culture. The most common predisposing factor was ocular trauma, in 22 patients (81.5%). Eleven patients (40.7%) had a presenting visual acuity worse than 6/60, due to central ulcer involvement. Approximately half of these (6 patients) experienced visual improvement post-treatment. Fusarium spp. was the most common fungus isolated (37%), followed by non-sporulating fungi and Curvularia spp. Three patients (7.4%) had corneal microperforations, which healed after gluing and bandage contact lens application. One patient (3.7%) required tectonic penetrating keratoplasty and 1 patient (3.7%) underwent evisceration. The final visual acuity was 6/18 or better in approximately half (14 patients) of our cohort and worse than 3/60 in approximately 20% (5 patients). Conclusion: Mycotic keratitis occurred mainly in males and secondary to ocular trauma. The most common organism isolated was Fusarium spp. Although treatment may improve vision, the visual outcome is guarded.

Tear cytokine levels in allergic rhinitis without ocular symptoms.

OBJECTIVE: To compare cytokine levels in the pre-corneal tear film between patients with allergic rhinitis, allergic rhinoconjunctivitis and the normal population. DESIGN: A comparative cross sectional study. PARTICIPANTS: Patients were divided into Group 1 (allergic rhinitis without conjunctivitis), Group 2 (allergic rhinoconjunctivitis), and Group 3 (normal population). METHODS: A comparative cross-sectional study was conducted. Patients were divided into; Group 1 (allergic rhinitis without conjunctivitis), Group 2 (allergic rhinoconjunctivitis), and Group 3 (normal controls). Tears were collected using Schirmer strips and cytokine analysis performed using enzyme linked immunosorbent assay. RESULTS: There were a total of 68 subjects. Median values of cytokines in the allergic rhinitis group were as follows; TNFa (45.34 pg/ml), IL-4 (61.91 pg/ml), IL-5 (8.92 pg/ml), IL-6 (538.37 pg/ml) and IL-8 (1438.72 pg/ml). Cytokine levels in the group with allergic rhinoconjunctivitis were approximately two-fold higher than in the group with allergic rhinitis only. The median cytokine level in the control group was lowest. A significant inter-group difference was observed for TNF-alpha, IL-4, IL-6 and IL-8 levels, with allergic rhinoconjunctivitis patients demonstrating significantly elevated cytokines compared to those with allergic rhinitis only (p<0.001). These four cytokines were also significantly higher in those with allergic rhinitis than in controls (p<0.005). Although the group with allergic rhinoconjunctivitis had the highest levels of IL-5, no statistically significant inter-group difference was noted (p=0.479). CONCLUSION: This study demonstrated the presence of raised tear film inflammatory cytokines even in allergic rhinitis patients without ocular symptoms. These patients may be at increased risk of developing allergic conjunctivitis. These findings not only substantiate the immunological theory of the naso-ocular reflex, but have clinical and therapeutic implications for the holistic management of allergic rhinitis and conjunctivitis.

Optic Perineuritis in Neuromyelitis Optica Spectrum Disorder.

Optic perineuritis (OPN) involvement in demyelinating disease is rarely encountered. To our knowledge, this is the first reported case of bilateral OPN associated with neuromyelitis optica spectrum disorder (NMOSD). We present a case of a healthy young gentleman who presented with OPN, initially presumed to have a young stroke but later diagnosed to be NMOSD. Early neuroimaging is essential to help distinguish optic neuritis (ON), and prolonged treatment of systemic immunosuppression is the mainstay of treatment.