The Effect of Combined Phacoemulsification and Endo-Cyclophotocoagulation on Intraocular Pressure Fluctuation Assessed by the Water Drinking Test in Patients with Primary Open Angle Glaucoma.

INTRODUCTION: The aim of this study was to assess the effect of phacoemulsification and endo-cyclophotocoagulation (phaco-ECP) on intraocular pressure (IOP) fluctuation as assessed by the water drinking test (WDT) in primary open angle glaucoma (POAG). METHODS: This was a prospective observational study carried out at a tertiary referral centre. POAG patients on topical antiglaucoma medications and planned for phaco-ECP were recruited. WDT was performed before surgery and 6 weeks postoperatively by drinking 10 mL/kg of water in 5 min followed by serial IOP by Goldmann applanation tonometry measurements at 15, 30, 45, and 60 min. Mean IOP, IOP fluctuation (difference between highest and lowest IOP), IOP reduction, and factors affecting IOP fluctuation were analysed. RESULTS: Twenty eyes from 17 patients were included. Baseline IOP was similar before (14.7 ± 2.7 mm Hg) and after (14.8 ± 3.4 mm Hg, p = 0.90) surgery. There was no difference in mean IOP (17.6 ± 3.4 mm Hg vs. 19.3 ± 4.7 mm Hg pre- and postoperative, respectively, p = 0.26) or peak IOP (19.37 ± 3.74 mm Hg vs. 21.23 ± 5.29 mm Hg, p = 0.25), albeit a significant reduction in IOP-lowering medications (2.2 ± 1.15 vs. 0.35 ± 0.93, p < 0.001) postoperatively. IOP fluctuation was significantly greater (6.4 ± 3.2 mm Hg vs. 4.6 ± 2.1 mm Hg, p = 0.015) with more eyes having significant IOP fluctuation of ≥6 mm Hg (11 eyes [55%] vs. 4 eyes [20%], p < 0.001) postoperatively. Factors that were significantly associated with increased postoperative IOP fluctuations were higher preoperative IOP fluctuation (ß = 0.69, 95% CI 0.379-1.582, p = 0.004) and more number of postoperative antiglaucoma medications (ß = 0.627, 95% CI 0.614-3.322, p = 0.008). CONCLUSION: Reducing aqueous production with phaco-ECP does not eliminate IOP fluctuation in POAG patients. The increase in postoperative IOP fluctuation suggests increased outflow resistance after phaco-ECP.

Evaluation of Refractive Status and Ocular Biometric Parameters in Primary Angle Closure Disease.

INTRODUCTION: The aim of the study was to evaluate the refractive status and ocular biometric parameters in subjects with angle closure in Malaysia. METHODS: This cross-sectional study was conducted on 171 primary angle closure patients (268 eyes). Visual acuity, refraction, and ocular biometry (central anterior chamber depth [ACD], axial length [AL], and lens thickness) were recorded. Vitreous cavity length (VL) and relative lens position (RLP) were calculated. RESULTS: A total of 92 Primary Angle Closure Suspect (PACS), 30 Primary Angle Closure (PAC), and 146 Primary Angle Closure Glaucoma (PACG) eyes were included. Chinese ethnicity formed the majority (n = 197, 73.5%), followed by Malay (n = 57, 21.3%) and Indian (n = 14, 5.2%). There was a significant female preponderance with a female to male ratio of 1.85. Mean age was 65.7 ± 7.7 years. Mean spherical equivalent was +0.33 ± 1.29 D. Approximately half (n = 137, 51%) of the eyes were hyperopic (spherical power ≥+0.5), with PACG having the highest percentage of hyperopia (n = 69, 50.4%). Myopia and emmetropia were present in 48 (17.9) and 83 (31%) eyes, respectively. Although AL and VL in myopia patients were significantly longer than emmetropic and hyperopic eyes (p < 0.001), the ACD was not significantly different (p = 0.427). While the RLP is smaller in myopic eyes, lens thickness was increased in hyperopic eyes. PACG was significantly higher in elderly patients compared to PACS and PAC (p = 0.005). A total of 37 (13.8%) eyes were blind (vision worse than 3/60) and 19 of them (51.3%) were female patients. CONCLUSION: A decrease in RLP is predictive of angle closure disease in myopic eyes, whereas increased lens thickness contributes to angle closure disease in hyperopic eyes.

Evaluation of Three-Dimensional Heads up Ophthalmic Surgery Demonstration From the Perspective of Surgeons and Postgraduate Trainees.

BACKGROUND: To evaluate the satisfaction of surgeons and trainees with three-dimensional (3D) ophthalmic surgery during a demonstration compared to traditional surgery. METHODS: This validated questionnaire-based study was conducted over 1-month during which Ngenuity 3D surgery was demonstrated. All surgeons and trainees exposed were recruited to complete a questionnaire comprising visualization, physical, ease of use, teaching and learning, and overall satisfaction. RESULTS: All 7 surgeons and 33 postgraduate students responded. Surgeons reported no significant difference except overall (P = 0.047, paired t-test). Postgraduate trainees reported significantly better experience with 3D for illumination (P = 0.008), manoeuvrability (P = 0.01), glare (P = 0.037), eye strain (P = 0.008), neck and upper back strain (P = 0.000), lower back pain (P = 0.019), communication (P = 0.002), comfortable environment (P = 0.001), sharing of knowledge (P = 0.000), and overall (P = 0.009). CONCLUSIONS: During early experience, surgeons and trainees reported better satisfaction with 3D overall. Trainees had better satisfaction with 3D in various subcomponents of visualization, physical, ease of use, and education.

Reversal of Peripheral Anterior Synechiae After Trabeculectomy With Argon Laser Synechiolysis.

We report a case of successful argon laser synechiolysis as a non-invasive alternative for peripheral anterior synechiae release after trabeculectomy in a young patient with steroid-induced ocular hypertension. Steroid-induced ocular hypertension is a known complication of vernal keratoconjunctivitis due to prolonged treatment with steroids. In refractive conditions, augmented trabeculectomy becomes the surgery of choice in these patients. In this article, we report successful treatment of iris tissue plugging the internal ostium with an argon laser and reinstatement of aqueous flow.

Delayed Horner's Syndrome Post Thyroid Carcinoma Surgery.

Post-thyroidectomy Horner's syndrome (HS) is a rare occurrence, and its probability increases when a modified radical neck dissection is performed. We present a case of a patient with papillary thyroid carcinoma who presented with Horner's syndrome one week after the right lateral dissection of the cervical lymph nodes. She underwent a complete thyroidectomy four months prior to this surgery. Both surgeries were uneventful intraoperatively. On examination, the right eye (RE) had partial ptosis with miosis and the absence of anhidrosis. A pharmacological test with phenylephrine 1% was used to localize the interruption of the oculosympathetic pathway with postganglionic third-order neuron involvement. She was treated conservatively, and her symptoms improved over time. Horner's syndrome is a rare and benign complication of post-thyroidectomy surgery with radical neck dissection surgery. Since it does not compromise visual acuity, the disease is constantly overlooked. However, in view of the facial disfigurement and the possibility of incomplete recovery, the patient needs to be forewarned regarding this complication.

Rare Case of Bilateral and Asymmetrical Multiple Evanescent White Dot Syndrome.

Bilateral presentation of multiple evanescent white dot syndrome (MEWDS) is a rare occurrence. We report a case of bilateral multiple evanescent white dot syndrome in a young female patient with asymmetrical manifestation. She presented with sudden onset of right eye central blurring of vision and dyschromatopsia. Fundus examination however showed bilateral multiple grey-white intra-retinal punctate lesions with an asymmetrical manifestation of the swollen optic disc and foveal granularity over the right. Spectral Domain Optical Coherence Tomography (SD-OCT) showed the presence of juxta foveal subretinal fluid and disrupted inner segment-outer segment (IS-OS) junction over the right eye. The patient had a spontaneous complete recovery within six weeks' time.

Myelin oligodendrocyte glycoprotein antibody-associated optic neuritis in a post-COVID-19 infection patient.

PURPOSE: SARS-CoV-2 viral infection affects multiple systems including the respiratory, gastrointestinal, neurological, cardiac, and ophthalmic systems. We report a case of myelin oligodendrocyte glycoprotein (MOG) related optic neuritis in a SARS-CoV-2 (COVID-19) patient. METHODS: Case report. RESULTS: A 36-year-old Malay gentleman with underlying hypertension presented with the first episode of bilateral progressively worsening blurred vision for 1 week associated with retrobulbar pain. There were no other neurological symptoms. He had fever a week before the eye symptoms and tested positive for COVID-19. He received COVID-19 booster vaccine a month before the disease onset. On examination, his vision was hand motion on right eye and 6/18 on left eye. Relative afferent pupillary defect (RAPD) was positive on right eye with abnormal optic nerve function tests. Anterior segments were unremarkable. Fundus examination showed bilateral optic disc swelling. MRI revealed multifocal hyperintense subcortical white matter lesions. Optic nerves appeared normal with no enhancement seen. Blood investigation showed a positive serum MOG antibody. Intravenous methylprednisolone was commenced followed by oral prednisolone after which his vision and ocular symptoms markedly improved. The oral prednisolone was tapered alongside addition of azathioprine. At 1 month, the disease was stable with no recurrence. CONCLUSION: While optic neuritis has been associated with both COVID-19 infection and vaccination, MOG IgG antibody-mediated optic neuritis is also a possible manifestation. This type of optic neuritis associated with COVID-19 infection does not show a similar pattern of frequent recurrences as seen in non-COVID-19 related optic neuritis.

Depression and Nystagmus as the Rare Masquerading Presentations of Pineal Germinoma.

Convergence-retraction nystagmus alongside behavioral changes can be rare manifestations of a potentially life-threatening midbrain lesion. After experiencing headaches for three months, a 13-year-old boy was diagnosed with depression due to exhibiting reduced speech, hypersomnia, and psychomotor slowing for three weeks. It was preceded by headache for three months. Examination revealed visual acuity of 6/6 bilaterally, convergence-retraction nystagmus worst on upgaze, limited bilateral ocular motility in upgaze, and light-near dissociation on pupil examination, all of which point towards Parinaud's syndrome. However, there was no lid retraction to suggest Collier's sign. Fundus examination revealed papilledema. Magnetic resonance imaging showed a large pineal mass extending to both thalami, dilated ventricles due to obstructive hydrocephalus, and cerebral edema. An urgent external ventricular drain was inserted, and biopsy revealed pineal gland germinoma. Chemotherapy and radiotherapy resulted in adequate tumor shrinkage. This case report highlights that subacute behavioral changes may mask a potentially life-threatening intracranial tumor, especially when associated with abnormal eye movement.

Impact of Postponement of Appointments on Vision and Psychological Well-Being Among Outpatients Attending Ophthalmology Clinics: A Malaysian Perspective.

INTRODUCTION: During the COVID-19 pandemic, non-frontline medical disciplines, including ophthalmology, were advised to minimize their services to channel crucial healthcare resources to manage the surge in COVID-19 cases. The ophthalmology department postponed all non-urgent appointments and elective surgical procedures. However, little is known about the visual and mental health impact of these changes in ophthalmology services. Therefore, our study aimed to explore the impact of postponement in ophthalmology outpatient clinic appointments towards visual acuity (VA) changes and the psychological well-being of patients during the COVID-19 pandemic in Malaysia. METHODOLOGY: This cross-sectional study, utilizing a convenience sampling method, recruited patients attending ophthalmology outpatient clinic services from July 2020 to June 2021 to participate in the study. The Snellen chart was used to measure the VA, and the Kessler psychological distress scale (K-10) was used to measure psychological distress levels among patients with (study) and without (controls) postponement of the appointment.  Results: A total of 485 patients were included in the data analysis; 267 study and 218 controls. There is a statistically significant difference in categorical change of VA (p < 0.001) and categorical K-10 score (p = 0.048) among the study and control groups. Nonetheless, a decline in VA alone does not show a statistically significant association with an increased probability of experiencing psychological distress (p=0.149). CONCLUSION: Postponement of ophthalmology appointments negatively affected the VA and the psychological well-being of patients. Appropriate assessment of patients before postponing their appointment is crucial to mitigate the worsening of VA and psychological distress.

Evaluation of Ocular Biometric and Optical Coherence Tomography Parameters in Preterm Children Without Retinopathy of Prematurity.

Purpose: To evaluate and compare biometric and optical coherence tomography parameters of ocular structures in preterm children without retinopathy of prematurity with term children. Methods: A cross-sectional, comparative study was carried out from 2018 to 2019. In this study, 124 eyes of 62 preterm children were compared with 132 eyes of 66 term children aged between 7 and 9 years. Preterm children were born at 28 to 32 weeks with a birth weight of less than 2 kg with no ocular abnormalities, and term children were delivered at 37 or greater weeks and had a birth weight of 2 kg or more. All children had standardized eye examinations, and ocular measurements using the anterior and posterior segment optical coherence tomography and laser interferometry. Results: Significant differences were found between the term and preterm children for horizontal corneal diameter: median, 12.2 mm (interquartile range [IQR], 0.4) versus median, 12.1 mm (IQR, 0.6; P < 0.005); axial length median, 23.03 mm (IQR, 1.10 mm) versus median, 22.88 mm (IQR, 1.35 mm; P = 0.017); global retinal nerve fiber layer thickness: mean ± standard deviation, 106.54 ± 10.23 µm versus mean ± standard deviation, 103.65 ± 10.178 µm (P = 0.024); temporal retinal nerve fiber layer thickness: median, 76 µm (IQR, 16 µm) vs median, 74 µm (IQR, 14 µm; P = 0.012); and the angle opening distance at 750 µm nasal: mean ± standard deviation, 0.815 ± 0.23 mm vs mean ± standard deviation, 0.749 ± 0.21 mm (P = 0.016). No significant differences were found for other anterior segment and angle parameters. Conclusions: Preterm children with no retinopathy of prematurity have smaller eyes and thinner retinal nerve fiber layers than their term counterparts. The long-term effects of interrupted ocular growth in preterm children should be further studied into adulthood. Translational Relevance: Preterm children maybe more predisposed to certain eye conditions because they have smaller eyes, and thus should be further monitored clinically.

Review of Evidence for the Usage of Antioxidants for Eye Aging.

Oxidative stress is one of the common factors leading to age-related eye diseases in older adults. Factors such as high oxygen consumption, high concentration of polyunsaturated fatty acids, and cumulative exposure to high-energy visible light in the eyes, lead to excessive generation of reactive oxygen species, hence triggering apoptosis of ocular cells and giving rise to ophthalmic diseases. Dietary supplements such as carotenoids, anthocyanins, and vitamins have antioxidant properties which may be of benefit in retaining better vision or reversing vision impairment; thus, studies have been conducted to understand the role of dietary supplements in the treatment or prevention of ophthalmic diseases. While high concentration of carotenoids such as lutein and zeaxanthin decrease the risk of developing age-related macular disease, anthocyanins and vitamins play a role in the treatment and prevention of other ophthalmic diseases: saffron extract reduced intraocular pressure in glaucoma patients; bilberry extract prevented impairments in lenses and retina, as well as alleviate symptoms of dry eye disease; high concentration of beta-carotene may reduce the risk of developing cataract. Further studies with clinical measurements are required to investigate the effectiveness of antioxidants on visual function and ophthalmic diseases.

Fungal Keratitis in a Tertiary Hospital in Malaysia.

Background Fungal keratitis is one of the commonest causes of corneal blindness in developing countries including Malaysia. We aim to evaluate the sociodemographic background, clinical features, predisposing factors, laboratory findings, management, complications, and visual outcome of patients with fungal keratitis in a tertiary hospital in Malaysia. Methods A retrospective review of medical and microbiology records of all patients treated for corneal ulcer from 2015 to 2019 at Hospital Sultanah Bahiyah was performed. Sociodemography, predisposing risk factors, clinical characteristics, causative organisms, and final visual outcome were analyzed. Results We identified 103 patients with a diagnosis of fungal keratitis. The majority of the patients were of Malay ethnicity (85.4%) and male gender (81.6%), with an age range of 21 to 60 years (94.1%). Ocular trauma was the main predisposing factor in 82 (79.6%) patients. Poor visual improvement was observed in groups with ulcer more than 4mm (67.5%), presence of hypopyon (50.9%), and high intraocular pressure (75.0%) upon presentation. Fusarium spp. (19.4%) was the commonest fungus isolated followed by Aspergillus spp. (5.8%). All patients were prescribed either topical, oral, intracameral, or combined therapy, whereas 20 (19.4%) patients required surgical intervention, of which 16 (15.5%) underwent penetrating keratoplasty and three (2.9%) required evisceration. Conclusion The epidemiological, socioeconomic, and predisposing factors may facilitate timely diagnosis and prompt treatment to achieve a better visual outcome and minimize complications including corneal blindness.

Review of the management of sight-threatening diabetic retinopathy during pregnancy.

Diabetes mellitus (DM) is a noncommunicable disease reaching epidemic proportions around the world. It affects younger individuals, including women of childbearing age. Diabetes can cause diabetic retinopathy (DR), which is potentially sight threatening when severe nonproliferative DR (NPDR), proliferative DR (PDR), or sight-threatening diabetic macular oedema (STDME) develops. Pregnancy is an independent risk factor for the progression of DR. Baseline DR at the onset of pregnancy is an important indicator of progression, with up to 10% of women with baseline NPDR progressing to PDR. Progression to sight-threatening DR (STDR) during pregnancy causes distress to the patient and often necessitates ocular treatment, which may have a systemic effect. Management includes prepregnancy counselling and, when possible, conventional treatment prior to pregnancy. During pregnancy, closer follow-up is required for those with a long duration of DM, poor baseline control of blood sugar and blood pressure, and worse DR, as these are risk factors for progression to STDR. Conventional treatment with anti-vascular endothelial growth factor agents for STDME can potentially lead to foetal loss. Treatment with laser photocoagulation may be preferred, and surgery under general anaesthesia should be avoided. This review provides a management plan for STDR from the perspective of practising ophthalmologists. A review of strategies for maintaining the eyesight of diabetic women with STDR with emphasis on prepregnancy counselling and planning, monitoring and safe treatment during pregnancy, and management of complications is presented.

Good Visual Outcome in Post Traumatic Exogenous Endophthalmitis Caused by Trichophyton Species.

Trichophyton species is a dermatophytic fungus commonly found in the skin, nails, hair, and other organic matters such as palm trees and soil. We report a rare case of a 23-year-old man who had a penetrating injury to the eye from the leaves of a palm tree and subsequently developed exogenous endophthalmitis. Culture from the vitreous tap revealed Trichophyton sp as the causative organism. Early vitrectomy and adequate intravitreal injection of amphotericin B resulted in good visual outcomes in an otherwise blinding condition. This is the first reported case of exogenous endophthalmitis secondary to Trichophyton species. Early diagnosis and prompt treatment may help improve visual outcomes.

Retinal Racemose Hemangioma With Optic Neuropathy in a Child.

The aim of this study is to report an unusual case of retinal racemose haemangioma (RRH) in a child resulting in optic neuropathy and its optical coherence tomography angiography (OCT-A) findings. This is a retrospective case report. For almost a year, a 13-year-old girl experienced gradual, painless, generalized blurred vision in her right eye. Visual acuity was 6/60 with a positive relative afferent pupillary defect (RAPD) in her right eye. The right-eye fundus showed enlarged and tortuous retinal vessels extending from the optic disc to all four quadrants, including the juxta foveal region. OCT analysis revealed distortion in the region of enlarged vessels with minimal retinal fluid while OCT-A of the macula area demonstrated dilated and tortuous vessels in the superficial layers of the retina. Right intra-orbital vascular channels surrounding the optic nerve with optic nerve atrophy and gliosis were detected on magnetic resonance imaging angiography/venography (MRA/MRV). The cerebral angiogram reported an abnormal tangle of small vessels within the right orbit that received supply from a dilated right ophthalmic artery indicating the presence of retro-orbital arteriovenous malformation (AVM). She was then referred to the neurosurgeon and a decision was made not to embolize or resect the dilated vessel as this might lead to occlusion of the ophthalmic artery and thus worsen her vision. RRH may present in the paediatric age group, and optic nerve atrophy is one of the disease manifestations. OCT-A is a less invasive diagnostic option compared to fundus fluorescein angiography (FFA) for diagnosis and monitoring of disease progression.

Ab-Externo Implantation of XEN Gel Stent for Refractory Steroid-Induced Glaucoma After Lamellar Keratoplasty.

The hazy corneal donor-recipient interface after corneal transplant may cause difficulties when implanting the XEN gel stent via ab-interno approach. We aim to describe XEN gel stent implantation via ab-externo approach in refractory steroid-induced glaucoma after corneal lamellar keratoplasty. Under local anaesthesia, the XEN injector needle was inserted 7 mm behind the limbus with the bevel facing up, directly beneath the conjunctiva and advanced to the marked 2.5 mm scleral entry wound. The needle then pierced the sclera until the needle tip was just visible in the anterior chamber (AC). The slider was pushed until the tip of the XEN stent was seen in the AC. The needle was slowly withdrawn while still pushing the slider to complete stent deployment. Subconjunctival Mitomycin C 0.01% (30 µg/0.3 mL) was then injected posterior to the bleb. Three eyes of three patients with steroid-induced glaucoma after lamellar keratoplasty underwent XEN gel stent implantation via ab-externo approach placed at the superotemporal quadrant. Pre-operatively, all patients had uncontrolled IOP between 30-45 mmHg despite maximum medications and selective laser trabeculoplasty. After XEN gel stent implantation, IOP ranged between 10-17 mmHg with one or two topical antiglaucoma at 12 months. Complications include hypotony maculopathy, stent migration and hyphaema, all of which were successfully managed. Corneal graft remained clear at 12 months. XEN gel stent implantation via ab-externo approach is able to achieve good intraocular pressure (IOP) control without compromising cornea graft in patients with steroid-induced glaucoma after lamellar keratoplasty at 12 months.

Optic Nerve Infiltration in Systemic Metastatic Retinal Lymphoma (SMRL): Multimodal Imaging and Challenges in Diagnosis.

A 45-year-old man was diagnosed with diffuse large B-cell lymphoma stage IV which was confirmed by celiac lymph node biopsy. He subsequently completed six cycles of R-CHOP chemotherapy. Six months later, he presented with panuveitis OU with positive relative afferent pupillary defect OD. OCT revealed hyper-reflective lesions and irregularity of the retinal pigment epithelium OU. Fundus fluorescein angiogram shows hyper-auto fluorescence and granular changes on the retina. A month later, he developed swollen optic disc OD and hemorrhagic retinitis OU and treated as presumed CMV retinitis. Anti-TB was started after a positive Mantoux test. He finally consented for a vitreous biopsy which showed atypical lymphoid cells highly suggestive for vitreoretinal lymphoma and subsequently received intravitreal methotrexate OU.Conclusion: Optic nerve infiltration in systemic metastatic retinal lymphoma may have initial occult signs but with profound visual loss. Ocular infections like CMV retinitis and tuberculosis may mask and delay the diagnosis in immunocompromised patients.

Good Visual Outcome Following Corticosteroid Treatment for Compressive Optic Neuropathy Secondary to Sinonasal Carcinoma.

Most patients with sinonasal carcinoma present to the otorhinolaryngologist with nasal symptoms. It is however uncommon for them to present with acute visual loss at first presentation. We report a case of compressive optic neuropathy secondary to sinonasal carcinoma, which presented acutely with right eye blurring of vision upon waking up. Computed tomography (CT) of the brain and orbit with contrast showed a locally invasive nasopharyngeal mass extending into the right orbit and cranial fossa. Histopathological examination revealed squamous cell sinonasal carcinoma. Her visual acuity improved with a three-day course of pulsed intravenous methylprednisolone 1 g per day, followed by a gradual tapering dose of oral prednisolone (1 mg/kg/day).

Pyogenic Granuloma Formation Following Ahmed Valve Glaucoma Implant.

Ocular pyogenic granuloma is a benign tumor seen after ocular insult secondary to ocular surgeries, trauma or infection. Although benign, intervention is sometimes necessary. Previous authors have reported pyogenic granuloma formation following oculoplastic surgeries. We report a pyogenic granuloma after an Ahmed glaucoma valve implantation. A 65-year-old gentleman presented with right eye redness associated with pain and swelling ~2 months after Ahmed glaucoma valve implantation. Examination found a sessile growth on the tube extruding puss with signs of endophthalmitis. The glaucoma drainage device was explanted and culture results grew Staphylococcus aureus. This article discusses the formation of pyogenic granuloma on a glaucoma drainage device and its management.