Sinonasal Lymphoma Presenting as Cavernous Sinus Syndrome: Case Report and Review of the Literature.

A 37-year-old man presented with a 1-week history of diplopia. He was under investigation by otorhinolaryngology for left sinonasal malignancy after imaging of the paranasal sinuses had revealed a large homogenous mass in the left nasal cavity. His visual acuity was 6/9 in each eye with no relative afferent pupillary defect. The left pupil, though was mid-dilated and unresponsive to light. He had a left-sided ptosis. Extraocular movements of the left eye were restricted in all directions of gaze and there was with limited abduction, dextroelevation and dextrodepression of the right eye. A trans-nasal biopsy revealed extranodal natural killer/T-cell lymphoma. Further imaging showed a large enhancing nasopharyngeal mass with intracranial extension to the cavernous sinuses and local infiltration together with intracranial abscesses. The patient was started on empirical intravenous antibiotics and supportive treatment. While awaiting institution of lymphoma chemotherapy, he died. The involvement of the cavernous sinus in sinonasal lymphoma represents an advanced stage. This case highlights that lymphoma should be considered in any patient presenting with a cavernous sinus syndrome and sinonasal disease.

Facial nerve palsy in otitis externa: A red flag?

Otitis externa is an infection of the external auditory canal. It rarely results in facial palsy except in severe cases such as necrotizing otitis externa, which is a life-threatening invasive infection of the external auditory canal. Early recognition with prompt and appropriate treatment of necrotizing otitis externa is crucial to prevent more sinister complications. Here we report a case of an elderly gentleman who presented with otitis externa and developed facial palsy a month later. We identified possible problems that may have led to the complication so that such an occurrence can be prevented in the future.

Comparative cohorts of retinopathy of prematurity outcomes of differing oxygen saturation: real-world outcomes.

OBJECTIVE: An ongoing third epidemic of retinopathy of prematurity (ROP) is contributed largely by developing nations. We describe a cohort of infants in a single neonatal unit where two limits of oxygen saturation were administered, to show real-world outcomes from trend in neonatology for higher oxygen to improve survival. METHODS AND ANALYSIS: This retrospective, comparative study of prospectively collected data in an ROP screening programme included infants indicated by gestational age ≤32 weeks, birth weight <1501 g, ventilation for 7 days or requiring oxygen >1 month, who underwent dilated fundoscopic examination from age 4 weeks, every 2 weeks until full retinal vascularisation. Infants with ROP were examined weekly and treated where indicated. Data were divided into two epochs. Epoch 1 oxygen saturation targets were [88-92%], epoch 2 targets [90-95% (99%)] with allowance of increase to 20% for several hours after procedures. Outcome measures included development of ROP, treatment, mortality, sepsis and intraventricular haemorrhage. RESULTS: A total of 651 infants underwent examination between 2003 and 2016. The incidence of ROP in epoch 1 was 29.1% and epoch 2 was 29.3% (p=0.24). ROP progression doubled in epoch 2 (5 vs 11%, p=0.006), proportion of cases treated halved (14% vs 6%, p=0.0005), sepsis was halved (78.5% vs 41.2%, p<0.0001) and intraventricular haemorrhage doubled (20.2% vs 43.8%, p=0.0001) in epoch 2. Mortality was 4% and 0% in epochs 1 and 2, respectively. CONCLUSION: Incidence of ROP did not differ, although ROP cases that worsened doubled with higher oxygen targets. ROP cases requiring treatment decreased, as did sepsis and mortality. Intraventricular haemorrhage cases doubled.

"Mummy, my eyelids are heavy": A case series of juvenile myasthenia gravis.

PURPOSE: To report three cases of juvenile myasthenia gravis aged between 18 and 24 months with ocular symptoms as their first presentation. METHOD: A case series. RESULTS: We present a case series of juvenile myasthenia gravis in a tertiary centre in Malaysia. Two of the three cases consist of a pair of twins who presented with ptosis of bilateral eyes; the first twin presented 4 months later than the second twin. These two cases were positive for anti-acetylcholine receptor antibodies and had generalized myasthenia gravis, whereas the other case was negative for receptor antibodies and was purely ocular myasthenia gravis. CONCLUSION: Juvenile myasthenia gravis is relatively rare in toddlers. Early diagnosis and commencement of treatment is important to slow the progression of the disease and avoiding life-threatening events.

Facial nerve palsy in otitis externa: A red flag?

@#Otitis externa is an infection of the external auditory canal. It rarely results in facial palsy except in severe cases such as necrotizing otitis externa, which is a life-threatening invasive infection of the external auditory canal. Early recognition with prompt and appropriate treatment of necrotizing otitis externa is crucial to prevent more sinister complications. Here we report a case of an elderly gentleman who presented with otitis externa and developed facial palsy a month later. We identified possible problems that may have led to the complication so that such an occurrence can be prevented in the future.

A Rare Case of Idiopathic Intracranial Hypertension in Prepubertal Age

@#A 2-year-old girl who was under genetic follow up for developmental delay and dysmorphism was accidentally found to have bilateral optic disc swelling during screening examination. She showed response to optokinetic drum examination and the anterior segment examination was unremarkable. Optic disc swellings were seen in both eyes. Lumbar puncture shows high opening pressure of 50 cm H2O with unremarkable CSF analysis. MRI of brain was done and showed features in keeping with mild cerebral atrophy, with no evidence of hydrocephalus or space occupying lesion. She was diagnosed with idiopathic intracranial hypertension and oral acetazolamide 125mg bd was commenced. However, papilloedema persist despite medical therapy. Ventriculoperitonel shunt was inserted to reduce the csf pressure. This case report highlights the importance of considering idiopathic intracranial hypertension as a cause of optic disc swelling in pre-pubertal children because delay in diagnosis and treatment may permanently affect visual function especially in children.

Central corneal thickness changes and horizontal corneal diameter in premature infants: A prospective analysis.

To report observations of horizontal corneal diameter (HCD) and central corneal thickness (CCT) changes in premature infants with stable optic disc cupping and intraocular pressures (IOPs). The HCD and CCT at term serve as a baseline for premature infants.Sixty-three premature infants were enrolled in a prospective case series. HCD, CCT, and IOP were measured. RetCam images of the optic discs were used to evaluate the cup-disc ratio (CDR) and read by an independent masked observer. Data were collected at between preterm (32-36 weeks) and again at term (37-41 weeks) postconceptual age. Left eye measurements were used for statistical analysis. Left eye findings were combined to construct predictive models for HCD and CCT.The mean HCD was 9.1 mm (standard deviation [SD] = 0.7 mm) at preterm and 10.0 mm (SD = 0.52 mm) at term. The mean CCT preterm was 618.8 (SD = 72.9) µm and at term 563.9 (SD = 50.7) µm, respectively. The average preterm CDR was 0.31 and at maturity was 0.33. Average IOP of preterm and term was 13.1 and 14.11 mm Hg, respectively. There was significant linear correlation between HCD with the postmenstrual age (r = 0.40, P < .01) and the head circumference (r = 0.33, P < .05). Predictive models were constructed for HCD (R = 0.52, 0.2 mm/wk) and CCT (R = 0.23, -11.4 µm/wk) with postconceptual ages.The HCD and CCT variation did not affect IOP reading over time. CCT was not correlated with birth parameters and decreased as the infant reached term. Corneal diameter correlated with gestational age at birth and head circumference.

Ocular perfusion pressure and ophthalmic artery flow in patients with normal tension glaucoma.

BACKGROUND: Vascular insufficiency has been reported to be a cause of normal tension glaucoma (NTG). The aim of this study was to compare ocular perfusion pressure (OPP) and ophthalmic artery flow (OAF) between patients with NTG and those without glaucoma. METHODS: We considered one eye each from 31 NTG and 15 non-glaucoma control patients. Blood pressure and intraocular pressure (IOP) were measured in the sitting position, for calculation of OPP. Humphrey visual field (HVF) assessment was then carried out on NTG patients. All patients then underwent Transcranial Doppler ultrasound measurements of OAF parameters, including mean flow velocity (MFV), end diastolic velocity (EDV), peak systolic velocity (PSV) and resistive index (RI). We looked at differences in OPP and OAF parameters between the two groups, and their correlations in NTG patients. T-tests, χ (2), ANOVA and Pearson Correlation tests were performed, with p < 0.05 considered statistically significant. RESULTS: There were no statistically significant differences in OPP between the NTG and control groups (60.5+/-8.7 mmHg and 62.9+/-10.2 mmHg respectively, p = 0.393), and also no statistically significant differences in MFV, EDV, PSV and RI (all p > 0.05). In the NTG group, there were positive correlations between OPP and both MFV (r = 0.416, p = 0.020) and EDV (r = 0.369, p = 0.041). There were no statistically significant correlations between HVF mean deviation and OPP or OAF parameters (all p > 0.05). CONCLUSION: There is no difference in OPP and OAF parameters between patients with NTG and non-glaucoma controls, suggesting that vascular insufficiency or dysregulation by themselves may not account for the pathogenesis of NTG.

Ocular Surface Disease in Glaucoma: Effect of Polypharmacy and Preservatives.

PURPOSE: To evaluate the prevalence of ocular surface disease (OSD) in glaucoma and nonglaucoma subjects using different clinical tests and to determine the effect of number of antiglaucoma medications and preservatives on OSD. METHODS: This is a cross-sectional, case-comparison study at the Eye Clinic of the University of Malaya Medical Centre, Malaysia, between June 2012 and January 2013. Glaucoma subjects (n = 105) using topical antiglaucoma medications were compared with control subjects (n = 102) who were not on any topical medications. The presence of OSD was assessed using the tear film breakup time (TBUT) test, corneal staining, Schirmer test, and Ocular Surface Disease Index (OSDI) questionnaire grading. RESULTS: The prevalence of OSD varied from 37 to 91% in the glaucoma group, depending on the type of clinical test. More subjects in the glaucoma group had corneal staining (63% vs. 36%, p = 0.004), abnormal Schirmer tests (39% vs. 25%, p = 0.049), and moderate OSDI symptoms (17% vs. 7%, p = 0.028). The percentage with abnormal TBUT increased with higher numbers of topical medications and was high with both benzalkonium chloride-containing and preservative-free eye drops (90% and 94%, respectively, both p < 0.001). Benzalkonium chloride was associated with a nearly three times higher odds ratio of showing abnormal OSDI. CONCLUSIONS: Ocular surface disease is common in those using topical antiglaucoma medications. Abnormal TBUT is associated with increasing number of eye drops and benzalkonium chloride-containing eye drops, although this also occurs with the use of preservative-free eye drops.

Combined low-dose oral propranolol and oral prednisolone as first-line treatment in periocular infantile hemangiomas.

PURPOSE: The purpose of this report was to describe 2 cases of periocular infantile hemangiomas (IHs) that were successfully treated with low-dose oral propranolol alone and in combination with oral prednisolone. METHODS: Two infants aged 3 months and 6 weeks, respectively, were referred for management of vision-threatening periocular IHs causing ocular displacement and obscuration of the visual axis. The first infant had a superficial left upper eyelid capillary hemangioma with extraconal extension and the second infant had a deep preseptal capillary hemangioma in the right lower eyelid with intraconal extension. Both cases were started on oral propranolol 0.5 mg/kg/day in divided doses and titrated up to 1.5 mg/kg/day as first-line therapy. The first infant was also given oral prednisolone 2 mg/kg/day during the initial first month of treatment. RESULTS: Rapid regression in sizes of the hemangiomas was seen within the first 3 days of treatment. By 2 months of therapy, both infants had achieved normal ocular alignment. The second infant experienced a transient period of hypotension after the first dose of propranolol was started but recovered spontaneously. Both infants did not experience any adverse effects of propranolol throughout the treatment period. CONCLUSIONS: Low-dose oral propranolol is an effective first-line therapy for the management of vision-threatening IH. Dose escalation in combination with oral prednisolone after pediatric assessment might be useful in avoiding adverse effects of propranolol in young infants.

Intravenous fluconazole for bilateral endogenous Candida endophthalmitis.

PURPOSE: To report a case of bilateral endogenous candida endophthalmitis treated with intravenous fluconazole. METHOD: A 54-year-old man with poorly controlled diabetes presented with blurring of vision in both eyes, associated with eye pain for the past 2 months. Ocular examination revealed vision RE 4/60 ph 6/24, left eye (LE) 3/60. Anterior chamber examination showed 2+ anterior chamber cells in the LE. A streak of hypopyon was also noted in the LE. Both fundi showed presence of vitritis and white opacities. Proliferative diabetic retinopathy was present bilaterally. A diagnosis of bilateral endogenous endophthalmitis was made. RESULT: The patient was empirically treated with intravitreal vancomycin/ceftazidime on 3 consecutive days pending culture and sensitivity result. Blood and urine samples were negative for organisms. Vitreous samples were taken at the first intravitreal. The culture and sensitivity report of the vitreous sample was positive for candida albicans, which was sensitive to fluconazole. The patient was commenced on intravenous fluconazole 400 mg daily. The patient underwent core vitrectomy in the LE. Fluconazole was continued for 4 weeks, and he showed dramatic improvement with vision 6/12 in both eyes (OU) and endophthalmitis completely resolved. CONCLUSION: There should be high index of suspicion of fungal endophthalmitis in patients with immune-compromised state even with no known septic foci.

Ocular Tuberculosis Initially Presenting as Central Retinal Vein Occlusion.

A 23-year-old man presented with central retinal vein occlusion. The retinal haemorrhages worsened and signs of retinal vasculitis appeared later as vision dropped from 6/60 to Counting Fingers. No signs of systemic disease were observed. Routine Mantoux test and chest radiograph were negative for tuberculosis. Fundus flourescein angiogram confirmed presence of retinal vasculitis. Both systemic and topical corticosteroid therapy were ineffective. Polymerase chain reaction analysis of vitreous fluid showed presence of Mycobacterium tuberculosis. A full 6-month course of antituberculosis therapy was given and inflammation subsided. Vision improved to 3/60. This is a rare case of ocular tuberculosis without evidence of systemic infection, presenting first as a central retinal vein occlusion.

Retinopathy of prematurity in extremely low birth weight infants in Malaysia.

PURPOSE: To identify differences in incidence, risk factors, and outcomes of retinopathy of prematurity (ROP) between 2 birth weight categories within a cohort of extremely low birth weight (ELBW) infants in Malaysia. METHODS: This was a prospective study of infants in the Special Care Nursery at the University of Malaya Medical Centre between 2003 and 2005. Outcome measures were presence or absence of ROP, most severe stage of ROP observed, and whether laser treatment was performed. Risk factors for treatment were analyzed in this cohort of treated patients, who were further divided into groups of birth weight <751 g and birth weight 751-1,000 g. RESULTS: The study protocol identified 70 qualifying ELBW infants. Of these, 41 (58.6%) developed ROP and 23 (32.9%) required laser treatment. Mean birth weight was 806.8 g (SD +/- 142.5); mean gestation was 27.4 weeks (SD +/- 2.2). Infants with birth weight <750 g were twice as likely to require treatment (OR = 2, p = 0.038). The risk factors for laser treatment by bivariate analysis were gestation <28 weeks (OR = 1.8, p = 0.001), duration of ventilation >1 week (OR = 1.5, p = 0.012), and intraventricular hemorrhage (OR = 2.5, p = 0.010). Zone 1 ROP was observed only in infants <751 g. CONCLUSIONS: The incidence of ROP in ELBW infants in Malaysia is comparable to that seen in the ETROP and CRYO-ROP studies. Within this group, birth weight <750 g doubled the likelihood that treatment would be required.