Evaluation of Retinal Nerve Fibre Layer Thickness and Choroidal Thickness in Parkinson Disease Patients.

To evaluate the retinal nerve fibre layer (RNFL) thickness and choroidal thickness (CT) in Parkinson disease (PD) patients. A comparative cross-sectional, hospital-based study. 39 PD and 39 controls were recruited, who were gender and age matched. Subjects that fulfilled the inclusion criteria underwent optical coherence tomography for evaluation of RNFL thickness and choroidal thickness (CT). There was significant reduction of RNFL thickness in average (adjusted mean 88.87 µm vs. 94.82 µm, P=0.001), superior (adjusted mean 110.08 µm vs. 119.10 µm, P=0.002) and temporal (adjusted mean 63.77 µm vs. 70.36 µm, P=0.004) in PD compared to controls. The central subfoveal CT was significantly thinner in PD compared to controls (adjusted mean 271.13 µm vs. 285.10 µm, P=0.003). In PD group, there was significant weak negative correlation between the duration of PD with average RNFL thickness (r=-0.354, P=0.027), moderate negative correlation between the duration of PD with central subfoveal CT (r=-0.493, P=0.001), and weak negative correlation between the stage of PD with central subfoveal CT (r=-0.380, P=0.017). PD group had significant thinner average, superior and temporal RNFL thickness and CT compared to controls.

Recurrent Retrobulbar Optic Neuritis in Seronegative Rheumatoid Arthritis

@#Rheumatoid arthritis (RA) is a multisystemic autoimmune disease which can be associated with visual threatening ocular manifestations. Common ocular associations with RA include necrotising scleritis and peripheral ulcerative keratitis (PUK). Optic nerve involvement otherwise is uncommon, especially as a presenting feature of RA. We report a rare case of recurrent bilateral retrobulbar optic neuritis (ON) with progressive visual deterioration as an early manifestation of seronegative RA. This case posed diagnostic and management challenges due to its unusual presentation and initially inconclusive investigations. The patient was diagnosed with seronegative RA three years after the first eye presentation. Her RA disease activity score (DAS-28) improved after treatment with a disease-modifying anti-rheumatic drugs (DMARDs), and her ON attacks have been controlled since then. However, her visual acuity, visual field and colour vision remained poor after multiple ON attacks. Multidisciplinary care is key to managing such a patient’s condition and its potential disease complications.

Optic Neuritis in Herpes Zoster Ophthalmicus: A Rare Manifestation of a Common Malady

@#Herpes zoster optic neuropathy (HZON) is a rare manifestation of herpes zoster ophthalmicus (HZO). It is a potentially blinding condition. We report a case of an immunocompetent patient with HZON following keratouveitis during the course of treatment. A 33-year-old gentleman presented with left eye (LE) worsening of visual acuity (6/9 reduced to 6/24) despite on treatment for HZO keratouveitis. It was associated with pain on ocular movement and central scotoma. He was on systemic acyclovir and topical corticosteroids prior to current complaint. Fundoscopy showed left optic disc swelling with impaired optic nerve functions. Diagnosis of left optic neuritis secondary to HZO was established in view of close temporal relationship with occurrence of cutaneous herpes zoster. Systemic corticosteroids was commenced. The patient had obtained good visual outcome at two months. Early referral for ophthalmology assessment is crucial to establish diagnosis of HZON and prompt initiation of treatment may preserve vision.

Diagnosis of Ankylosing Spondylitis: Do not let the spine bites the eye

@#Background: A diagnosis of ankylosing spondylitis (AS) is challenging and often delayed despitebpatients being symptomatic. Low back pain is the most common initial symptom, appearing in the second and third decades of life. Acute anterior uveitis (AAU) occurs much later in the course of the disease, often when the destruction of the spine is already debilitating. Objective: Here, we report three cases of AS that were diagnosed after the patients developed AAU. Methods: A case series illustrated AAU leading to the diagnosis of AS years after the initial episode of low back pain. A comparison of the clinical presentation, diagnosis, and outcomes was also illustrated. Result: We report three cases of acute anterior uveitis (AAU)-associated AS diagnosed only after many visits to the primary health care provider with the complaint of chronic low back pain. All three patients had irreversible radiological changes upon diagnosis of AS. The AAU resolved with topical steroids, and one patient developed cataract. Conclusion: A high index of suspicion of AS in a young adult with chronic back pain before the development of AAU may prevent further functional loss and provide a better prognosis. Diagnosis of AS following AAU is not only associated with dependency but also may rob the vision of a young adult.

Commemorating the 40-Year Journey of the School of Medical Sciences, Universiti Sains Malaysia

@#The School of Medical Sciences of Universiti Sains Malaysia (USM) is the launching pad for this journal. From the school’s humble beginning at the USM Main Campus in Pulau Pinang, Malaysia, it has grown in stature at its current location in the USM Health Campus, Kubang Kerian, Kelantan, Malaysia. Commemorating its 40th anniversary, this editorial aims to recollect, although not exhaustively, the wealth of returns for the USM, as well as for the nation, which the school has managed to deliver in that period. Resolute to its vision and mission, this article highlights the outstanding accomplishments in various core aspects of the school’s academic, research and professional growth as we continually strive to train globally competitive and compassionate medical graduates, medical specialists and scientists, skilled to serve nation’s needs and broader markets worldwide. Currently guided by the Malaysian Higher Education Blueprint (2015–2025), the school shall remain ingenious in its duties in the many more years to come, as we head for a world-class trajectory.

Comparison of peripapillary retinal nerve fiber layer thickness between myopia severity groups and controls.

AIM: To compare the peripapillary retinal nerve fiber layer (RNFL) thickness measured via optical coherence tomography (OCT) between different groups of myopia severity and controls. METHODS: This was a prospective cross-sectional study. All subjects underwent a full ophthalmic examination, refraction, visual field analysis and A-scan biometry. Myopic patients were classified as low myopia (LM) [spherical equivalent (SE) from greater than -0.5 D, up to -3.0 D], moderate myopia (MM; SE greater than -3.0 D, up to -6.0 D) and high myopia (HM; SE greater than -6.0 D). The control group consisted of emmetropic (EM) patients (SE from +0.5 D to -0.5 D). A Zeiss Cirrus HD-OCT machine was used to measure the peripapillary RNFL thickness of both eyes of each subject. The mean peripapillary RNFL thickness between groups was compared using both analysis of variance and analysis of covariance. RESULTS: A total of 403 eyes of 403 subjects were included in this study. The mean age was 31.48±10.23y. There were 180 (44.7%) eyes with EM, 124 (30.8%) with LM, 73 (18.1%) with MM and 26 (6.5%) with HM. All groups of myopia severity had a thinner average RNFL than the EM group, but after controlling for gender, age, and axial eye length, only the HM group differed significantly from the EM group (P=0.017). Likewise, the superior, inferior and nasal RNFL was thinner in all myopia groups compared to controls, but after controlling for confounders, only the inferior quadrant RNFL was significantly thinner in the HM group, when compared to the EM group (P=0.017). CONCLUSION: The average and inferior quadrant RNFL is thinner in highly myopic eyes compared to emmetropic eyes. Refractive status must be taken into consideration when interpreting the OCT of myopic patients, as RNFL thickness varies with the degree of myopia.

Use of recombinant tissue plasminogen activator for treatment of recalcitrant anterior uveitis: A case series.

Management of inflammation after surgery for recalcitrant anterior uveitis is challenging. Herein, we report successful treatment using intracameral injection of recombinant tissue plasminogen activator (rtPA) in two patients with recalcitrant anterior uveitis, due to infective uveitis and Vogt-Koyanagi-Harada disease, respectively. A 40-year-old woman presented with bilateral redness and vision reduction that had persisted 2 weeks. She also had bilateral anterior uveitis, vasculitis, retinitis, and optic disc swelling. Serology was positive for Bartonella henselae and Toxoplasma gondii. She was treated using long-term systemic corticosteroids and appropriate antibiotics. Our second case; a healthy 30-year-old man with bilateral eye redness and reduced vision without pain, and associated with headache and tinnitus for 1 weeks. He showed bilateral granulomatous inflammation with vitritis, choroiditis, retinitis, and hyperemic optic disc. The patient was diagnosed with Vogt-Koyanagi-Harada disease and treated with systemic corticosteroids. Both patients developed secondary cataracts and glaucoma that necessitated surgical intervention. Persistent chronic inflammation led to the formation of a thick fibrin membrane anterior to the intraocular lens (IOL) after phacoemulsification surgery with IOL implantation. This membrane was removed surgically, and intracameral injection of rtPA (25 µg) was carried out. The persistent inflammation had resolved and visual acuity had significantly improved within 1 week of intracameral rtPA injection. There were no reported ocular or systemic side effects. Intracameral rtPA is beneficial in patients with recalcitrant anterior uveitis who have undergone intraocular surgery. In most cases, surgical intervention improves the patients' vision. Intracameral rtPA should be considered in cases of persistent inflammation of varying etiology.

Effect of Axial Eye Length on Retinal Vessel Parameters in 6 to 12-Year-Old Malay Girls.

PURPOSE: Retinal vessel analysis is affected by both systemic and ocular factors. Malays are the major ethnicity in South East Asia. Data on the retinal microvasculature in Malays is limited, especially among children. We aim to evaluate the influence of ocular biometry on retinal vessel parameters in young Malay girls. METHODS: This was a cross-sectional, hospital-based study involving 86 Malay girls aged 6 to 12 years old in Hospital Universiti Sains Malaysia from 2015-2016. Ocular examination, refraction, biometry, retinal photography, and anthropometric measurements were performed. The central retinal arteriolar equivalent (CRAE), central retinal venular equivalent (CRVE) and overall fractal dimension (Df) were measured using validated computer-based methods (Singapore I vessel analyzer, SIVA version 3.0, Singapore). The associations of ocular biometry and CRAE, CRVE and Df were analyzed using multivariable analysis. RESULTS: The mean CRAE, CRVE and Df in Malay girls were 171.40 (14.40) um, 248.02 (16.95) um and 1.42 (0.05) respectively. Each 1 mm increase in axial length was associated with a reduction of 4.25 um in the CRAE (p = 0.03) and a reduction of 0.02 in the Df (p = 0.02), after adjustment for age, blood pressure and body mass index. No association was observed between axial length and CRVE. Anterior chamber depth and corneal curvature had no association with CRAE, CRVE or Df. CONCLUSION: Axial length affects retinal vessel measurements. Narrower retinal arterioles and reduced retinal fractal dimension were observed in Malay girls with longer axial lengths.

Factors predicting visual improvement post pars plana vitrectomy for proliferative diabetic retinopathy / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To identify factors predicting visual improvement post vitrectomy for sequelae of proliferative diabetic retinopathy (PDR).METHODS: This was a retrospective analysis of pars plana vitrectomy indicated for sequelae of PDR from Jan.to Dec.2014 in Hospital Sultanah Bahiyah,Alor Star,Kedah,Malaysia.Data collected included patient demographics,baseline visual acuity (VA) and post-operative logMAR best corrected VA at 1y.Data analysis was performed with IBM SPSS Statistics Version 22.0.RESULTS: A total of 103 patients were included.The mean age was 51.2y.On multivariable analysis,each pre-operative positive deviation of 1 logMAR from a baseline VA of 0 logMAR was associated with a post-operative improvement of 0.859 logMAR (P<0.001).Likewise,an attached macula pre-operatively was associated with a 0.374 (P=0.003) logMAR improvement post vitrectomy.Absence of iris neovascularisation and absence of post-operative complications were associated with a post vitrectomy improvement in logMAR by 1.126 (P=0.001) and 0.377 (P=0.005) respectively.Absence of long-acting intraocular tamponade was associated with a 0.302 (P=0.010) improvement of logMAR post vitrectomy.CONCLUSION: Factors associated with visual improvement after vitrectomy are poor pre-operative VA,an attached macula,absence of iris neovascularisation,absence of post-operative complications and abstaining from use of long-acting intraocular tamponade.A thorough understanding of the factors predicting visual improvement will facilitate decision-making in vitreoretinal surgery.

Visual electrophy siological tests in obstructive sleep apnoea / 国际眼科杂志(Guoji Yanke Zazhi)

AIM:To compare the pattern electroretinogram (PERG) and pattern visual evoked potential (PVEP) between obstructive sleep apnoea (OSA) patients and controls.METHODS: This was a prospective cross-sectional study involving 40 OSA patients and 31 control subjects in Hospital Universiti Sains Malaysia.Patients with a confirmed diagnosis of OSA who had no ocular pathology were randomly selected to participate in the study.The apnoea-hypopnoea index (AHI) was obtained from their records and used for stratification of OSA severity.Electrophysiological tests (PVEP and PERG) were performed on each patient by a trained technician in the electrophysiology laboratory of the Department of Ophthalmology, USM.The results obtained were recorded as median values.Data analysis was done using IBM Statistics Version 21.0.RESULTS: Among OSA patients, we observed a significant reduction of the PERG amplitude P50 (P<0.001) and the PVEP amplitude P100 (P<0.001) compared to the control group.OSA patients also had a significant increase in PVEP time to peak P100 (P=0.003) and time to peak N75 (P=0.004).However, no significant differences were detected in PERG time to peak between OSA patients and controls.There were likewise no significant differences in PVEP or PERG between OSA patients with different disease severity.CONCLUSION: OSA patients have significant abnormalities in PVEP amplitude and time to peak, as well as PERG amplitude.This may reflect subclinical optic nerve dysfunction in OSA.Further research is needed to determine the association between the severity of OSA and the degree of optic nerve dysfunction.

Thymectomy in Myasthenia Gravis at Hospital Unversiti Sains Malaysia - A 10 Years Review of Cases at the Hospital Universiti Sains Malaysia

Background: A thymectomy is considered effective for patients with myasthenia gravis (MG). Although a few studies have described the role of a thymectomy in the treatment of MG in Asians countries, there are no published data on the application of this surgical approach for MG in Malaysia. We aimed to describe the clinical outcomes of MG patients who underwent a thymectomy and the factors affecting these outcomes. Methods: This was a retrospective study involving 16 patients with MG who underwent a thymectomy at the Hospital Universiti Sains Malaysia (HUSM) from January 2002 until December 2012, with a follow-up period ranging from 3–120 months. Results: The study consisted of 16 patients aged 22–78 years, 10 of whom were males. The overall remission/improvement rate was 87.5%, and the rate of clinical outcomes classified as unchanged/ worsened was 12.5%. Thymomamatous or non-thymomamatous MG, histology features, Osserman stage and the duration of follow-up were not significant prognostic factors. Post-operative mortality was 6.2% (1 of 16 patients died of septic shock). Conclusion: A thymectomy seems to be an effective treatment for MG, with low surgical morbidity. Patients with a lower Osserman stage and those with/without thymomas had favourable outcomes.

Neuroretinitis in ocular bartonellosis: a case series.

We report a case series of neuroretinitis in ocular bartonellosis and describe the serologic verification for Bartonella henselae. This is a retrospective interventional case series of four patients who presented in the ophthalmology clinic of Hospital Universiti Sains Malaysia from June 2012 to March 2013. All four patients had a history of contact with cats and had fever prior to ocular symptoms. Each patient presented with neuroretinitis characterized by optic disc swelling with macular star. Serology analysis showed strongly positive for B. henselae in all of the patients. All patients were treated with oral azithromycin (except case 4, who was treated with oral doxycycline), and two patients (case 1 and case 3) had poor vision at initial presentation that warranted the use of oral prednisolone. All patients showed a good visual outcome except case 3. Vision-threatening ocular manifestation of cat scratch disease can be improved with systemic antibiotics and steroids.

Open globe injury in Hospital Universiti Sains Malaysia - A 10-year review.

AIM: To identify the aetiology of open globe injuries at Hospital Universiti Sains Malaysia over a period of 10y and the prognostic factors for visual outcome. METHODS: Retrospective review of medical records of open globe injury cases that presented from January 2000 to December 2009. Classification of open globe injury was based on the Birmingham Eye Trauma Terminology (BETT). Records were obtained with hospital permission via the in-house electronic patient management system, and the case notes of all patients with a diagnosis of open globe injury were scrutinised. Patients with prior ocular trauma, pre-existing ocular conditions affecting the visual acuity, contrast sensitivity, central vision or corneal thickness, as well as those with a history of previous intraocular or refractive surgery were excluded. Analysis of data was with SPSS version 20.0. Ordinal logistic regression analysis was used to examine the association between prognostic factors and visual outcome. RESULTS: This study involved 220 patients (n=222 eyes). The most common place of injury was the home (51.8%), followed by the workplace (23.4%). Among children aged less than 16y of age, domestic-related injury was the predominant cause (54.6%), while in those aged 16y and above, occupational injuries were the most common cause (40.0%). Most eyes (76.5%) had an initial visual acuity worse than 3/60, and in half of these, the visual acuity improved. The visual outcome was found to be significantly associated with the initial visual acuity (P<0.005), posterior extent of wound (P<0.001), length of wound (P<0.001), presence of hyphaema (P<0.001) and presence of vitreous prolapse ((P<0.005). CONCLUSION: The most common causes of open globe injury are domestic accidents and occupational injuries. Significant prognostic factors for final visual outcome in patients with open globe injury are initial visual acuity, posterior extent and length of wound, presence of hyphaema and presence of vitreous prolapse. Awareness of the factors predicting a poor visual outcome may be helpful during counselling of patients with open globe injuries.

Migraine with aura complicated by “migraine triggered seizures” and “occipital lobe infarction”: A case report

Migraine with aura is one of the major subtypes of migraine, and can be associated with ischaemic brain infarction. Use of oral contraceptive pills (OCPs) increases the risk of infarction in this type of migraine. Seizures and migraine also have a complex relationship, one element of which is migrainetriggered seizures. We report a case of bilateral occipital lobe infarction and migraine-triggered seizures, most likely precipitated by oral contraceptive pills (OCPs) in a patient with migraine with visual aura. OCPs, triptans and ergotamines should be used cautiously in these patients. Methods of birth control other than OCPs should be considered.

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.

Clinical profile and aetiology of optic neuritis in Hospital Universiti Sains Malaysia--5 years review.

Although few studies concerning optic neuritis (ON) in Asian countries have been reported, there is no report about ON in Malaysia particularly within the Malay population. We aimed to determine the clinical manifestation, visual outcome and aetiology of ON in Malays, and discussed the literature of ON studies in other Asian populations. This was a retrospective study involving 31 consecutive patients (41 eyes) with ON treated at Hospital Universiti Sains Malaysia commencing from July 2005 till January 2010 with a period of follow-up ranging from 18-60 months. The clinical features, laboratory results, possible aetiology, and visual acuity after one year were analysed. Females were the predominant group. The age of the patients ranged between 3-55 years and peaked between 21-30 years old. 67.7% of the patients had unilateral involvement. Pain on ocular movement was observed in 31.7% of the affected eyes. 73.3% of 41 involved eyes showed visual acuity equal 6/60 or worse on presentation. Paracentral scotoma was the most common visual field defect noted. Optic disc papillitis proved more widespread compared to the retrobulbar type of ON. The aetiology was idiopathic in more than 50%, while the risk of multiple sclerosis was extremely low (3.2%) in our series. 66.0% demonstrating visual acuity improved to 6/12 or better at one year after the attack. 16.1% showed evidence of recurrence during follow-up. In conclusion, the clinical profile and aetiology of ON in Malay patients are comparable to other ON studies reported by other Asian countries.

Isolated optic neuritis secondary to presumed tuberculosis in an immunocompetent child.

Isolated optic neuritis as a presenting sign of tuberculosis in children is uncommon. We report a case of an immunocompetent child who displayed features of bilateral optic neuritis secondary to presumed tuberculosis. It is essential to highlight this alarming presentation in a child, as the presence of tuberculosis has re-emerged as a serious public health problem especially in developing countries.

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.

Serological IgG avidity test for ocular toxoplasmosis.

BACKGROUND: The purpose of this study was to evaluate the immunoglobulin (Ig) G avidity of serological toxoplasmosis testing in patients with ocular inflammation and to determine the clinical manifestations of ocular toxoplasmosis. METHODS: A retrospective review of all patients presenting with ocular inflammation to the Hospital Universiti Sains Malaysia, Kelantan, Malaysia between 2005 and 2009 was undertaken. Visual acuity, clinical manifestations at presentation, toxoplasmosis antibody testing, and treatment records were analyzed. RESULTS: A total of 130 patients with ocular inflammation were reviewed retrospectively. The patients had a mean age of 38.41 (standard deviation 19.24, range 6-83) years. Seventy-one patients (54.6%) were found to be seropositive, of whom five (3.8%) were both IgG and IgM positive (suggestive of recently acquired ocular toxoplasmosis) while one (0.8%) showed IgG avidity ≤40% (suggestive of recently acquired ocular toxoplasmosis) and 65 patients (50.0%) showed IgG avidity >40% (suggestive of reactivation of toxoplasmosis infection). Chorioretinal scarring as an ocular manifestation was significantly more common in patients with seropositive toxoplasmosis (P = 0.036). Eighteen patients (13.8%) were diagnosed as having recent and/or active ocular toxoplasmosis based on clinical manifestations and serological testing. CONCLUSION: Ocular toxoplasmosis is a clinical diagnosis, but specific toxoplasmosis antibody testing helps to support the diagnosis and to differentiate between reactivation of infection and recently acquired ocular toxoplasmosis.