CENTRAL CORNEAL THICKNESS AND INTRAOCULAR PRESSURE CHANGES POST- PHACOEMULSIFICATION SURGERY IN GLAUCOMA PATIENTS WITH CATARACT.

AIMS: To compare the changes of central corneal thickness (CCT) and intraocular pressure (IOP) post-phacoemulsification between cataract patients with and without pre-existing glaucoma. MATERIALS AND METHODS: A prospective cohort study of 86 patients with visually significant cataract: 43 with pre-existing glaucoma (GC group) and 43 without pre-existing glaucoma (CO group). CCT and IOP were evaluated at baseline (pre-phacoemulsification), as well as at 2 hours, 1 day, 1 week and 6 weeks post-phacoemulsification. RESULTS: The GC group have significantly thinner CCT pre-operatively (p = 0.003). There was a steady increase of CCT with the highest peak at 1 day post-phacoemulsification, followed by a steady decline of CCT and back to baseline at 6 weeks post-phacoemulsification in both groups. The GC group demonstrated a significant difference in CCT at 2 hours (mean difference 60.2 µm, p = 0.003) and 1 day (mean difference 70.6 µm, p = 0.002) post-phacoemulsification, compared to the CO group. There was a sudden increase in IOP at 2 hours post-phacoemulsification measured by GAT and DCT in both groups. This was followed by a gradual reduction of IOP, with significant reduction at 6 weeks post-phacoemulsification in both groups. However, there was no significant difference in IOP between the two groups. IOP measured by GAT and DCT showed strong correlation (r > 0.75, p < 0.001) in both groups. There was no significant correlation between GAT-IOP and CCT changes; nor between DCT-IOP and CCT changes in both groups. CONCLUSIONS: CCT changes post-phacoemulsification in patients with pre-existing glaucoma were similar, in spite of having thinner CCT pre-operatively. IOP measurement was not affected by CCT changes in glaucoma patients post-phacoemulsification. IOP measurement using GAT is comparable with DCT post-phacoemulsification.

TUBE VERSUS TRABECULECTOMY IN JUVENILE-ONSET OPEN ANGLE GLAUCOMA - TREATMENT OUTCOMES IN TERTIARY HOSPITALS IN MALAYSIA.

AIM OF THE STUDY: To compare the intraocular pressure (IOP) lowering effect and postoperative complications between primary augmented trabeculectomy and glaucoma drainage device (GDD) implantation as primary surgical intervention in patients with juvenile-onset open angle glaucoma (JOAG). PATIENTS AND METHODS: A retrospective review study involving 20 eyes that underwent primary augmented trabeculectomy with mitomycin (MMC) and 10 eyes GDD implantation in 3 tertiary centres in Malaysia between 1 January 2013 and 31 December 2019. They were followed up for at least 12 months postsurgical intervention. Intraocular pressure (IOP), number of topical IOP lowering medication and complications were evaluated at 1, 3, 6 and 12 months post-intervention. Based on the IOP, the success was divided into complete and partial success, and failure. IOP and postsurgical complications were compared using the Repetitive Measure Analysis of Variance (RM ANOVA) and the Pearson chi-square test. RESULTS: Both methods were effective in lowering the IOP. Eyes with primary augmented trabeculectomy have significant lower IOP compared to GDD implantation (p = 0.037). There was a higher incidence of postoperative hypotony (30%) in the trabeculectomy group. There was also a significant reduction of mean number of topical pressure-lowering drugs required postoperatively (p = 0.015). Complete success was achieved in 100% of eyes with trabeculectomy and 67% in GDD implantation (p = 0.047). CONCLUSIONS: Primary augmented trabeculectomy and GDD implantation are good surgical options for the treatment of JOAG. Both methods provide IOP lowering at 1 year. However, trabeculectomy provides better pressure lowering, compared to GDD implantation in patients with JOAG.

AN IN VIVO STUDY OF INTRAVITREAL RANIBIZUMAB FOLLOWING SUBRETINAL INOCULATION OF RB CELLS IN RABBITS EYES.

AIM: This study aimed to determine the effects of a single intravitreal ranibizumab injection in rabbits induced with retinoblastoma (RB). MATERIAL AND METHODS: RB was induced in six New Zealand white rabbits by subretinal injection of a cultured WERI-RBb-1 cell line into the right eye. After six weeks, Group A (n = 3) was given intravitreal ranibizumab injection (0.3mg in 0.03ml) and Group B (n = 3) was the control. Baseline and serial clinical examinations were performed on days 1, 3, 6, 12, 15, 18 and 21. The right eyes were enucleated for both groups on day 21 for histopathological examination. RESULTS: The rabbits in both groups developed intraocular lesions which was detectable clinically at one-week post-tumor inoculation. The tumor grew slowly without spontaneous regression. After the animals in Group A were given an intravitreal ranibizumab injection, regression of the tumor was detected clinically, while the tumor in Group B continued to grow slowly. Histopathological findings confirmed the presence of a tumor that closely resembled features of poorly differentiated human RB cells. At the end of 21 days, the size of the tumor was larger in Group B in comparison to Group A. However, the treated group also developed a focal area of retinal hyperplasia. There was no significant side effect of ranibizumab injection except temporary high intraocular pressure immediately post-injection, which was relieved after paracentesis. CONCLUSIONS: Intravitreal ranibizumab is a potential treatment for RB. It is an effective therapy with a tolerable safety profile in this animal experimental study.

Ocular Perfusion Pressure and Severity of Glaucoma: Is There a Link?

AIM AND OBJECTIVE: To establish the association between 12-month inter-visits ocular perfusion pressure (OPP) and severity of glaucoma. MATERIALS AND METHODS: A total of 164 eyes (60 primary open-angle glaucoma, 52 normal-tension glaucoma, and 52 primary angle-closure glaucoma) of 164 patients were analyzed in this prospective cohort study. Patients who demonstrated good compliance to treatment were recruited. The severity of glaucoma was stratified according to the Advanced Glaucoma Intervention Study (AGIS) score based on reliable and reproducible visual field analysis at baseline. OPP was obtained at baseline and a 3-monthly follow-up visit over a 12-month duration. The pattern and fluctuation of mean OPP were studied. Repetitive measure ANOVA and one-way ANOVA were used for statistical analysis. RESULTS: The inter-visits mean OPP (p = 0.010), systolic OPP (p = 0.020), diastolic OPP (p = 0.010), systolic blood pressure (p = 0.040), and diastolic blood pressure (p = 0.006) showed significant difference with severity of glaucoma. There was no significant difference between mean inter-visits intraocular pressure (IOP) and severity of glaucoma (p = 0.410). The end-stage glaucoma group had the lowest mean OPP and widest inter-visit mean OPP fluctuation. Early and mild glaucoma patients demonstrated higher mean OPP compared with moderate, severe, and end-stage glaucoma. CONCLUSION: There is a significant association between OPP and the severity of glaucoma. Balancing blood pressure and IOP is important in optimizing adequate perfusion and prevent further damage to the optic nerve head. HOW TO CITE THIS ARTICLE: Ch'ng TW, Chua CY, Ummi Kalsom MA, et al. Ocular Perfusion Pressure and Severity of Glaucoma: Is There a Link? J Curr Glaucoma Pract 2021;15(2):78-85.

Distance vision, near vision and quality of life between preferred emmetropia and residual myopia in monofocal intraocular lens implantation- A Comparative study.

INTRODUCTION: This study was done to evaluate the visual acuity and quality of life in predicted emmetropia (EM) and predicted residual myopia (RM) patients following phacoemulsification with monofocal intraocular lens implantation. MATERIALS AND METHODS: This prospective comparative study was conducted in the ophthalmology clinic of the Universiti Sains Malaysia Hospital, Kelantan, Malaysia. Overall, 139 patients with senile cataract were randomised into EM and RM groups. At three months post-operatively, patients were assessed for distance and near vision, as well as quality of life using a modified VF-14 questionnaire. RESULTS: Thirty-six patients (64.3%) in the EM group and 30 patients (52.6%) in the RM group (p = 0.209) showed good distance vision (LogMAR 0.3 or better). Fifty patients (87.7%) in the RM group and 27 patients (48.2%) in the EM group gained significantly higher satisfactory near vision (p < 0.05). The quality of life in both groups was good, with a mean modified VF-14 score of 94.5 (SD 2.68) for the EM group and 95.1 (SD 3.19) for the RM group (p = 0.286). Female patients scored significantly higher than males for total activities (p = 0.010) and distance vision-related activities (p = 0.001). The RM group had significantly better patient satisfaction for near vision-related activities compared to the EM group (p = 0.001). In particular, the item 'reading small print' was significantly better in the RM group (p = 0.003). CONCLUSION: Patients in the predicted RM group gained more satisfactory near vision than patients in the EM group, with significantly better quality of life for near vision activities.

Ocular tuberculosis in Hospital Universiti Sains Malaysia - A case series.

INTRODUCTION: Ocular tuberculosis (TB) encompasses a broad spectrum of clinical manifestations affecting different structures of the eye. It is caused by Mycobacterium tuberculosis, a great ancient organism that induces various types of diseases and unfavorable outcomes if unrecognized and not well treated. PURPOSE: To report the clinical profile of 34 ocular TB cases observed during 6 years period in Hospital Universiti Sains Malaysia (HUSM). METHOD: A retrospective review of medical records from 34 patients diagnosed with ocular TB in HUSM from January 2011 until December 2016. RESULTS: The mean age was 43 ± 14.6 years old. Both male and female affected in about 1:1 ratio. The majority of subjects were local Malays (91.2%). Risk factors included previous contact with pulmonary TB patients (38.2%), and patients with underlying diabetes mellitus (26.5%). Most patients showed normal chest radiography (79.4%). However they had positive Mantoux test (94.1%) and raised erythrocyte sedimentation rate (ESR) value (58.8%). Uveitis was the most common ocular manifestation of ocular TB (70.6%) while the rare ocular manifestations included optic perineuritis and optic neuritis, orbital apex syndrome, orbital cellulitis, sclerokeratitis, corneal ulcer and conjunctival abscess. All patients responded well to anti-TB treatment, but visual outcome was variable. CONCLUSIONS: This review shows the diverse entity of ocular TB spectrum in an endemic area. Good clinical response to anti-tuberculous therapy supported the presumed diagnosis of ocular TB in majority of the cases.

Recurrent transient visual loss in a middle aged woman.

Visual loss is a common presenting complaint in primary care. We present a case of recurrent transient visual loss in a middle aged woman. Her funduscopy showed bilateral optic disc swelling. We have highlighted the differentiation of bilateral optic disc swelling at the primary care level as the management differs according to the diagnosis.

Clinical presentation, severity and progression of primary angle closure in malays.

INTRODUCTION: There is limited knowledge on primary angle closure (PAC) in Malays. Understanding the clinical presentation and progression of PAC in Malays is important for prevention of blindness in Southeast Asia. MATERIAL AND METHODS: A retrospective record review study was conducted on Malay patients seen in the eye clinic of two tertiary hospitals in Kelantan, Malaysia. Based on the available data, Malay patients re-diagnosed as primary angle closure suspect (PACS), primary angle closure (PAC), and primary angle closure glaucoma (PACG) based on the International Society Geographical Epidemiological classification. Clinical data was collected from initial presentation including the presence of acute primary angle closure until at least 5 years follow up. Progression was defined based on gonioscopic changes, vertical cup to disc ratio (VCDR), intraocular pressure (IOP) and Humphrey visual field (HVF) analysis. Progression and severity of PACG was defined based Hodapp-Parrish-Anderson classification on reliable HVF central 24-2 or 30-2 analysis. RESULTS: A total of 100 patients (200 eyes) with at least 5 years follow up were included. 94 eyes (47%) presented with APAC. During initial presentation, 135 eyes (67.5%) were diagnosed with glaucomatous changes with 91 eyes already blind. After 5 years of follow up, 155 eyes (77.5%) progressed. There was 4 times risk of progression in eyes with PAC (p=0.071) and 16 times risk of progression in PACG (p=0.001). Absence of laser peripheral iridotomy was associated with 10 times the risk of progression. CONCLUSION: Angle closure is common in Malays. Majority presented with optic neuropathy at the initial presentation and progressed further. Preventive measures including promoting public awareness among Malay population is important to prevent blindness.

Full thickness macular hole: Early intervention is an important factor in visual prognosis.

Full thickness macular hole is an eye disease, which can cause permanent visual impairment. Current advancement in vitreoretinal surgery has high success rates in repairing them, leading to a significant visual improvement, especially if patient presents early. In this article, three cases of idiopathic full thickness macular hole with different visual outcomes have been presented. All cases were referred by the primary care practitioners and had undergone macular hole surgery with the same vitreoretinal surgeon. The visual outcome was best in the patient who had the earliest presentation and referral. Early detection and referral of these patients is vital so that early surgical intervention can be carried out to improve their vision.

Clinical presentation, severity and progression of primary angle closure in malay and chinese patients.

OBJECTIVE: To compare the clinical presentation, severity and progression of primary angle closure between Chinese and Malays residing in Malaysia. METHODS: A comparative retrospective record review study was conducted involving one hundred (200 eyes) Malay and fifty eight (116 eyes) Chinese patients. They were selected from medical records of Hospital Universiti Sains Malaysia, Kelantan and Hospital Pulau Pinang, Penang, Malaysia. The selected patients were re-diagnosed based on the International Society of Geographical and Epidemiological classification. The clinical data on presentation including the presence of systemic diseases were documented. Progression of the disease was based on available reliable visual fields and optic disc changes of patients who have been on follow-up for at least five years. RESULTS: Malay patients presented at older age (61.4 years SD 8.4) compared to Chinese (60.6 years SD 8.3). There was significant higher baseline Intraocular Pressure (IOP) among Malays (34.7 SD 18.5mmHg) compared to Chinese (30.3 SD 16.7mmHg) (p=0.032). The Chinese patients presented with significantly better visual acuity (p<0.001) and less advanced cup to disc changes (p=0.001) compared to Malays. Malay patients progressed faster than the Chinese. Majority progressed within 1 year of diagnosis. Malays without laser peripheral iridotomy (LPI) have a 4 fold (95% CI 1.4, 10.9) risk of progression. Higher baseline IOP, more advanced visual field defect and absence of LPI was identified as significant predictors associated with progression. CONCLUSION: The Malays presented with more advanced angle closure glaucoma as compared to the Chinese in Malaysia. Aggressive disease progression was observed in Malays with the onset of optic neuropathy. Effective public awareness and aggressive management is important to prevent blindness in the Malaysian population.

Monsoon and primary acute angle closure in malaysia.

INTRODUCTION: Acute angle closure (AAC) without prompt treatment may lead to optic neuropathy. Environmental factor such as climate change may precipitate pupillary block, the possible mechanism of AAC. OBJECTIVE: To determine the association of northeast monsoon and incidence of AAC in Malaysia. MATERIALS AND METHODS: A retrospective study was conducted on AAC patients admitted to two main tertiary hospitals in Kelantan, Malaysia between January 2001 and December 2011. The cumulative number of rainy day, amount of rain, mean cloud cover and 24 hours mean humidity at the estimated day of attack were obtained from the Department of Meteorology, Malaysia. RESULTS: A total 73 cases of AAC were admitted with mean duration of 4.1SD 2.0 days. More than half have previous history of possibility of AAC. There was higher incidence of AAC during the northeast monsoon (October to March). There was also significant correlation of number of rainy day (r=0.718, p<0.001), amount of rain (r=0.587, p<0.001), cloud cover (r=0.637, p<0.001), mean daily global radiation (r=- 0.596, P<0.001), 24 hours mean temperature (r=-0.298, p=0.015) and 24 hours mean humidity (r=0.508, p<0.001) with cumulative number of admission for AAC for 12 calendar months. CONCLUSION: Higher incidence of AAC during northeast monsoon suggested the effect of climate as the potential risk factor. Prompt treatment to arrest pupillary block and reduction of the intraocular pressure is important to prevent potential glaucomatous damage. Public awareness of AAC and accessibility to treatment should be part of preparation to face the effect of northeast monsoon.

Sequelae of neglected senile cataract.

Cataract is the most common cause of blindness in the world. An attack of phacolytic and phacomorphic glaucoma as a result of neglected cataract constitutes a medical emergency that must be addressed immediately. Ocular emergencies such as these is challenging for the surgeon with guarded or poor prognosis. We describe the presentation, management and prognosis of three cases of phacomorphic and phacolytic glaucoma. All three patients underwent aggressive management of intraocular pressure. Despite successful cataract operation with implantation of intraocular lens, there was only mild improvement of the vision. Optic nerve and pupil functions were permanently affected following the insult. Phacomorphic and phacolytic glaucoma present a very challenging problem to the surgeon with poor visual outcome. Public health education and awareness are important and health workers should encourage patients with cataract to seek early treatment for better prognosis.

Successful treatment of a refractory stromal fungal keratitis by intrastromal injection of amphotericin B / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To report a successful intrastromal injection of amphotericin B 5mg/L in a refractory fungal keratitis.METHODS: An interventional case report RESULTS: A 48-year-old lady presented with history of redness of the right eye for one week duration followed by decrease in vision and corneal opacity for two days. There was no histow of trauma or foreign body. Examination revealed visual acuity of 6/16 with pinhole of 6/12 of the right eye. The conjunctiva was injected with minimal eye discharge. There was a full thickness stromal abscess at the paracentral area of the cornea. It was irregular,feathery margin with few satellite lesions. There was no epithelial defect noted. Hypopyon level was also seen.The left eye was normal. A presumptive diagnosis of fungal keratitis was entertained. Despite three weeks of intensive treatment with topical amphotericin B every 2 hours and natamycin every 4 hours and antibiotic cover,the lesion showed no sign of resolution. It grew larger and a new focal lesion of stromal abscess appeared at the 12 o'clock position. We decided to proceed with an intrastromal injection of amphotericin B 5mg/L in lieu of therapeutic penetrating keratoplasty. The size of the ulcer was substantially reduced with total disappearance of hypopyon. There was no ocular toxicity observed following the intervention. Patient regained her normal visual acuity of 6/6 after 2 months of intervention.CONCLUSION: An intrastromal injection of amphotericin B 5mg/L provides an alternative method of treating refractory fungal keratitis. It is also shown to be an effective and safe procedure with promising results.