The effect of palm oil-derived tocotrienol-rich fraction in preserving normal retinal vascular diameter in streptozotocin-induced diabetic rats.

PURPOSE: Angiogenesis in diabetic retinopathy (DR) is associated with increased retinal expression of angiopoietin-2 (Ang-2) and protein kinase C (PKC). Tocotrienol-rich fraction (TRF) has been shown to reduce the expression vascular endothelial growth factor (VEGF) in several experimental models. However, its effect against other angiogenic markers such as Ang-2 and PKC in rat model of diabetes remains unknown. Therefore, we investigated the effect of TRF on the retinal vascular changes and Ang-2 and PKC expressions in rats with streptozotocin (STZ)-induced DR. METHODS: Sprague-Dawley rats were divided into normal control rats (N) which received vehicle, and diabetic rats which either received vehicle (DV) or 100 mg/kg of TRF (DT). Diabetes was induced with intraperitoneal injection of STZ (60 mg/kg body weight). Treatments were given orally, once daily, for 12 weeks after confirmation of hyperglycaemia. Fundus photographs were captured at baseline, 6- and 12-week post-STZ injection and average diameter of retinal veins and arteries were measured. At 12-week post-STZ injection, rats were euthanised, and retinae were collected for measurement of Ang-2 and PKC gene and protein expressions. RESULTS: Retinal venous and arterial diameters were significantly greater in DV compared to DT at week 12 post-STZ injection (p < 0.001 and < 0.05, respectively). The vessel diameter measurements in DT were comparable to N and this effect of TRF was associated with significantly lower Ang-2 and PKC gene and protein expressions compared to DV. CONCLUSION: Oral TRF reduces the expression of retinal angiogenic markers and preserves the retinal vascular diameter of rats with STZ-induced DR.

Retinal Vessel Analysis as a Novel Screening Tool to Identify Childhood Acute Lymphoblastic Leukemia Survivors at Risk of Cardiovascular Disease.

BACKGROUND: Microvascular endothelial dysfunction is central to the pathogenesis of cardiovascular disease (CVD). The eye offers direct access for endothelial health assessment via the retinal microvasculature. The aim of the study was to investigate whether image-based retinal vessel analysis is a feasible method of assessing endothelial health in survivors of childhood acute lymphoblastic leukemia (cALL). MATERIALS AND METHODS: Cardiovascular risk factors (CRFs) were estimated using the 30-year Framingham Risk Score in 73 childhood leukemia survivors (median age: 25; median years from diagnosis: 19) and 78 healthy controls (median age: 23). Radial arterial stiffness was measured using pulse wave analyzer, while endothelial activation markers were measured by soluble intercellular adhesion molecule 1 (sICAM-1) and soluble vascular cell adhesion molecule 1 (sVCAM-1). Retinal fundus images were analyzed for central retinal artery/vein equivalents (CRAE/CRVE) and arteriolar-venular ratio (AVR). RESULTS: cALL survivors had higher CRF (P<0.0001), arterial stiffness (P=0.001), and sVCAM-1 (P=0.007) compared with controls. Survivors also had significantly higher CRVE (P=0.021) while AVR was significantly lower (P=0.026) in survivors compared with controls, compatible with endothelial dysfunction. In cALL survivors with intermediate risk for CVD, CRAE, and AVR are significantly lower, while sVCAM-1 and sICAM-1 are significantly higher when compared with survivors with low CVD risk after adjusting with covariates (age, sex, and smoking status). CONCLUSIONS: cALL survivors have an increased risk of CVD compared with age-matched peers. The survivors demonstrated microvasculopathy, as measured by retinal vascular analysis, in addition to physical and biochemical evidence of endothelial dysfunction. These changes predate other measures of CVD. Retinal vessel analysis may be utilized as a robust screening tool for identifying survivors at increased risk for developing CVD.

Corneal Hysteresis Is Reduced in Obstructive Sleep Apnea Syndrome.

SIGNIFICANCE: To our knowledge, this is the first time a study looking at the association between corneal hysteresis (CH) and obstructive sleep apnea syndrome (OSAS) severity has been reported. We provide evidence that CH is lower in OSAS and speculate on the possible causes. PURPOSE: The present study aims to look at the association between CH and severity of OSAS, and whether CH could be another link between OSAS and the development of glaucoma. METHODS: This was a cross-sectional, observational study at the University Malaya Medical Centre, Kuala Lumpur. Patients undergoing polysomnography for assessment of OSAS were recruited. We measured central corneal thickness (CCT) using optical biometry, and CH using ocular response analysis. Intraocular pressure (IOP) and Humphrey visual field (HVF) indices were also measured. The Apnea Hypopnea Index (AHI) divided patients into normal, mild, moderate, and severe OSAS categories. The normal and mild categories (47.9%) were then collectively called group 1, and the moderate and severe categories (52.1%) were called group 2. T tests, Pearson correlation tests, and general linear model analysis were performed, with P <.05 considered statistically significant. RESULTS: One eye each from 117 patients (75 men, 42 women) was included. Patients in group 2 had lower CH (9.8 ± 1.4 vs. 10.3 ± 1.1 mm Hg, P = .029), with unchanged estimated marginal means after correcting for age, sex, CCT, and IOP (P = .026). There were no statistically significant differences in IOP, CCT, or HVF indices between the two groups (all P > .05). CH correlated negatively with AHI (r = -0.229, P = .013) and positively with lowest oxygen saturation (r = 0.213, P = .022). CONCLUSIONS: CH is lower in moderate/severe OSAS than in normal/mild cases. This may be another link between OSAS and the development of glaucoma; further studies are indicated to determine the significance of this connection.

In vivo proton magnetic resonance spectroscopy (1H-MRS) evaluation of the metabolite concentration of optic radiation in primary open angle glaucoma.

OBJECTIVE: To compare the metabolite concentration of optic radiation in glaucoma patients with that of healthy subjects using Proton Magnetic Resonance Spectroscopy (1H-MRS). METHODS: 1H-MRS utilising the Single-Voxel Spectroscopy (SVS) technique was performed using a 3.0Tesla MRI on 45 optic radiations (15 from healthy subjects, 15 from mild glaucoma patients, and 15 from severe glaucoma patients). A standardised Volume of Interest (VOI) of 20 × 20 × 20 mm was placed in the region of optic radiation. Mild and severe glaucoma patients were categorised based on the Hodapp-Parrish-Anderson (HPA) classification. Mean and multiple group comparisons for metabolite concentration and metabolite concentration ratio between glaucoma grades and healthy subjects were obtained using one-way ANOVA. RESULTS: The metabolite concentration and metabolite concentration ratio between the optic radiations of glaucoma patients and healthy subjects did not demonstrate any significant difference (p > 0.05). CONCLUSION: Our findings show no significant alteration of metabolite concentration associated with neurodegeneration that could be measured by single-voxel 1H-MRS in optic radiation among glaucoma patients. KEY POINTS: • Glaucoma disease has a neurodegenerative component. • Metabolite changes have been observed in the neurodegenerative process in the brain. • Using SVS, no metabolite changes in optic radiation were attributed to glaucoma.

Ocular perfusion pressure and ophthalmic artery flow in patients with normal tension glaucoma.

BACKGROUND: Vascular insufficiency has been reported to be a cause of normal tension glaucoma (NTG). The aim of this study was to compare ocular perfusion pressure (OPP) and ophthalmic artery flow (OAF) between patients with NTG and those without glaucoma. METHODS: We considered one eye each from 31 NTG and 15 non-glaucoma control patients. Blood pressure and intraocular pressure (IOP) were measured in the sitting position, for calculation of OPP. Humphrey visual field (HVF) assessment was then carried out on NTG patients. All patients then underwent Transcranial Doppler ultrasound measurements of OAF parameters, including mean flow velocity (MFV), end diastolic velocity (EDV), peak systolic velocity (PSV) and resistive index (RI). We looked at differences in OPP and OAF parameters between the two groups, and their correlations in NTG patients. T-tests, χ (2), ANOVA and Pearson Correlation tests were performed, with p < 0.05 considered statistically significant. RESULTS: There were no statistically significant differences in OPP between the NTG and control groups (60.5+/-8.7 mmHg and 62.9+/-10.2 mmHg respectively, p = 0.393), and also no statistically significant differences in MFV, EDV, PSV and RI (all p > 0.05). In the NTG group, there were positive correlations between OPP and both MFV (r = 0.416, p = 0.020) and EDV (r = 0.369, p = 0.041). There were no statistically significant correlations between HVF mean deviation and OPP or OAF parameters (all p > 0.05). CONCLUSION: There is no difference in OPP and OAF parameters between patients with NTG and non-glaucoma controls, suggesting that vascular insufficiency or dysregulation by themselves may not account for the pathogenesis of NTG.

Ocular Surface Disease in Glaucoma: Effect of Polypharmacy and Preservatives.

PURPOSE: To evaluate the prevalence of ocular surface disease (OSD) in glaucoma and nonglaucoma subjects using different clinical tests and to determine the effect of number of antiglaucoma medications and preservatives on OSD. METHODS: This is a cross-sectional, case-comparison study at the Eye Clinic of the University of Malaya Medical Centre, Malaysia, between June 2012 and January 2013. Glaucoma subjects (n = 105) using topical antiglaucoma medications were compared with control subjects (n = 102) who were not on any topical medications. The presence of OSD was assessed using the tear film breakup time (TBUT) test, corneal staining, Schirmer test, and Ocular Surface Disease Index (OSDI) questionnaire grading. RESULTS: The prevalence of OSD varied from 37 to 91% in the glaucoma group, depending on the type of clinical test. More subjects in the glaucoma group had corneal staining (63% vs. 36%, p = 0.004), abnormal Schirmer tests (39% vs. 25%, p = 0.049), and moderate OSDI symptoms (17% vs. 7%, p = 0.028). The percentage with abnormal TBUT increased with higher numbers of topical medications and was high with both benzalkonium chloride-containing and preservative-free eye drops (90% and 94%, respectively, both p < 0.001). Benzalkonium chloride was associated with a nearly three times higher odds ratio of showing abnormal OSDI. CONCLUSIONS: Ocular surface disease is common in those using topical antiglaucoma medications. Abnormal TBUT is associated with increasing number of eye drops and benzalkonium chloride-containing eye drops, although this also occurs with the use of preservative-free eye drops.

Proptosis--Correlation and Agreement between Hertel Exophthalmometry and Computed Tomography.

AIM: To determine the correlation and agreement between Hertel exophthalmometry and computed tomography (CT) of the orbits in measuring proptosis. MATERIALS AND METHODS: 80 patients (40 normal and 40 with proptosis) were recruited for this study. Exophthalmometry were performed on all of them using the Hertel exophthalmometer and CT. Values and correlations between the modalities were analysed with unpaired t-tests, intraclass correlation coefficients (ICC), and Pearson correlation coefficients (PCC). The Bland-Altman method was used to analyse the agreement between the two modalities. RESULTS: Hertel exophthalmometer and CT measurements did not differ significantly (p > 0.05), although exophthalmometry measurements of the normal (14.5 ± 2.2 mm) and proptosis groups (20.5 ± 3.9 mm) were higher than those obtained from CT (13.9 ± 2.4 mm and 20.0 ± 3.7 mm, respectively). ICC for both the Hertel exophthalmometer and CT measurements were both 0.99, indicating high intra-observer reliability and reproducibility. PCC between Hertel exophthalmometer and CT measurements in both normal and proptosis groups were strongly correlated (r = 0.96 and 0.93, respectively, p = 0.01). The 95% limits of agreement (LOA) between Hertel exophthalmometer and CT measurements for the normal and proptosis groups were -0.70 to 1.78 mm and -2.36 to 3.33 mm, respectively. CONCLUSION: Although Hertel exophthalmometer and CT measurements are similar and strongly correlated, they do not agree well with each other in the presence of proptosis. The measurements should not be used interchangeably as the differences between them may lead to errors in clinical interpretation.

Novel use of 3T MRI in assessment of optic nerve volume in glaucoma.

PURPOSE: To measure optic nerve (ON) volume using 3 T magnetic resonance imaging (MRI), to correlate ON volume with retinal nerve fiber layer (RNFL) thickness, and to determine the viability of MRI as an objective tool in distinguishing glaucoma severity. METHODS: In this cross-sectional study, 30 severe glaucoma patients, 30 mild glaucoma patients and 30 age-matched controls were recruited. All subjects underwent standard automated perimetry, RNFL analysis and 3 T MRI examinations. Glaucoma patients were classified according to the Hodapp-Anderson-Parish classification. Pearson's correlation coefficient was used to correlate ON volume with RNFL, and receiver operating curve (ROC) analysis was performed to determine the sensitivity and specificity of ON volume in detecting glaucoma severity. RESULTS: Optic nerve volume was significantly lower in both the left and right eyes of the severe glaucoma group (168.70 ± 46.28 mm(3); 167.40 ± 45.36 mm(3)) than in the mild glaucoma group (264.03 ± 78.53 mm(3); 264.76 ± 78.88 mm(3)) and the control group (297.80 ± 71.45 mm(3); 296.56 ± 71.02 mm(3)). Moderate correlation was observed between: RNFL thickness and ON volume (r = 0.51, p <0.001), and in mean deviation of visual field and optic nerve volume (r = 0.60, p < 0.001). ON volume below 236 mm(3) was 96 % sensitive and 80 % specific for the detection of severe glaucoma. CONCLUSIONS: MRI measured optic nerve volume is a reliable method of assessing glaucomatous damage beyond the optic nerve head. A value of 236 mm(3) and below can be used to define severe glaucoma.

Darkroom prone provocative test in primary angle closure glaucoma relatives.

PURPOSE: To evaluate ocular biometric parameters and darkroom prone provocative test (DPPT) in family members of primary angle closure (PAC) glaucoma (PACG) patients and to establish any correlation between these biometric parameters and the DPPT response. METHODS: Seventy-four family members of PACG patients underwent ultrasound ocular biometry, slit lamp biomicroscopy, Goldmann applanation tonometry, fundus examination, and gonioscopy. Lastly, DPPT was performed. RESULTS: Of 74 family members examined, 6 (8.1%) were found to have PAC, 8 (10.8%) were PAC suspects, and 60 (81.1%) were unaffected. Of those affected, 4 (66.7%) had a positive DPPT response, whereas 87.5% of the PAC suspects had a positive or a borderline DPPT response. Affected and PAC suspects had the shallowest anterior chamber depth, thickest lens, shortest axial length, and most anteriorly positioned lens. Anterior chamber depth and lens thickness showed a significant correlation with positive DPPT. CONCLUSIONS: Anterior chamber depth and lens thickness and, to a lesser extent, axial length and lens position were significantly correlated with a positive DPPT response. The ocular biometric risk factors associated with PACG patients are also found in their respective family members who are affected and suspected of having PAC. We suggest a longitudinal study to determine the reliability of DPPT in identifying individuals who are at risk of PAC.

When brakes fail you: Oculocardiac reflex elicited by a retained foreign body in a penetrating orbital injury.

Purpose: To report a case of oculocardiac reflex following penetrating orbital injury with entrapment of extraocular muscle secondary to a retained orbital foreign body. Observation: A 19-year-old man with no known comorbidities presented with a foreign object in his right orbit following a motor vehicle accident. Visual acuity was 20/20 bilaterally with positive relative afferent pupillary defect for the right eye. A motorcycle brake lever was embedded in the right inferotemporal conjunctival fornix, missing his globe. He was bradycardic in the emergency department, with a pulse rate ranging between 45 and 48 beats per minute. An urgent computed tomography scan of the orbit confirmed the penetrating injury with a linear hyperdense foreign body extending from the right inferior orbit into the right maxillary sinus. This foreign body was seen abutting the right lateral rectus and the globe inferiorly. Fractures involving the inferior and medial wall of the right orbit were seen with the inferior rectus, and orbital fat herniated into the maxillary sinus.The patient underwent urgent orbit exploration with foreign body removal and orbital floor repair under general anesthesia. Immediately after removing the foreign body, his pulse rate returned to normal, within 72-80 beats per minute. Six months postoperatively, visual acuity was 20/20 for both eyes. Although he had persistent diplopia on upgaze, he refused any other interventions. Conclusion and importance: Prompt detection of the oculocardiac reflex and removal of the inciting stimulus is vital to prevent any life-threatening events.

Longitudinal Changes in the Retinal Nerve Fiber Layer Thickness in Amyotrophic Lateral Sclerosis and Parkinson's Disease.

BACKGROUND AND PURPOSE: There is increasing evidence that the anterior visual pathways are involved in neurodegenerative diseases including amyotrophic lateral sclerosis (ALS) and Parkinson's disease (PD). This study investigated longitudinal changes in retinal nerve fiber layer (RNFL) thickness in patients with ALS and PD with the aim of better understanding their roles as biomarkers of disease progression. METHODS: This study recruited 21 ALS patients, 19 age-matched PD patients, and 21 agematched healthy controls. Patient demographics and clinical scores relating to the respective diseases were documented. The RNFL thickness was measured using optical coherence tomography at baseline and after 6 months. RESULTS: At baseline, the RNFL in the superior quadrant was significantly thinner in the patients with ALS than in healthy controls (109.90±22.41 µm vs. 127.81±17.05 µm [mean±standard deviation], p=0.008). The RNFL thickness did not differ significantly between the ALS and PD patients or between the PD patients and healthy controls. At 6 months, there was further significant RNFL thinning in patients with ALS, for both the overall thickness (baseline: median=94.5 µm, range=83.0-106.0 µm; follow-up: median=93.5 µm, range=82.5-104.5 µm, p=0.043) and the thickness in the inferior quadrant (median=126 µm, range=109.5-142.5 µm; and median=117.5 µm, range=98.5-136.5 µm; respectively, p=0.032). However, these changes were not correlated with the ALS functional scores. In contrast, the patients with PD did not demonstrate a significant change in RNFL thickness between the two time points. CONCLUSIONS: The RNFL thickness is a promising biomarker of disease progression in patients with ALS but not in those with PD, which has a slower disease progression.

Diagnostic challenge: Diffuse large B-cell lymphoma masquerading as orbital cellulitis.

We report a clinical case of orbital lymphoma masquerading as orbital cellulitis. Orbital lymphoma and lymphoma of the orbital adnexa are relatively rare types of lymphoma. They represent the malignant end of a spectrum of lymphoproliferative lesions that occur in the orbit, conjunctiva and eyelid. Diffuse large B-cell lymphomas (DLBCL) with variable clinical presentations have a relatively poor prognosis with rapid visual loss. Therefore, thorough evaluation and assessment with a multi-specialty effort are warranted for earlier diagnosis and initiation of treatment to save life and prevent sight loss.

A Case Report of Dengue-Associated Maculopathy With Literature Review.

We report a case of dengue-associated maculopathy in a healthy adult. A 31-year-old lady with dengue fever presented with both eye sudden, painless blurry vision in the left eye. On examination, the best-corrected visual acuity was 6/18 in her right eye and 2/60 in her left eye. Anterior segment examination was unremarkable. Fundi showed bilateral macula edema with cotton wool spots. Optical coherence tomography (OCT) macula scan was suggestive of bilateral macula edema, with higher severity in the left eye. She was started on intravenous methylprednisolone 500mg once daily for three days. Upon completion of steroids, her right eye visual acuity improved to 6/6 however her left eye vision worsened to 3/60 after six months. Her OCT six months later showed resolved macula edema on both eyes. Ocular manifestation associated with dengue fever is rare but may result in permanent visual impairment. The use of high-dose steroids helps in improving visual acuity.

Incidence and Predictive Risk Factors for Post-Cataract Surgery Endophthalmitis in Ministry of Health Hospitals from 2012 to 2020.

PURPOSE: Postoperative endophthalmitis is a devastating complication, leading to poor visual prognosis. The purpose of this study is to determine the incidence, risk factors, and visual outcome of post-cataract surgery endophthalmitis in Malaysia over a 9-year period (2012-2020). METHODS: Data from National Eye Database (NED), involving all patients who have undergone cataract surgery from January 2012 until December 2020 were analyzed. RESULTS: Total number of patients who had undergone cataract surgery between the year 2012 till 2020 were 231,281 patients (267,781 eyes). Incidence of POE in this population was 0.08%. Patient aged 70 and above (p-value 0.047), Malay ethnicity (p-value: 0.009), presence of ischemic heart disease, renal failure, diabetic retinopathy, and poorer preoperative vision were shown to have a higher risk of POE. Cataract surgeries done in KK-KKM, duration more than 45 minutes, use of general anaesthesia, and no IOL or ACIOL implantation were significantly more in POE patients. Multivariate analysis revealed Malay ethnicity, presence of ocular comorbidity, poor preoperative vision, ACIOL, and presence of intra-operative complication were predictive factors for POE. CONCLUSIONS: Incidence of POE is low in the Malaysian population. Surgeons have to be aware that Malay ethnicity, presence of ocular comorbidity, poor preoperative visual acuity, placement of IOL and complicated cataract operation have higher risk of POE.

Effects of regular exercise on intraocular pressure.

BACKGROUND: Exercise may potentially provide an adjunctive measure to help control intraocular pressure in glaucoma patients. However, currently, there is still no substantial evidence that regular exercise can produce a prolonged effect of intraocular pressure reduction. We aim to determine the effects of regular exercise on intraocular pressure in healthy individuals. METHODS: We conducted a prospective, interventional study at the University of Malaya Medical Centre. Our subjects consist of 45 healthy participants in the intervention arm, and 38 healthy control participants who were age- and gender-matched. The intervention arm was enrolled into a supervised exercise programme for a 6-week period, where controls were asked to continue their usual daily lifestyle. The intervention consists of three sessions every week, which focused on aerobic exercise and strength training. RESULTS: Baseline intraocular pressure was measured, and then remeasured again at the end of 6 weeks of exercise conditioning. In the intervention group, there was a reduction of baseline intraocular pressure from pre-intervention mean intraocular pressure of 15.55 ± 2.63 mmHg, down to 13.36 ± 3.16 mmHg at 6 weeks, a statistically significant reduction of -2.18 ± 2.25 mmHg (p < 0.001) post-intervention. On the other hand, the control group recorded a non-statistically significant mean increase of 0.63 ± 2.47 mmHg (p = 0.123) at 6 weeks. CONCLUSIONS: Our study concluded that regular exercise results in a significant intraocular pressure reduction in healthy individuals.

Contrast sensitivity is associated with frailty.

PURPOSE: Using data from the Malaysian Elders Longitudinal Research (MELoR), this study investigated the association between visual function (visual acuity and contrast sensitivity) and frailty in a group of urban-dwelling older adults. METHODS: This was a cross-sectional study. 1332 participants aged ≥ 55 years were selected by random sampling from the parliamentary electoral register. Only 1274 participants completed the frailty assessment and 1278 participants completed the contrast sensitivity assessment. Impaired vision was defined as a Snellen visual acuity of worse than 6/12 in the better eye. Poor contrast sensitivity was defined as a score on the Pelli Robson chart of lower than 1.65. Frailty was defined with the Fried's phenotype criteria. Inter-group comparisons were determined with the independent T-test for continuous variables and the Pearson's Chi-squared test for categorical variables. The odds ratio (OR) with 95% confidence interval (CI) was used to evaluate the cross-sectional association between frailty and visual function. RESULTS: The mean age of participants was 68.8 ± 7.5 years, of which 58.1% (774) were women. Impaired vision and poor contrast sensitivity were present in 187 (14%) and 271 (21.2%) subjects respectively. 73 (5.8%) individuals were classified as frail, 1161 (91.0.%) pre-frail, and 40 (2.8%) non-frail. There was no significant difference in frailty phenotypes between those with good and impaired vision (p = 0.241). Fried's component of handgrip strength, gait speed and exhaustion were significantly better in those with good visual function (p < 0.05). Participants with poor contrast sensitivity were significantly more likely to be frail (OR: 5.34, p = 0.004). CONCLUSION: Poor contrast sensitivity was significantly associated with frailty. This highlights the importance of incorporating assessment of contrast sensitivity in those at risk of frailty.

The Malaysian Elders Longitudinal Research (MELoR): Prevalence and Factors Associated With Vision Impairment in an Urban Population in Malaysia.

Low vision and blindness are major health issues affecting ageing population. This cross-sectional study aims to determine the prevalence of visual impairment (VI) in Petaling Jaya North, Petaling Jaya South, and Lembah Pantai using data from the Malaysian Elders Longitudinal Research. There were 1322 participants aged ≥55 years selected by random sampling from parliamentary electoral rolls. Visual acuity was assessed using the logarithm of the minimum angle of resolution chart at 4 m distance. The overall population-adjusted prevalence of VI was 9.0%. The estimated prevalence of VI was highest in Malays followed by Indians and Chinese. Following adjustments for ethnic discrepancies in age, marital status, education level, gender and medical illness, the Malay ethnicity remained an independent association for VI. Education level was associated with Indian ethnicity. In conclusion, the Malay ethnicity and lower education level among Indian ethnicity were found to be associated with VI among the older population in Malaysia. The Malay ethnicity showed the highest prevalence of VI followed by Indians and Chinese.

Premature Ocular Aging Features in Childhood Acute Lymphoblastic Leukemia Survivors.

Purpose: Childhood cancer survivors (CCS) demonstrate features of premature aging in a multitude of organ systems. The aim of this pilot study is to determine the presence of premature ocular aging features in CCS, specifically childhood acute lymphoblastic leukemia (ALL) survivors. Methods: This prospective case-control study was conducted over a period of 21 months, starting July 2015 till March 2017. A total of 59 childhood ALL survivors who attended the Paediatric Oncology Clinic of University Malaya Medical Centre (UMMC) and 48 age, race, and gender-matched controls went through a series of ocular examinations and tests. Inclusion criteria used to recruit survivors were age above 16 years, history of ALL in childhood, completion of treatment for ALL, and a remission period of at least 5 years. Patients with ocular disease and those who received hematopoietic stem cell transplantation were excluded. The parameters measured were visual acuity, amplitude of accommodation, pupil cycle time (PCT), and tear break-up time (TBUT). Results: Survivors of childhood ALL demonstrated significant differences in amplitude of accommodation, PCT, and TBUT compared to age-matched controls. Survivors had a lower median (interquartile range [IQR]) amplitude of accommodation compared to controls (11.0 D [9.0-13.0] vs. 12.0 D [10.5-15]; p = 0.045). Survivors also showed a longer median (IQR) PCT in comparison to controls (931.00 mseconds (857.00-1063.00) vs. 875.50 mseconds (825.75-966.00); p = 0.024). In addition, median (IQR) TBUT was worse in survivors in comparison to the control group (9 seconds [6-13] vs. 11 seconds [10-15]; p = 0.001). Conclusion: Survivors of childhood ALL demonstrate premature ocular aging features compared to age-matched controls. Thus, survivors may benefit from having ocular examinations as part of their routine late-effects screening to detect age-related ocular morbidities early in its course.

Herpes zoster keratouveitis with hypopyon and hyphema.

This study aims to report two cases with an uncommon, early manifestation of herpes zoster ophthalmicus which is keratouveitis. The first patient is a 61-year-old female who had presented with painful facial skin eruption and right eye redness without impairment of vision. She was treated initially as herpes zoster blepharoconjunctivitis; however, the disease had progressed to neurotrophic keratitis with severe anterior chamber reaction manifested by a mixture of hypopyon and hyphema. The second patient is a 74-year-old female who had presented after 2 weeks of facial skin eruption with blurring of vision and similar keratouveitic manifestations. Both patients had poor visual outcome due to severe ocular inflammation.

Visual loss after long-haul flight.

BACKGROUND: Deep cerebral venous sinus thrombosis is a reversible yet potentially serious thromboembolic event. A number of reports suggest a relationship between long-haul flights and thromboembolic events, mainly deep venous thrombosis (DVT) and pulmonary embolism (PE). It is rarely reported to cause deep cerebral venous sinus thrombosis. We report a case of a bilateral papilledema after long-haul flight secondary to deep cerebral venous sinus thrombosis with subsequent complete recovery post corticosteroid and anticoagulant therapy. CASE: A case of a 21-year-old woman with no known medical illness who presented with gradual painless bilateral visual loss is described. She had a history of travelling on a long-haul flight 3 weeks prior to presentation. Examination showed presence of bilateral papilloedema, no vitritis, choroiditis and retinitis. Blood investigations showed raised international normalised ratio (INR). Otherwise, workup for infectious causes of optic disc swelling, connective tissue disease screening were normal. Magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) of the brain showed loss of flow signal in the right transverse sinus and the left sigmoid sinus. Blood workup for preexisting hypercoagulable state was normal. She was diagnosed with deep cerebral venous sinus thrombosis and showed complete recovery with oral corticosteroid and anticoagulant therapy. CONCLUSION: Deep cerebral venous sinus thrombosis is a potentially serious consequence of long-haul flights. A high index of suspicion along with radiological techniques is needed for early detection and initiation of anticoagulation for this reversible condition.