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 January2000 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 version20.0.Ordinal logistic regression analysis was used to examine the association between prognostic factors and visual outcome.RESULTS:This study involved 220 patients(n=222eyes).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.

Randomized controlled trial of Letrozole versus Clomiphene citrate for induction of ovulation in polycystic ovarian syndrome (PCOS): A Malaysian experience

Background: The purpose of this study was to compare the effectiveness of Letrozole versus Clomiphene citrate for ovulation induction in polycystic ovarian syndrome (PCOS) with infertility. Methods: This was a prospective randomized trial involving 150 women with PCOS attending the Infertility Clinic at three hospitals in Malaysia. During the initial visit, anthropometric measurements and baseline investigations were performed. Patients were randomized to 5.0 mg Letrozole daily (75 patients) or 100 mg Clomiphene citrate daily (75 patients) from the fifth until the ninth day of menstruation. Serial transvaginal scans were performed to see the dominant follicles, endometrial thickness and number of follicles. Transvaginal scans were performed serially to look for evidence of ovulation. Results: The subjects were homogenously distributed. The difference between Letrozole and Clomiphene citrate for ovulation rate was 59 (78.7%) versus 40 (53.3%). Patients taking Letrozole exhibited a mean endometrial thickness (ET) at mid cycle of menses (Day 11-D14) of9.2 mm(SD ± 2.3) versus8.4 mm(SD ± 2.2) for patients taking Clomiphene citrate, and these differences were statistically significant

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±10.23 y. 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.

Diffusion tensor imaging pipeline measures of cerebral white matter integrity: An overview of recent advances and prospects

Cerebral small vessel disease(CSVD)is a leading cause of age-related microvascular cognitive decline,resulting in significant morbidity and decreased quality of life.Despite a progress on its key pathophysiological bases and general acceptance of key terms from neuroimaging findings as observed on the magnetic resonance imaging(MRI),key questions on CSVD remain elusive.Enhanced relationships and reliable lesion studies,such as white matter tractography using diffusion-based MRI(dMRI)are necessary in order to improve the assessment of white matter architecture and connectivity in CSVD.Diffusion tensor imaging(DTI)and tractography is an application of dMRI that provides data that can be used to non-invasively appraise the brain white matter connections via fiber tracking and enable visualization of individual patient-specific white matter fiber tracts to reflect the extent of CSVD-associated white matter damage.However,due to a lack of standardization on various sets of software or image pipeline processing utilized in this technique that driven mostly from research setting,interpreting the findings remain contentious,especially to inform an improved diagnosis and/or prognosis of CSVD for routine clinical use.In this minireview,we highlight the advances in DTI pipeline processing and the prospect of this DTI metrics as potential imaging biomarker for CSVD,even for subclinical CSVD in at-risk individuals.

Endogenous endophthalmitis secondary to melioidosis in paediatric patients: Case series and review article

Endogenous endophthalmitis is a devastating infection of the eye which can lead to permanent blindness. We report two rare cases of paediatric endogenous endophthalmitis secondary to melioidosis with contrasting visual outcomes. Both patients presented with acute painful visual loss with poor vision on presentation after exposure to open water sources (swimming at two separate locations with waterfalls). Both were diagnosed to have melioidosis endogenous endophthalmitis based on the ocular features clinically and via positive melioidosis serology. They otherwise did not exhibit any symptoms and signs suggestive of systemic melioidosis infection. Even though the two children demonstrated severe ocular involvement, ocular culture from vitreous and aqueous sampling taken from one of the patients did not yield any positive results. No ocular sampling was taken from the other patient. After standard antimicrobial treatment, the first patient responded well with good visual recovery without requiring any surgical intervention for the endophthalmitis. In contrast, our second patient ended up with poor visual outcome despite undergoing multiple intravitreal antibiotic injections and early pars plana vitrectomy. This is because he developed extensive retinal detachment due to the aggressive ocular infection. The diagnosis of endogenous endophthalmitis due to ocular melioidosis remains challenging and requires a high index of suspicion in areas endemic for the causative organism. Early empirical antibiotic treatment should be initiated in suspicious cases, even though the treatment outcomes may vary greatly.

Excellent outcome of primary Neisseria meningitidis keratoconjunctivitis

Infectious conjunctivitis is a very common presentation to medical professional and ophthalmologist all over the world.Although its typically self-limiting and treatable in almost all of the cases,but we need to be aware of the rare and potentially life threatening if the cause is not promptly identified and treated accordingly.In our case report,we highlighted the rare case of Neisseria meningitidis as a primary cause of keratoconjunctivitis.Neisseria meningitidis is a rare etiology of keratoconjunctivitis and its ocular presentations are quite similar with other bacterial or viral infection.The infection may potentially fatal if systemic invasion occurred,however with immediate and proper treatment the outcome is satisfactory.Early diagnosis and proper antibiotic treatment are critical to prevent systemic spread of the infection.Public health intervention is needed to prevent outbreak of the disease.

Dorsal midbrain syndrome secondary to pineal gland tumours: case series and review on manifestations, management and outcome

Dorsal midbrain syndrome or Parinaud syndrome is a supranuclear brainstem syndrome involving the vertical gaze centre.These are case series with three patients who were diagnosed with dorsal midbrain syndrome secondary to pineal gland tumours.The prognosis varied depending on tumour types,age of presentation and treatment received.All of them were presented with life-threatening obstructive hydrocephalus.Our first patient was successfully treated with emergency surgery followed by radiotherapy.He regained normal visual acuity and full recovery of his ocular movement.Second and third patients had undergone surgery for raised intracranial pressure.Both had an inoperable pineal gland tumour.As for our second patient,we detected a worsening of vertical gaze during his four years follow-up.However,his bilateral good visual acuity was preserved.The third patient passed away as a result of uncontrolled enlarging tumour.We also briefly reviewed the clinical presentation,diagnosis,and therapeutic approach of the three patients.One of the caveats is that urgent radiological study is crucial to differentiate the tumour type via the pathognomonic features and to delineate the tumour extension.The preferable treatment options vary among each tumour type.A multidisciplinary approach is crucial in early detection,in addition to treatment initiation and long term follow up to achieve a better outcome.

Clinical critics in the management of diabetes mellitus

There is a global epidemic of diabetes with its prevalence expected to increase from 5.1% in 2003 to 6.3% in 2025. This increase in diabetes is occurring in all nations, however, developing nations are particularly at risk. It spares no group and affects men, women, the elderly, young and people from very racial and socio-economic background. Nevertheless, certain ethnic groups including Asians are affected more than Caucasians. Large randomized clinical trials have shown that improvement in glycaemic control, together with management of diabetes-related risk factors like blood pressure and lipid control significantly reduce the micro and macro complications in individuals with type 1 and type 2 diabetes. Patient education plays a crucial role in the prevention of diabetic fool problems. In Geneva, the rate of lower limb amputations was reduced by almost 75% after an educational intervention. People with diabetes must acquire the knowledge and skills through education to provide daily self-care in diabetes management which involves maintenance of healthy living, recognition and management of diabetes problems when they arise and taking preventive measures. Some factors include patients’ biomedical variables, the psychosocial environment, the knowledge, attitudes and beliefs of patients themselves, home careers and health care providers, healthcare systems’ accessibility and availability and even the national political context may influence these self-care behaviors.

Bilateral optic nerve infiltration in tuberculous meningitis: A diagnostic dilemma

Rationale:Tuberculous meningitis(TBM)is severe extrapulmonary tuberculosis that can cause poor outcomes without timely treatment.We report a case of presumed TBM that presented solely ocular complaints without other neurological features.Patient's concerns:A 71-year-old man presented with a sudden central visual defect in both eyes for 10 days.Fundoscopy showed bilateral hyperaemic swelling disc with infiltrates.Diagnosis:A diagnosis of presumptive TBM was made with Mantoux test reading 15 mm,elevated erythrocyte sedimentation rate,subdural effusion on CT scan,and high opening pressure.Intervention:Anti-tuberculous treatment.Outcomes:Bilateral vision improved and optic discs swelling resolved.Lessons:Early recognition of TBM with optic nerve infiltration is crucial for prompt treatment that may lead to a good prognosis.Neuroimaging will facilitate the diagnosis when other investigations show a borderline result.

Diffuse unilateral subacute neuroretinitis in children:Report of three cases

Rationale:Diffuse unilateral subacute neuroretinitis is a form of posterior uveitis and has a few clinical presentations according to the onset of presentation.Patients’concern:A girl(5-year-old)and 2 boys(both 12-year-old)were included in this report.Upon presentation,the visual acuity ranges from 6/12 to 6/60.All three cases had different symptoms(case 1:floaters;case 2:eye redness and pain;case 3:central scotoma).All of them had variable posterior uveitis features(case 1:vitritis and focal retinitis;case 2:subretinal larva track;case 3:choroiditis).Diagnosis:Diffuse unilateral subacute neuroretinitis.Intervention:All 3 patients were treated with oral albendazole.Outcome:All patients showed remarkable resolution of inflammatory reactions of the eye and also improvement of vision.Lesson:High index of suspicion should be made for children and young adults who are previously healthy but presented with suddenly onset of reduced vision with clinical features of posterior uveitis of variable degree.Clinical features together with a full blood picture can help to diagnose the problem when other parameters are negative.

Translation, Cross-Cultural Adaptation, Reliability and Validity of the Malay Version of Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) V3.1

Introduction: A psychoactive substance has become an overwhelming public health burden globally. It causes social problems for the user and surrounding people which may affect work or study and cause negative economic impact. Objective: This study aims to translate and culturally adapt the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) into Malay and to assess its reliability and validity. Methods: The Malay version of the ASSIST v 3.1 was developed after the translation and back-translation, which included the stages recommended by Beaton. The ASSIST v 3.1 was administered to 125 respondents. The Malay ASSIST v 3.1 was completed twice by each respondent 7 to 14-day intervals to assess test-retest reliability based on the intra-rater and interrater correlation coefficient. Results: Majority of the respondents were male, Malay and currently employed. The intra-rater reliability is 0.84 and the test-retest reliability (ICC = 0.97) were excellent. Conclusion: Malay ASSIST v3.1 was a valid and reliable tool to screen substances abuse at varying degree. Nonetheless, further studies are needed to assess its responsiveness.

Lower Lid Entropion Secondary to Missed Intraorbital Foreign Body in a Child

Background: Intraorbital foreign bodies can result in various complications if not appropriately managed. Aim: To report a case of lower lid entropion secondary to a missed intraorbital foreign body. Case Presentation: A 7-year-old boy presented with inward turning of the left lower lid for three days prior to admission. A week before, the child was in the garden when part of the roof of their home suddenly broke off, with pieces of the debris falling near him. He complained of left eye irritation, but a visit to a general practitioner found no eye abnormalities. Three days after that, the mother sought an ophthalmology opinion as she noticed inversion of the left lower lid. On examination, visual acuity in both eyes was 6/6. There was left lower lid entropion, and a deeply embedded foreign body seen in the lower lid. No other eye abnormalities noted. Computed tomography scan of the orbits revealed a welldefined foreign object in the lower orbit, fracturing the antero-superior wall of the left maxillary sinus. The left eye foreign body was removed uneventfully via a transconjunctival approach. Conclusion: A thorough examination is mandatory in any case of ocular trauma especially in young children, who are usually unable to provide a clear history of the injury.

Dengue Maculopathy: Case Series

We report a case series of dengue maculopathy with different ocular manifestations, managements, visual outcomes and sequelae of patients. All three cases were diagnosed to have dengue fever. Patients presented with symptoms of central scotoma (case 1 and case 3) and blurring of vision (case 2) on Day 9 of dengue fever. Fundus examination showed intra retinal haemorrhages (case 1 and case 2) and macula thickening (case 3). Optical coherence tomography (OCT) revealed macular thickening with intra retinal fluid (case 1) and diffuse retinal thickening (case 3), while in case 2, it had irregular ellipsoid line in OCT. Fundus fluorescence angiography (FFA) revealed parafoveal vasculitis. After treatment with systemic steroids, one patient had good visual outcome (case 2), while two others had a persistent central scotoma due to macula atrophy (case 3). Although it is a self limiting disease, but the mode of treatment is variable. Treatment with corticosteroids may hasten recovery of vision and prevent permanent visual impairment.

Bilateral Central Scotoma Due to CSCR in an Asthmatic Policeman

Central serous chorioretinopathy (CSCR) is a retinal condition characterized by fluid accumulation in the subretinal space, resulting in neurosensory detachment or pigment epithelial detachment. The risk factors associated with this condition include male gender, middle age, smoking, stress and use of corticosteroids. We report a case of CSCR in a 37-year-old policeman with hypertension and bronchial asthma. He presented with sudden onset of bilateral blurring of central vision for 1 day, worse over the left eye. There were no other significant eye complaints. He is an active smoker and has been on long-term corticosteroids for asthma. On examination, the visual acuity was 6/9 bilaterally. The anterior segment of both eyes was normal. Examination of the right fundus revealed a dome-shaped swelling inferior to the fovea, while the left fundus showed circular detachment of the neurosensory retina at the macula. He was diagnosed to have bilateral central serous chorioretinopathy. He was also counseled to stop smoking. The corticosteroids were continued due to the risk of precipitating an asthma attack if they were withheld. Upon his next review two months later, his condition remained stable. CSCR is usually a self-limited condition, with good visual outcome. A thorough medical, social and drug history should be obtained, and patients advised to modify their lifestyle to eliminate or reduce risk factors such as smoking, stress and corticosteroid use.

Matrix regeneration therapy:a solution to enhance healing in fungal keratitis

Corneal ulcers,especially of fungal origin,are a relatively common clinical entity within the spectrum of keratitis in tropical countries.The persistence of a non-healing epithelial defect is a known complication of these ulcers.Despite advances in medical therapy,the management of this condition is still challenging.CACICOL20^(®)is a new ophthalmic matrix therapy that has been proved efficient as a corneal healing agent.To the best of our knowledge there have been reports of the limited use of matrix therapy in ocular healing,specifically in fungal keratitis.We report 2 cases of the efficacy of it as an adjuvant to topical amphotericin B in treating non-healing epithelial defects secondary to fungal corneal ulcers.