Guidelines from an expert panel for the management of diabetic macular edema in the Malaysian population.

AIM: To derive a Malaysia guideline and consensus as part of the Malaysia Retina Group's efforts for diagnosis, treatment, and best practices of diabetic macular edema (DME). The experts' panel suggests that the treatment algorithm to be divided into groups according to involvement the central macula. The purpose of DME therapy is to improve edema and achieve the best visual results with the least amount of treatment load. METHODS: On two different occasions, a panel of 14 retinal specialists from Malaysia, together with an external expert, responded to a questionnaire on management of DME. A consensus was sought by voting after compiling, analyzing and discussion on first-phase replies on the round table discussion. A recommendation was deemed to have attained consensus when 12 out of the 14 panellists (85%) agreed with it. RESULTS: The terms target response, adequate response, nonresponse, and inadequate response were developed when the DME patients' treatment responses were first characterized. The panelists reached agreement on a number of DME treatment-related issues, including the need to classify patients prior to treatment, first-line treatment options, the right time to switch between treatment modalities, and side effects associated with steroids. From this agreement, recommendations were derived and a treatment algorithm was created. CONCLUSION: A detail and comprehensive treatment algorithm by Malaysia Retina Group for the Malaysian population provides guidance for treatment allocation of patients with DME.

Ocular Syphilis: Our Experience in Selayang Hospital, Malaysia.

OBJECTIVES: This study aims to describe the demographic features, clinical profile, Human Immunodeficiency Virus (HIV) status, and visual outcome after completing treatment in patients diagnosed with uveitic syphilis.  Methods: A retrospective review was conducted of all cases diagnosed with ocular syphilis from January 2014 to December 2019 at the ophthalmology clinic of Selayang Hospital, Selangor, Malaysia. A total of 31 cases were reviewed, and the collected data included demographic features, history of high-risk behavior, ocular symptoms and signs, visual acuity at presentation and after completing treatment, treatment received, complications, and HIV status. Serology tests to confirm the diagnosis were also included, such as the rapid plasma reagin (RPR), venereal disease research laboratory test (VDRL) titer, and treponema pallidum hemagglutination (TPHA) tests, and some cases also included the VDRL cerebrospinal fluid (CSF) test.  Results: A total of 31 patients with ocular syphilis were identified within the study period. Male patients comprised the majority with 27 cases. Nineteen patients were below the age of 50. The majority were ethnic Malay (21 patients). Seventeen patients were identified to have HIV co-infection. Twenty patients reported high-risk behaviors, and among them, six cases were HIV-infected homosexuals. The commonest symptom was blurring of vision (61%), followed by eye redness (16%), floaters (13%), and incidental findings (10%). There were 18 bilateral cases and 13 unilateral cases. The larger share presented as panuveitis (14 cases), followed by intermediate uveitis (nine cases), anterior uveitis (four cases), posterior uveitis (two cases), endophthalmitis (one case), and branch retinal vein occlusion (one case). RPR and TPHA tests were done for all patients. Only 12 patients consented to lumbar puncture for a CSF VDRL test, and one tested positive. All patients received intravenous (IV) administration of 3.0 to 4.0 million units of benzylpenicillin every four hours for 14 days. All cases reported a good outcome with an improvement in visual acuity of at least two Snellen lines after treatment.  Conclusion: Early detection and treatment of ocular syphilis will usually preserve visual acuity and ocular function. This study highlights the need for a high degree of suspicion of HIV co-infection, as the majority of our patients were discovered to be HIV-seropositive. Thus, HIV screening is mandatory in all patients presenting with syphilitic uveitis.

Bilateral Choroidal Osteoma in a Teenage Girl With Chronic Posterior Scleritis.

A 14-year-old girl with bilateral chronic posterior scleritis was referred to us for poor control of ocular inflammation. There was an incidental finding of choroidal osteoma bilaterally whereby the choroidal mass in her right eye demonstrated a significant tumor growth in a short duration of two months. The right eye choroidal tumor was orangy in color with a well-defined margin, two-disc diameter in size, and located at the macula encroaching the fovea. Multimodal imaging assessments, including serial color fundus photo, enhanced depth imaging optical coherence tomography (EDI-OCT), and B scan ultrasonography monitoring, confirmed a continuous rapid growth of choroidal osteoma with episodes of scleritis flare-ups. Furthermore, intolerance toward second-line immunosuppressants and loss of follow-ups during the coronavirus disease 2019 (COVID-19) pandemic lockdown led to frequent relapses of her posterior scleritis. Therefore, a new treatment plan was designed, and close monitoring of choroidal osteoma growth and control of posterior scleritis were initiated. Subsequently, bilateral posterior scleritis remained quiescent, and her vision remained stable with stagnant growth of choroidal osteoma.

Cladosporium spp. endogenous endophthalmitis simulating the classic "headlight-in-the-fog" appearance of active toxoplasmosis.

Endogenous fungal endophthalmitis caused by an unusual fungus poses both diagnostic and therapeutic challenges. We report a case of endogenous endophthalmitis caused by a rare mold, namely Cladosporium spp., which presented with a foveal abscess. A 52-year-old male patient who was diagnosed with rectal carcinoma presented with pain, redness, and a loss of vision in the right eye. He had been experiencing the symptoms for 1 week. The patient had undergone gastrointestinal surgery 2 weeks before experiencing the eye complaint. His best-corrected visual acuity was hand movements. Fundus examination revealed a foveal abscess of around a half-disc diameter in size that simulated retinochoroiditis with vitritis. Optical coherence tomography of the macula revealed a hyperreflective lesion in the fovea, which breached the full thickness of the fovea and extended into the preretinal space. Ocular toxoplasmosis was considered. On that basis, oral trimethoprim/sulfamethoxazole was given for 1 week, although the patient's condition worsened. A vitreous tap and an intravitreal combination of vancomycin, ceftazidime, and amphotericin B were administered twice but did not improve the patient's condition. Pars plana vitrectomy was performed and the vitreous biopsy results revealed the presence of Cladosporium spp. Intravitreal voriconazole was given three times and the foveal abscess resolved into a scar. Endophthalmitis caused by Cladosporium spp. is uncommon and published case reports are extremely limited. The present case may provide insight into the variable presentation of fungal endophthalmitis and, therefore, assist with the early diagnosis and appropriate management of the condition.

A child with a rare presentation of ocular bartonellosis.

A 6-year-old boy was referred from the optometrist for bilateral painless blurred vision of 2 weeks duration during routine screening. Upon examination, best-corrected visual acuity was 20/200 (right eye) and 20/120 (left eye). Anterior segment examination was normal for both eyes. Funduscopy showed bilateral optic disc swelling with peripapillary exudates and diffuse retinochoroiditis involving the posterior pole. Optical coherence tomography revealed diffuse retinal thickening with intraretinal fluids and cystoid changes of central fovea. Fluorescein angiography showed bilateral hot discs with vasculitis in all quadrants and large areas of nonperfusion at peripheral retina. The patient was initially treated as presumed ocular tuberculosis (TB) based on clinical presentation and history of contact with family member having pulmonary TB. Antituberculous therapy was started and both eyes received panretinal laser photocoagulation. After 3 weeks of anti-TB treatment, serology for Bartonella turned out to be positive. Treatment was changed to intravenous ceftriaxone for 10 days followed by oral cotrimoxazole for 6 weeks and combined treatment with oral prednisolone. Gradual clinical improvement was seen with corresponding visual gain due to the reduction of macular edema, but residual thickening remained due to its chronicity.

Recurrence of SRF Post Intravitreal Ranibizumab for Pediatric Choroidal Neovascularisation Secondary to Best Disease.

We present five cases of choroidal neovascularization secondary to pediatric Best disease which were treated with two different doses of intravitreal ranibizumab. Optical coherence tomography was used for monitoring of the cases. Three cases had subretinal fibrosis at presentation and two out of these 3 cases required repeat intravitreal ranibizumab at one year follow-up due to recurrence of subfoveal subretinal fluid.

Total Protein Concentration and Tumor Necrosis Factor α in Tears of Nonproliferative Diabetic Retinopathy.

SIGNIFICANCE: Total protein concentration (TPC) and tumor necrosis factor α (TNF-α) concentration in tears are correlated with severity of retinopathy. However, minimal data are available in the literature for investigating tear TPC and TNF-α concentrations in Asian individuals with different severity of nonproliferative diabetic retinopathy (NPDR). PURPOSE: This study evaluated differences of TPC and TNF-α concentrations in tears at different severity of NPDR among participants with diabetes in comparison with normal participants. METHODS: A total of 75 participants were categorized based on Early Treatment for Diabetic Retinopathy Study scale, with 15 participants representing each group, namely, normal, diabetes without retinopathy, mild NPDR, moderate NPDR, and severe NPDR. All participants were screened using McMonnies questionnaire. Refraction was conducted subjectively. Visual acuity was measured using a LogMAR chart. Twenty-five microliters of basal tears was collected using glass capillary tubes. Total protein concentration and TNF-α concentrations were determined using Bradford assay and enzyme-linked immunosorbent assay, respectively. RESULTS: Mean ± SD age of participants (n = 75) was 57.88 ± 4.71 years, and participants scored equally in McMonnies questionnaire (P = .90). Mean visual acuity was significantly different in severe NPDR (P = .003). Mean tear TPC was significantly lower, and mean tear TNF-α concentration was significantly higher in moderate and severe NPDR (P < .001). Mean ± SD tear TPC and TNF-α concentrations for normal were 7.10 ± 1.53 and 1.39 ± 0.24 pg/mL; for diabetes without retinopathy, 6.37 ± 1.65 and 1.53 ± 0.27 pg/mL; for mild NPDR, 6.32 ± 2.05 and 1.60 ± 0.21 pg/mL; for moderate NPDR, 3.88 ± 1.38 and 1.99 ± 0.05 pg/mL; and for severe NPDR, 3.64 ± 1.26 and 2.21 ± 0.04 pg/mL, respectively. Tear TPC and TNF-α concentrations were significantly correlated (r = -0.50, P < .0001). Visual acuity was significantly correlated with tear TPC (r = -0.236, P = .04) and TNF-α concentrations (r = 0.432, P < .0001). CONCLUSIONS: This cross-sectional study identified differences in tear TPC and TNF-α concentrations with increasing severity of NPDR.

Intravitreal Ranibizumab for Choroidal Neovascularization in Best's Vitelliform Macular Dystrophy in a 6-Year-Old Boy.

A 6-year-old boy with a family history of Best's vitelliform macular dystrophy presented with a unilateral choroidal neovascularization. He responded well to a single injection of intravitreal ranibizumab. His visual acuity improved from 6/18 to 6/9 in the affected eye. His condition remained stable for 1½ years after treatment.