A comparative analysis of avoidable causes of childhood blindness in Malaysia with low income, middle income and high income countries.

To determine the avoidable causes of childhood blindness in Malaysia and to compare this to other middle income countries, low income countries and high income countries. Data were obtained from a school of the blind study by Patel et al. and analysed for avoidable causes of childhood blindness. Six other studies with previously published data on childhood blindness in Bangladesh, Ethiopia, Nigeria, Indonesia, China and the United Kingdom were reviewed for avoidable causes. Comparisons of data and limitations of the studies are described. Prevalence of avoidable causes of childhood blindness in Malaysia is 50.5 % of all the cases of childhood blindness, whilst in the poor income countries such as Bangladesh, Ethiopia, Nigeria and Indonesia, the prevalence was in excess of 60 %. China had a low prevalence, but this is largely due to the fact that most schools were urban, and thus did not represent the situation of the country. High income countries had the lowest prevalence of avoidable childhood blindness. In middle income countries, such as Malaysia, cataract and retinopathy of prematurity are the main causes of avoidable childhood blindness. Low income countries continue to struggle with infections such as measles and nutritional deficiencies, such as vitamin A, both of which are the main contributors to childhood blindness. In high income countries, such as the United Kingdom, these problems are almost non-existent.

Diagnostic Challenges in an Atypical Case of IRVAN Syndrome: Literature Review.

A 60-year-old female with known seropositive rheumatoid arthritis and other co-morbids, presented with right eye hypertensive retinopathy and exudative macroaneurysms. Over the years, she developed vitreous haemorrhage, macula oedema and full thickness macula hole. Fluorescein angiography showed macroaneurysms and ischaemic retinal vasculitis. Initial diagnosis was thought to be hypertensive retinopathy with macroaneurysms and retinal vasculitis secondary to rheumatoid arthritis. Laboratory investigations did not support other causes for macroaneurysms and vasculitis. Hence, delayed diagnosis of IRVAN syndrome was made after detailed review of clinical findings, investigations, and angiographic evidence. Our understanding of IRVAN continues to evolve in the face of challenging presentations. To our knowledge, this is the first reported case of IRVAN associated with rheumatoid arthritis.

Lack of association between Gly82Ser, 1704G/T and 2184A/G of RAGE gene polymorphisms and retinopathy susceptibility in Malaysian diabetic patients.

Diabetic retinopathy is the most common diabetic eye disease, occurring in about 60% of type 2 diabetic patients. Other than known clinical risk factors, the influence of genes has been suggested as part of the development of diabetic retinopathy. We investigated the association of Gly82Ser, 1704G/T and 2184A/G polymorphisms in the RAGE gene with retinopathy in type 2 diabetic patients in Malaysia. Ninety-eight unrelated retinopathy patients and 185 unrelated healthy controls from all over Malaysia were recruited in this study. The allele and genotype frequencies of the three gene polymorphisms were investigated using PCR-RFLP. The allele frequency of the three polymorphisms did not differ significantly between the control and the retinopathy group (P > 0.05). Analysis of the frequency of GA+AA, GT+TT and AG+GG in the retinopathy group did not reveal significant differences (P > 0.05) compared to the control group. We conclude that RAGE gene Gly82Ser, 1704G/T and 2184A/G polymorphisms are not associated with retinopathy development in the Malaysian population.

The association between various visual function tests and low fragility hip fractures among the elderly: a Malaysian experience.

BACKGROUND: hip fractures are an increasing source of morbidity and mortality in older people. The role of visual function tests such as visual impairment, stereopsis, contrast sensitivity and visual field defects in low fragility hip fractures in Asian populations is not well understood. OBJECTIVE: to determine the association between various visual function tests and low fragility hip fractures in an Asian population. DESIGN: case-control study. SETTING: University Malaya Medical Centre, Kuala Lumpur, Malaysia. SUBJECTS: 108 cases aged > or = 55 years admitted with low fragility fractures and 108 controls (matched for age, gender and race). METHODS: both cases and controls underwent a detailed ophthalmological examination, which included visual acuity, stereopsis, contrast sensitivity and visual field testing. RESULTS: poorer visual acuity (odds ratio, OR = 4.08; 95% confidence interval, CI: 1.44, 11.51), stereopsis (OR = 3.60, 95% CI: 1.55, 8.38), contrast sensitivity (OR = 3.34, 95% CI: 1.48, 7.57) and visual field defects (OR = 11.60, 95% CI: 5.21, 25.81) increased the risk of fracture. Increased falls were associated with poorer visual acuity (OR = 2.30, 95% CI: 1.04, 5.13), stereopsis (OR = 2.11, 95% CI: 1.03, 4.32), contrast sensitivity (OR = 2.12, 95% CI: 1.05, 4.30) and visual field defects (OR = 3.40, 95% CI: 1.69, 6.86). CONCLUSION: impaired visual acuity, stereopsis, contrast sensitivity and visual field defects are associated with an increased risk of low fragility hip fractures. We recommend that all patients aged > or = 55 should have an annual ophthalmological examination that includes visual acuity, contrast sensitivity, stereopsis and visual field testing to assess the risks for falls and low fragility fractures.

Minimally invasive image-guided removal of retrobulbar intraconal foreign body.

Surgical approaches are becoming increasingly minimally invasive, without compromising either safety or ease. Penetrating ocular foreign bodies has traditionally been approached either by intraocular or supraorbital access. We successfully attempted a minimally invasive approach to remove a retrobulbar foreign body under computer-assisted image guidance in a 19-year-old man involved in an industrial mishap.

Ophthalmology inpatient consultation: does it make a difference to inpatient management?

Ophthalmology consultation is one of the commonest requested services for inpatients in a tertiary hospital. A total of 290 ophthalmology consultation requests were received over a period of six months (average 12 consultation requests per week) and from these, 222 patients were examined. The patient demographics, the hospitalization data, type of consultations (screening, new problem, preexisting problem), reasons for consultations and the ophthalmology diagnosis were determined. Out of 290 consultation requests, internal medicine services requested the highest number (95, 32.8%); the commonest type of consultation was screening for eye diseases (161, 55.5%) and the most common reason for consultation was to rule out diabetic retinopathy (125, 43.1%). The top five ophthalmology diagnoses after examination were diabetic retinopathy (45, 20.3%), diabetic retinopathy ruled out (37, 16.6%), conjunctivitis (12, 5.4%), refractive error (11, 4.8%) and normal ocular examination (11, 4.9%). Inpatient ophthalmologic procedures were performed in 146 patients, the commonest of which was retinal laser photocoagulation. A total of 133 (59.9%) inpatients had a change in their management as a result of the ophthalmology consultation.

Acute retinal necrosis by cytomegalovirus in an immunocompetent adult: case report and review of the literature.

A rare case of acute retinal necrosis caused by cytomegalovirus in an immunocompetent adult, diagnosed by polymerase chain reaction of vitreous aspirate, with good visual outcome after intravitreal and intravenous ganciclovir and oral prednisolone therapy, is reported. A 50-year-old healthy lady presented with redness and diminution of vision in her right eye of 10 days duration. She had anterior chamber inflammation, marked vitritis, and anterior retinal necrosis in the right eye. Blood and other investigations did not reveal any infectious diseases and HIV testing was negative. The retinal lesions and panuveitis resolved with treatment. Two months later she developed retinal detachment which was treated successfully. The best-corrected vision was 6/12 in the right eye. Seven cases of cytomegalovirus ocular infection in immunocompetent healthy adults, reported in the literature, were reviewed. The different presentations of this disease and the importance of suspecting this causative agent are highlighted.

Awareness and knowledge on eye donation among university students.

Four hundred (400) students studying first year Medicine, Dentistry, Laboratory Technology, Pharmacy, Biomedicine and Bioengineering degree courses in the University of Malaya were assessed on their awareness and knowledge on eye donation using an open ended questionnaire. The majority of the students (344, 86%) in this study were aware about eye donation; the awareness was higher in biomedical (77.1%) and medical students (76.7%) compared to the others (55.9%-70.7%). One hundred and eight students (27%) were willing to donate their eyes. Most of the students (376, 94%) did not know about any eye bank in Malaysia. One hundred and sixty (40%) students were aware that whole eye can be removed from the donor and 101 (25.25%) were aware that the cornea can be removed separately. However, only 121 (30.25%) knew that donated eyes were used for corneal grafting. More than half of the students (231, 57.7%) did not know that the donor eye could be stored before transplantation. The results of this study indicate that there is a need to educate the young adults in our society about corneal transplantation so that they can in turn motivate other members of society and their own family members to become eye donors, thus facilitating the availability of donor corneas for corneal transplantation in Malaysia.

Endoscopic orbital decompression for optic neuropathy in thyroid ophthalmopathy.

Optic neuropathy, an uncommon manifestation occurs in 5% of patients with Graves' ophthalmopathy. Its outcome is good if early and proper treatment given. We reported a 49 years old male patient of Graves' disease with bilateral optic neuropathy. He underwent bilateral transnasal endoscopic orbital decompression with marked improvement of visual acuity bilaterally. The preoperative visual acuity was 6/36 in his right eye and 6/60 in his left eye. Two days after operation, his visual acuity was 6/12 in his right eye and 6/24 in his left eye. Transnasal endoscopic orbital decompression is a choice of treatment in optic neuropathy in thyroid ophthalmopathy after trial of corticosteroids.

Knowledge and practice of contact lens wear and care among medical students of University of Malaya.

The knowledge related to contact lens wear and practice care of contact lenses among medical students of University of Malaya was assessed through a structured questionnaire. One hundred and twenty-one contact lens wearers participated in this study. Majority of contact lens wearers were females (106, 87.6%); the duration of contact lens wear varied from less than six months to two years or more; 53 (43.8%) cited cosmetic purpose for wearing contact lens; 16 (13.2%) were not removing their contact lenses prior to sleeping at night. Despite 107 (88.4%) were aware of complications of contact lens usage, only 102 (84.3%) were adhering strictly to proper hygiene and contact lens care; and 17 (14%) continued wearing in spite of eye symptoms. Forty seven (38.8%) students sought ophthalmic consultation for eye problems. Improper practice of contact lens wear and care even in educated users such as medical students could increase the risk of complications. Therefore, a need for more education to the consumers is desired.

Contact lens-related infectious keratitis in Malaysia.

Fifty-six contact lens-related corneal ulcers (central in 32; hypopyon in 24 and stromal abscess in 6) were studied. Culture was positive in 78.9%. Corneal ulcers healed with intense antibiotic therapy in nearly all patients. Increased awareness of lens care/disinfection and frequent replacement of storage cases and solution, and early detection of pathogens and intensive appropriate antibiotic therapy are key points in management.

Primary Conjunctiva Tuberculosis and Review of Literature.

The causes of chronic conjunctivitis are exhaustive, infection being the commonest. Primary tuberculosis(TB) involving the conjunctiva is rare. History of chronicity, worsening symptoms with steroids and clinical signs of subconjunctiva nodules could point towards the diagnosis of primary conjunctiva tuberculosis especially in endemic countries. Clinicopathological diagnosis is imperative to confirm this diagnosis. We report a case of a young lady who presented with a non-resolving chronic conjunctivitis that was proven to be TB and responded well to anti-tuberculosis treatment.

Acute retinal necrosis complicating chickenpox in a healthy adult--a case report and review of literature.

Acute retinal necrosis (ARN) is known to occur in conjunction with primary varicella or chickenpox infection. The majority of ARN cases reported in the literature were of milder form with mild to moderate vitritis, limited retinitis, and rare occurrence of retinal breaks or detachment that responded well to intravenous acyclovir, with or without oral prednisolone. We report a case of unilateral ARN with marked vitritis and retinal necrosis leading to retinal breaks following chickenpox in a 32-year-old healthy lady. This patient was successfully treated with intravenous acyclovir followed by oral acyclovir and orbital floor triamcinolone injections to contain the inflammation with barrier laser therapy to secure the retinal breaks with good visual outcome. This case is unusual in its severity, and to our knowledge, orbital floor triamcinolone therapy was not used earlier to contain ARN inflammation.

Dropped nucleus following phacoemulsification cataract surgery.

Twenty two cases of dropped nucleus following 1,196 phacoemulsification procedures in cataract surgery were examined retrospectively to determine the incidence, predisposing factors and visual outcomes of this dreaded complication. All the cases underwent pars plana vitrectomy and the lens fragments were removed with phacofragmotome, vitrectomy cutter or delivered through limbus. The incidence of dropped nucleus was 1.84%. The predisposing factors were hard cataracts (13.6%), polar cataracts (9.1%), previously vitrectomized eyes (4.5%) and high myopia (4.5%). The final visual outcome was > or = 6/12 in 10 eyes (45.5%); complications were seen in 5 eyes (22.7%). The interval between initial surgery and vitrectomy, the method of fragment removal and the type of lens implanted, did not influence the final visual outcome.

Prevalence and risk factors for diabetic retinopathy--a study of 217 patients from University of Malaya Medical Centre.

Two hundred and seventeen diabetic patients attending the eye clinic were examined to determine the prevalence of retinal changes, and the association between diabetic retinopathy and risk factors. A detailed fundus examination was done, after dilating the pupils, using 90 D lens and slitlamp biomicroscope. Diabetic retinopathy was detected in 112 patients (51.6%). Background retinopathy was seen in 40 out of 217 (18.4%), pre-proliferative retinopathy in 11 (5.1%), proliferative retinopathy in 61 (28.1%) and maculopathy in 58 (26.7%) patients. Factors significantly associated with occurrence of retinopathy were duration of diabetes, presence of hypertension and presence of systemic complications (diabetic foot ulcer, lower limb amputation, nephropathy, and peripheral neuropathy).

Childhood blindness and severe visual impairment in Malaysia: a nationwide study.

AIM: To determine the causes of childhood blindness and severe visual impairment (BL/SVI) in schools for the blind in Malaysia. METHODS: All children ≤ 15 years attending 24 schools for the blind throughout the country were examined using the WHO Prevention of Blindness Programme (WHO/PBL) eye examination record for children, and visual loss was classified according to the International Classification of Disease (ICD). RESULTS: In all, 469 children were examined, of whom 448 (95.6%) had BL/SVI. The major causes of visual loss were retinal disorders (n=148, 33%; mainly retinopathy of prematurity (n=78, 17.4%)), cataract/pseudophakia/aphakia (n=77, 17.2%), and anomalies affecting the whole globe. (n=86, 19.2%). The major underlying etiology was undetermined (n = 193, 43.1%), followed by hereditary factors, 21.7% (mainly retinal dystrophies), and perinatal factors, 20.5%. More than 34 (7.6%) cases were considered potentially preventable and 192 (42.9%) potentially treatable. CONCLUSION: Diseases of the retina are the major cause of visual impairment, with retinopathy of prematurity being an important avoidable cause. This reflects expansion of neonatal services in Malaysia, and improved survival of very low birth weight and preterm babies. Lens-related causes of visual impairment reflect the need to further improve pediatric ophthalmology services in Malaysia.

Bilateral scleromalacia perforans and peripheral corneal thinning in Wegener's granulomatosis.

A rare case of bilateral scleromalacia perforans, bilateral peripheral corneal thinning (contact lens cornea) and unilateral orbital inflammatory disease in a 50 year old female patient with an indolent form Wegener's granulomatosis(WG) involving lungs and sinuses is reported. The patient survived for 12 years after the initial diagnosis of systemic disease. There was perforation of left globe following trauma and no perforation of the right globe till the last follow up of the patient.

Adverse outcomes in Type I diabetic pregnant women with proliferative diabetic retinopathy.

AIM: To report maternal and fetal adverse outcomes, in spite of appropriate treatment and regular follow up, in diabetic pregnant women with proliferative diabetic retinopathy. METHODS: Case series of four young pregnant diabetics aged between 20 and 25 years with type I diabetes mellitus and proliferative diabetic retrinopathy. RESULTS: The maternal adverse outcomes were abortion in one patient, pre-eclampsia and preterm delivery in one patient, and renal failure requiring dialysis in one patient. The fetal adverse outcomes were neonatal death in one case and premature baby in another case. CONCLUSION: These cases highlight the fact that diabetic pregnant women should be closely followed up by the obstetricians and physicians when they have proliferative retinopathy. The proliferative diabetic retinopathy should be considered as a part of the assessment when counseling a diabetic woman in antenatal check up and also in the follow up visits during pregnancy.

Awareness of eye complications and prevalence of retinopathy in the first visit to eye clinic among type 2 diabetic patients.

AIM: To assess the awareness of eye complications and the prevalence of retinopathy, in the first visit to eye clinic, among type 2 diabetic patients attending a tertiary medical centre in Kuala Lumpur, Malaysia. METHODS: An investigator-administered questionnaire was given to 137 patients with diabetes undergoing first time eye screening in the eye clinic. This was followed by a detailed fundus examination by a senior ophthalmologist to assess for presence of retinopathy. RESULTS: Almost 86% of respondents were aware of diabetic eye complications, especially in patients who had achieved tertiary educational level (96.3%). The majority of the patients (78.8%) were referred by their physicians and only 20.4% came on their own initiative. Many of the patients (43.8%) did not know how frequent they should go for an eye check-up and 72.3% did not know what treatments were available. Lack of understanding on diabetic eye diseases (68.6%) was the main barrier for most patients for not coming for eye screening earlier. Despite a high level of awareness, only 21.9% had recorded HbA1c level of <6.5% while 31.4% were under the erroneous assumption of having a good blood sugar control. A total of 29.2% had diabetic retinopathy in their first visit eye testing. CONCLUSION: In the present study, 29.2% of type 2 diabetic patients had retinopathy in their first time eye testing. Although the awareness of diabetic eye complications was high among first time eye screening patients, the appropriate eye care-seeking behavior was comparatively less and should be rectified to prevent the rise of this sight threatening eye disease.