This study aimed to review the risk factors and clinical outcomes of patients undergoing pars planar vitrectomy (PPV) for breakthrough bleeding (BTB) from age related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV). We performed a retrospective review of medical records of 346 patients operated by the vitreoretinal unit at Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia from January 2008 - June 2011. We found eight eyes of 8 patients with AMD/IPCV-related BTB who underwent PPV. Mean age of patients was 64.4 years (range 41-80 years) with 5 males. Five were Chinese. Duration of symptoms ranged from days to months. Four patients were on anti-coagulants. Two had history of prior photodynamic therapy. There were five cases of PCV, of which three were macular in location. All three cases of AMD were macular. Intraoperative intravitreal ranibizumab injection was given in three cases and two had combined vitrectomy and cataract extraction. All cases reported improvement in visual acuity with four cases achieving 6/60 or better post operatively including two cases of extramacular PCV achieving 6/9 vision. Mean follow-up was 60 weeks. Postoperative complications included retinal tear and detachment in one case, reattached on reoperation. Six patients had a history of hypertension including one individual with stroke. Our small series indicates a predominance of Chinese individuals with BTB. Usage of anticoagulants and hypertension may be a predisposing factor. Better visual prognosis occurs with extramacular lesions which tend to be of PCV type.
A 24-year-old Chinese gentleman presented with two weeks history of sudden floaters in his right temporal visual field associated with blurring of vision. This ex-smoker also reported chronic, bloody cough for two years and recent pleuritic chest pain. Examination revealed a thin patient with right eye visual acuity of 6/18 associated with optic nerve dysfunction, optic disc swelling and macula star, retinal vasculitis and retinitis. Despite anti-tuberculosis medication and corticosteroids, he developed neovascularisation. Subsequent vitreous haemorrhage necessitated trans pars plana vitrectomy, membrane peeling, endolaser and silicone oil injection. Final visual acuity was 6/9 with quiescent retinopathy.
Retinal detachment is one of the common complications of pathological myopia due to presence of retinal break.
However, retinal break commonly occurs in the peripheral retina. This case report illustrates the rare incidence of
retinal break adjacent to the optic disc, highlights the possible causes of poor visual outcome following surgical
repair as well as the possible measures to treat the complications.
Subluxation or dislocation of PCIOL is one of the complications of cataract operation in RP patients. This paper reports the presentation of PCIOL dislocation and subluxation and the management and outcome in 3 eyes of 2 RP patients. Two medical records of patients with RP who developed dislocated or subluxated PCIOL and subsequently underwent explantation of the dropped IOL were evaluated. Two patients had bilateral eye cataract operation done and had PCIOL implanted. Patient 1 developed left eye subluxated PCIOL inferiorly after 2 years of the cataract operation and right eye dislocated PCIOL anteriorly 4 years after cataract operation. Patient 2 develop right eye subluxated PCIOL inferiorly after 12 years of the cataract operation. Patient 1 with right eye dislocated PCIOL underwent intraocular lens (IOL) explantation and was left aphakic as her visual prognosis was poor due to advanced RP. The left IOL remained within the visual axis despite subluxation and no intervention has been done. Patient 2 with right eye subluxated PCIOL underwent IOL explantation and anterior chamber intraocular lens (ACIOL) implantation. ACIOL remained stable and visual acuity improved post-operation. Both the operations were uneventful. Post-operatively, there was no elevated intraocular pressure and no prolonged ocular inflammation, which required prolonged anti-inflammatory and no retinal detachment was seen. Both patient and surgeon should be aware of potential PCIOL subluxation or dislocation in RP. The presentation may be as late as more than a decade after the cataract operation.
Central retinal vein occlusion (CRVO) is uncommon among young patients. Among the young adults, CRVO tends to be more benign with good visual prognosis. Macular oedema secondary to retinal vein occlusion is a relatively common complication that is currently being treated with intravitreal anti vascular endothelial growth factor with good outcomes. Other complications include lamellar hole, vitreous hemorrhage and neovascular glaucoma. We report a case of central retinal vein occlusion in a young female who presented to us with the complaint of blurring of vision in the left eye for four months. Fundus examination showed hyperemic optic disc, dilated tortuous vein, extensive retinal hemorrhages with macular oedema and an inferior shallow exudative retinal detachment. One month later, intravitreal ranibizumab injection for her macular oedema, a full thickness macular hole developed with reduction of macular oedema. Four months later, the hole spontaneously closed but her macular oedema persisted. The possibility of rare complications like exudative retinal detachment and full thickness macular hole must be kept in mind to ensure early detection and effective management is provided to preserve vision.
Spontaneous closure of idiopathic full thickness macular hole is a rare case as it occurs in only 3.5% while awaiting vitrectomy surgery. There are few pathologies associated with it such as vitreomacular traction (VMT) and posterior vitreous detachment. We report a case in a 74-year-old man who presented with right eye painless, progressive blurring of vision with idiopathic stage 4 full thickness macular hole which was confirmed on optical coherence tomography. It closed spontaneously after sometimes while waiting for surgery. It is important to monitor closely for the possibility of spontaneous closure based on the optical coherence tomography findings.
Steroid-induced glaucoma is the most serious complication of the injudicious use of steroids,
particularly among children affected by allergic conjunctivitis. This condition is steroid-dependent,
and children are commonly being prescribed topical anti-inflammatories, including topical steroids,
by general practitioners. Furthermore, topical steroids are also available over the counter, and this
availability contributes to overuse without proper monitoring by an ophthalmologist. We present
a series of five cases illustrating the devastating effect of unmonitored, long-term use of steroids
among children for vernal keratoconjunctivitis. The medications were prescribed initially by general
ophthalmologists and were continually bought over the counter by parents. At the presentation to
our center, these patients were already compromised visually, exhibiting glaucomatous optic disc
changes and high intraocular pressure. The series highlights the optic nerve damage resulting in
irreversible visual compromises among children on long-term, topical steroids and the importance
of regular monitoring with a low threshold for ophthalmologist referral.
Kajian ini bertujuan untuk mengkaji hubung kait antara diameter kornea dan diameter kanta di kalangan kanak-kanak. Kajian ini melibatkan sejumlah empat puluh kanak-kanak (40 mata) yang kurang daripada 4 tahun yang menjalani pemeriksaan, prosedur atau pembedahan di Hospital Kuala Lumpur dari Januari 2010 sehingga September 2011. Pemeriksaan dijalankan dengan menggunakan bius am di dewan bedah. Diameter kornea diukur dengan ‘Holladay-Godwin cornea gauge’ sementara diameter kanta diukur dengan menggunakan mesin ultrasound yang mempunyai resolusi tinggi ‘ultrasound biomicroscope (UBM)’. Purata umur populasi kajian adalah 24.7 + 12.1 bulan. Purata diameter kornea melintang adalah 11.62 + 0.50 mm, lebih besar berbanding dengan purata diameter kornea menegak yang berukuran 11.20 + 0.58 mm. Purata diameter kanta adalah 7.94 + 0.47 mm. Diameter kornea didapati mempunyai korelasi positif yang sederhana dengan diameter kanta (r=0.479, p=0.002). Terdapat hubung kait yang kukuh di antara diameter kanta dengan umur pesakit (r=0.718, p
A retrospective case series review was conducted to determine the pre-operative role and safety of pre-operative adjunctive anti-vascular endothelial growth factor (anti- VEGF) agent ranibizumab “LUCENTISTM” in patients with diabetic retinopathy requiring vitrectomy. The study involved twenty consecutive eyes of sixteen patients (age range: 46-72 years; mean 57.5 years) which received intravitreal injection of 0.5 - 1 mg of ranibizumab 3 to 8 days (mean 4.4 days) prior to vitrectomy for diabetic retinopathy. There were no local or systemic post-injection complications. Indications for vitrectomy were retinal detachment (RD) [n=11; 3 combined tractional (TRD) - rhegmatogenous RD (RRD), 8 TRD], TRD with vitreous haemorrhage (VH) (n=3) ,VH (n=8) and vitreomacular traction syndrome (n=1). Inclusion criteria include all consecutive eyes of diabetic patients requiring vitrectomy receiving a first pre-operative injection of anti- VEGF. Pre-operative visual acuity (VA) ranged from 6/36 to light perception. All eyes had minimal to moderate intraoperative bleeding. Post-operative VH in eyes without tamponade or gas tamponade was nil (n=1), mild (n=13) or moderate (n=1). Silicone filled eyes had nil (n=1), moderate (n=3) or severe haemorrhages (n=1). Post-operative VA was unchanged (n=2) (10%), improved (n = 14) (70%) or worsened (n=4). VA was 2/60 or better (n=15) to no light perception (n=1). Two eyes achieved 6/12 or better vision (10%). Ten eyes (50%) had 6/36 or better vision. In conclusion, pre-operative intravitreal ranibizumab is safe and useful in diabetic vitrectomy and appears to help with perioperative bleeding leading to improvement in vision.
Phacoemulsification (PEA) is currently the procedure of choice for most cataract extraction. However, intra-operative complications may require the procedure to be converted to extracapsular cataract extraction (ECCE). We have evaluated the indications for conversion and visual outcomes in cases converted from phacoemulsification to ECCE. A retrospective review was performed on 33 eyes in which phacoemulsification was initiated and then converted to ECCE. The main parameters evaluated were indications for conversion and visual outcomes at 3 months. Thirty-three cases out of 1448 operations were identified from January 2013 to February 2014.The incidence of PEA converted to ECCE was 2.2%. The indications for ECCE conversion were posterior capsular rupture (PCR) in twenty-two cases, combined capsulorhexis extension with PCR in three cases, capsulorhexis extension and zonular dialysis in two cases respectively. Combined zonular dialysis with PCR, corneal toxicity, Descemet’s tear and obscured edge of capsulorhexis had one case each. Twenty-six (78%) cases had gain in vision, one (3%) case had unchanged vision and six (18%) cases had worsening of vision. The incidence of complicated phacoemulsification surgery requiring intra-operative conversion to ECCE was low in our study (2.2%). Seventy-eight percent of cases achieved final VA of 6/12 or better. Therefore, early recognition of complications and timely intra-operative conversion of PEA to ECCE may result in good visual outcome.
Scleral buckle placement is a well-established technique for the treatment of primary rhegmatogenous retinal
detachment. Complications associated with scleral buckle are uncommon and its presentations can be vary. We
report a case of recurrent orbital cellulitis with anterior segment ischemia following a forgotten episode of previous
scleral buckling surgery, presenting with blurring of vision, redness and swelling of the lids. The presence of scleral
buckle was detected by detailed examination and confirmed by orbital imaging. Orbital infection and rubeosis iridis
were successfully treated with scleral buckle removal, intravenous antibiotics and intracameral ranibizumab.
However, the retinal detachment recurred and the visual acuity deteriorated to light perception. There was no further
intervention as the family declined in view of her old age. In cases of recurrent orbital infection, detailed clinical
examination is important to look for evidence of ocular prostheses as a source of infection. Orbital imaging is an
adjunct for making the diagnosis especially in cases where history is unreliable. Anterior segment ischemia due to
scleral buckle responds well to buckle removal with ranibizumab injection.
Pneumatic retinopexy is known as one of the treatment options for a specific type of retinal detachment. It is done in
an office setting and may be the most cost-effective means of retinal reattachment surgery. Location and size of the
retinal break remain as the major criteria for a successful outcome. We describe a case that fulfilled all except one
major criteria for pneumatic retinopexy and underwent multiple procedures but failed. Fluctuation in the resolution
of the retinal detachment such as in this particular case suggested possibility of early treatment failure.
Polypoidal choroidal vasculopathy (PCV) is a retinal disorder characterized
by aneurismal polypoidal lesions in choroidal vasculature. PCV appears to
preferentially affect pigmented individuals and is considerably high among Asians.
Most reports on patterns of PCV around Asia are based on a homogenous race
(e.g. Chinese, Japanese) and very few descriptions from a multiracial population
like those seen in Malaysia. The present study aimed to describe the demographic
features, clinical and investigative characteristics of PCV in a multiracial group at
Universiti Kebangsaaan Malaysia Medical Centre (UKMMC). Ninety one eyes of 86
PCV patients, comprising of Chinese (65.1%), Malays (31.4%), Indians (2.3%) and
Eurasian (1.2%) were retrospectively reviewed. All underwent complete ophthalmic
examination and investigations. Mean patient age was 70.4 years with a male
preponderance (59.3%), and mostly unilateral presentation (94.1%). The logMAR
mean presenting visual acuity was 0.78 ± 0.64. Polypoidal vascular lesions were
located generally within the macula area (86.8%), manifesting mainly as submacular
hemorrhage (59.3%). Interestingly a number of eyes (43.9%) had associated drusen.
Optical coherence tomography largely demonstrated exudative changes (75.9%)
and almost all patients (97.7%) had loss of external limiting membrane (ELM) and
IS/OS interface. On indocyanine green angiography, majority of eyes had multiple
polyps (82.4%) with ‘cluster’ (58.2%) being the commonest configuration. In
conclusion, although the patterns of PCV in UKMMC were mainly similar to other
Asian patients, a number of our patients had associated drusen. This indicates
that PCV in our population could be a variant of neovascular age related macular
degeneration and not solely idiopathic in nature.