Purtscher-like retinopathy and paracentral acute middle maculopathy following breast filler injection.

BACKGROUND: To report a rare case of pulmonary and ocular complications with visual loss due to bilateral Purtscher-like retinopathy and paracentral acute middle maculopathy (PAMM) following a hyaluronic acid (HA) filler injection to the breast. Systemic and visual recovery was attained following corticosteroid therapy. CASE PRESENTATION: A 27-year-old lady presented with painless blurring of vision in both eyes for 2 weeks following hyaluronic acid breast filler injections by a non-medical practitioner. She was initially admitted to the medical ward for diffuse alveolar haemorrhage and altered sensorium. The presenting visual acuity was counting fingers in both eyes. Bilateral dilated fundus examination showed hyperaemic discs, concentric rim of retinal whitening around macula with patches of polygonal-shaped retinal whitening, generalised cotton-wool spots, tortuous veins, and flame-shaped haemorrhages. Spectral-domain optical coherence tomography (SD-OCT) macula revealed hyper-reflective bands at the inner nuclear layer (INL). Fluorescein angiography demonstrated hot discs, delayed arm-to-retina time, arterial filling, and arterio-venous transit time with staining of the vessels at the posterior pole. She was managed with a tapering dose of systemic corticosteroids. The visual acuity improved to 6/12 over 8 weeks with significant anatomical and functional improvement. Dilated fundus examination showed resolution of initial funduscopy findings. The hyper-reflective bands on the OCT had resolved with subsequent thinning of the INL and disorganisation of retinal inner layers. CONCLUSION: Filler injections are in increasing demand and are frequently being performed by non-medical practitioners. Visual loss from non-facial HA fillers is rare. Inadvertent entry of HA into a blood vessel may potentially cause systemic and sight-threatening ocular complications. Good anatomical knowledge and proper injection technique are vital in preventing this unfortunate sequela. There are limited reports on successful visual recovery following various treatment approaches and we hope this case provides valuable insights.

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.

Fenofibrate for the prevention of progression of non-proliferative diabetic retinopathy: review, consensus recommendations and guidance for clinical practice.

The prevalence of diabetic retinopathy (DR), and associated morbidity is high in the Asia-Pacific region. Emerging evidence suggests a potential role for fenofibrate in the prevention of progression of DR, especially in patients with cardiovascular risk, and pre-existing mild-to-moderate DR. Fenofibrate has also been found to reduce maculopathy, and the need for laser treatment in these patients. Considering these benefits of fenofibrate, a group of experts from the fields of endocrinology and ophthalmology convened in May 2017, to discuss on the the mechanism of action, and clinical efficacy of fenofibrate in DR. The findings from key clinical studies on fenofibrate in DR were reviewed by the experts, and consensus statements were derived to define the role of fenofibrate in the prevention and treatment of DR. The statements were rated based on the GRADE criteria. An algorithm was also developed for the screening and treatment of DR in patients with type 2 diabetes (T2D), and the place of fenofibrate was defined in the algorithm. The expert recommendations, and the algorithm provided in this review will serve as a guide to the clinicians to reconsider the adjunctive use of fenofibrate for preventing the progression of DR in selected T2D patients.

Demography and clinical pattern of newly diagnosed uveitis patients in Malaysia.

INTRODUCTION: Uveitis is one of the common causes of visual impairment in Malaysia. It remains a challenging entity to diagnose and manage due to variation in its clinical presentation. This study aims to observe the demographic and clinical pattern of cases from the participating ophthalmology units in Malaysia. METHODS: This study involved prospective and multicentered data collection for patients newly diagnosed with uveitis from 1st January 2018 to 31st December 2018. Variables collected and analyzed included age, gender, ethnicity, nationality, state of origin, laterality, granulomatous or non-granulomatous uveitis, and etiology of uveitis. RESULTS: A total of 1199 newly diagnosed uveitis patients were analyzed within the study period. There was a significant association between the anatomical location of uveitis with age at presentation. The percentage of patients with anterior uveitis was higher in the '40 to 60' years and 'above 60' years age groups at 52.1% (n = 210) and 61.3% (n = 114) respectively. In contrast the percentage of patients with posterior and panuveitis was higher in the 1 to 20 and 20 to 40 years age groups at 51.4% (n = 54) and 48.7% (n = 246) respectively. Sixty three percent of the patients presented with unilateral uveitis (n = 760, p < 0.001) vs bilateral. Non-granulomatous uveitis comprised 84.5% of all patients (n = 1013, p < 0.001) compared to granulomatous uveitis. Non-infectious etiology contributed to 65.7% of all patients (n = 788, p < 0.001) with the majority being unclassifiable uveitis (n = 686, 57.2%,). Specific inflammatory entities contributed to only 8.5% (n = 102) of the non-infectious causes with Vogt-Koyanagi-Harada (VKH) syndrome being the most common (n = 25, 2.1%,). Infectious uveitis comprised 34.3% (n = 411) with tubercular (TB) uveitis (n = 105, 8.8%) and viral uveitis (n = 107, 8.9%) contributing the most followed by ocular Toxoplasmosis (n = 93,7.8%).] CONCLUSION: This study has highlighted the demographic data and common causes of uveitis in Malaysia.

Endogenous endophthalmitis: a 9-year retrospective study at a tertiary referral hospital in Malaysia.

BACKGROUND: The objective of this study was to determine the clinical presentation, systemic risk factors, source of infective microorganism, treatment outcomes, and prognostic indicators of endogenous endophthalmitis at a main tertiary referral hospital for uveitis in Malaysia. A retrospective review of medical records of 120 patients (143 eyes) with endogenous endophthalmitis over a period of 9 years between January 2007 and December 2015 was undertaken. RESULTS: Identifiable systemic risk factors were present in 79.2%, with the majority related to diabetes mellitus (60.0%). The most common source of bacteremia was urinary tract infection (17.5%). A positive culture from ocular fluid or other body fluids was obtained in 82 patients (68.9%), and the blood was the highest source among all culture-positive results (42.0%). Gram-negative organisms accounted 42 cases (50.6%) of which Klebsiella pneumonia was the most common organism isolated (32.5%). Sixty-nine eyes (48.6%) were managed medically, and 73 eyes (51.4%) underwent vitrectomy. Final visual acuity of counting fingers (CF) or better was achieved in 100 eyes (73.0%). Presenting visual acuity of CF or better was significantly associated with a better final acuity of CF or better (p = 0.001). CONCLUSIONS: The visual prognosis of endogenous endophthalmitis is often poor, leading to blindness. As expected, gram-negative organisms specifically Klebsiella pneumonia were the most common organisms isolated. Urinary tract infection was the main source of infection. Poor presenting visual acuity was significantly associated with grave visual outcomes. A high index of suspicion, early diagnosis, and treatment are crucial to salvage useful vision.