This article describes the case of a 21-year-old female habitual contact lens wearer who complained of left eye pain, redness, and decreased vision for one week. When a ring-shaped corneal infiltration indicative of an Acanthamoeba infection was discovered, standard anti-amoebic topical therapy with polyhexamethylene biguanide and chlorhexidine was commenced. However, her keratitis worsened. At the same time, corneal scraping revealed no pathogens. An anterior chamber examination revealed a loss of corneal sensation, and a positive herpes simplex virus (HSV) immunoglobulin G serology test indicated HSV keratitis. She was eventually treated with oral anti-viral medication and recovered completely. Her case was unusual, as she had a history of contact lens use, painful corneal ulceration, and the development of Acanthamoeba keratitis-like corneal ring infiltration. This case also reinforces the various manifestations of HSV keratitis, which lead to delayed diagnosis and treatment.
Objective To describe the patient demographics, clinical findings, investigations, surgical outcomes, and histopathological findings of seven cases of orbital solitary fibrous tumours. Method This was a retrospective review of seven cases of orbital solitary fibrous tumour, which were followed up in Hospital Serdang, a national oculoplastic centre, from years 2008-2017. Results This study included seven patients with ages between 21 and 35 years old; two were males and five were females. All seven patients presented with painless chronic unilateral proptosis. Radiological imaging of the orbit showed a localized contrast enhancing intraorbital mass. All patients underwent orbitotomy and excisional biopsy. Intraoperative findings showed a well-encapsulated and vascularized mass. Histological findings of spindle-shaped cells were noted. All cases had positive staining for cluster of differentiation (CD) 34, five were positive for CD 99, four were positive for B-cell lymphoma (BCL-2), and five patients had positive staining for S-100. Three of the patients did not have clear margins during the primary operation and subsequently had a recurrence within two years. Conclusion A solitary fibrous tumour is a rare mesenchymal tumour with a pleural origin. The orbit is the most common extrapleural site of the tumour and they are usually benign. Immunohistochemistry is important to differentiate it from other, more aggressive forms of orbital tumours. Regular follow-up is important to monitor for recurrence.
Kodamaea ohmeri keratitis is an opportunistic pathogen seen in patients who have undergone invasive procedures and immunocompromised state. It has been identified in septicemia patients, resulting in mortality. To the best of our knowledge, we identified the first case of K. ohmeri keratitis following an injury with vegetative material. A 57-year-old woman with underlying, poorly controlled diabetes mellitus was gardening when a tree leaf accidentally poked her in the eye. Two weeks later, the patient presented with right eye pain, redness and progressive blurring of vision due to a traumatised right cornea. Slit-lamp examination showed a small inferior paracentral corneal stromal infiltrate with overlying epithelial defect. A corneal scraping sample yielded K. ohmeri from Analytical Profile Index (API) 20C yeast identification system. She was treated with intensive topical amphotericin B and fluconazole. After 6 weeks of treatment, the keratitis resolved with faint scar tissue, and her visual acuity improved.
Ocular toxoplasmosis has multiple devastating complications with possible recurrence. A potentially blinding complication of ocular toxoplasmosis is macular pucker. Here, we report a case of macular pucker in ocular toxoplasmosis treated with azithromycin and prednisolone. A 35-year-old woman complained of central scotoma for six days, which was associated with fever, headache, joint pain, and myalgia. Her visual acuity was counting finger OD and 6/18 OS. Her right eye optic nerve function test was impaired. Fundoscopy showed bilateral optic disc swelling that progressed to retinal fibrosis over papillomacular bundle and macular pucker over the right eye. CT scan of the brain and orbit was normal. Toxoplasma titer was positive. She was diagnosed to have a right eye macular pucker secondary to ocular toxoplasmosis. Oral azithromycin and oral prednisolone (on a tapering dose) were administered for six weeks. Fundoscopy showed resolved optic disc swelling. However, her vision in the right eye remained poor. Ocular toxoplasmosis may progress to macular pucker which can lead to poor vision and legal blindness. Reduced vision-related quality of life notably in the younger population as a complication of ocular toxoplasmosis is difficult to prevent. However, therapy with azithromycin and prednisolone may reduce the negative consequences of inflammation and shrink lesions, especially when the lesions are located at the macula or near the optic disc. Vitrectomy is an alternative treatment for complications such as macular pucker in selected cases.
A 66-year-old male presented with a three-month history of subacute painless decreased vision in the left eye. His ocular history included complicated phacoemulsification surgery of the left eye more than 20 years prior to the presentation. Slit lamp examination revealed a retained lens nuclear fragment in the superonasal quadrant. Surgical removal of the lens nuclear fragment improved the patient's condition. The retained lens nuclear fragments were presumably lodged behind the iris during the phacoemulsification surgery and spontaneously displaced downward due to liquefaction of the vitreous body with age. To the best of our knowledge, this case involves one of the longest reported time periods from phacoemulsification surgery to the clinical presentation of retained lens material without causing inflammation. We recommend detailed ocular assessment post complicated phacoemulsification surgery to ensure that no lens materials are retained.
Infiltrative optic neuropathy is a condition characterized by the invasion of tumor cells into the optic nerve. Breast carcinoma can metastasize to various organs, most commonly the bones, lungs, and liver, and rarely involves the orbit. Orbital involvement may result in debilitating visual impairment and blindness. We report a case of infiltrative optic neuropathy secondary to advanced breast carcinoma. A 39-year-old woman with stage 4 breast carcinoma presented with sudden-onset blurred vision in her right eye for one week. It was associated with a localized scotoma in the visual field. She was previously diagnosed with secondary metastases involving the liver and bone and is currently undergoing treatment with chemotherapy and radiotherapy. Visual acuity in the right eye was 6/7.5, with a positive relative afferent pupillary defect and an inferonasal field defect. The extraocular muscle movement was full, with no significant proptosis. Both anterior segments were unremarkable. Fundoscopy showed a normal optic disc in both eyes, with no optic disc swelling. A computed tomography (CT) scan of the brain and orbit revealed secondary metastases in the dura and right orbital apex. Magnetic resonance imaging (MRI) of the brain revealed right infiltrative optic neuropathy. The patient received whole-brain radiotherapy (WBRT), followed by 12 cycles of chemotherapy. On follow-up, the patient was stable; however, her vision in the right eye deteriorated from 6/7.5 to perception of light. In conclusion, orbital metastasis should be the leading diagnostic consideration when the affected patient has a history of cancer. Early detection, coupled with prompt treatment, can help patients achieve better visual outcomes and, whenever possible, preserve their vision.
Traumatic globe luxation associated with optic nerve avulsion is rare. We describe a case of a 42-year-old Indian gentleman who was involved in a motor vehicle accident (MVA). He sustained a deep laceration wound from the right side of the nose extending to the left medial canthal region and left eyelid. The left globe was not visualized, and only the left optic nerve stump was seen. A computerized tomography (CT) scan showed a left globe dislocated inferotemporal with discontinuity of the left optic nerve, inferior rectus, and lateral rectus muscle. There were also comminuted fractures at the floor and lateral wall of the left orbit with significant lateral displacement of the bone fragments. He underwent left eye enucleation, toilet, and suturing of the laceration wounds and open reduction internal fixation (ORIF) of the fractures. We report this case as it is not commonly seen in Malaysia.
Introduction The emergence of electronic cigarettes as the "healthier" version of smoking has been popular, especially among young adults. However, knowledge about the potential effects of e-cigarettes on ocular structures is scarce. Objective To compare the mean change in dry eye parameters between e-cigarette smokers and non-smokers and to correlate between dry eye parameters with device power output. Methodology A cross-sectional, single-visit study was conducted involving 85 e-cigarette smokers and 85 non-smokers. All participants were evaluated on dry eye parameters, including the Ocular Surface Disease Index (OSDI) score, tear meniscus height (TMH), tear break-up time (TBUT), cornea fluorescein staining, and Schirmer's I test. The mean change in dry eye parameters was compared between e-cigarette smokers and non-smokers. The correlation between dry eye parameters with device power output was analyzed. Results Specifically, 32.94% of e-cigarette smokers were found to have a TMH <0.2 mm, compared to only 5.88% of non-smokers (p<0.001). A significant change in mean TBUT was found between the e-cigarette smokers (10.41+2.65 seconds) and non-smokers (12.66+3.14 seconds, p<0.001). The lower mean Schirmer's I test was found among e-cigarette smokers (12.75+7.24 mm, p<0.001). No significant change in the median OSDI score and corneal fluorescein staining. The OSDI score and device power output were found to have a significant positive correlation (p=0.003). There was a significant association between dry eye signs and device power output, including TMH (p=0.047), TBUT (p=0.002), Schirmer's I test (p<0.001), and corneal fluorescein staining (p<0.001). Conclusion Electronic cigarette smokers are prone to develop dry eyes. Concern should be raised on the risk of electronic cigarette use on ocular health, and regulation on e-cigarette ban should be revisited.
A thymectomy is considered effective for patients with myasthenia gravis (MG). Although a few studies have described the role of a thymectomy in the treatment of MG in Asians countries, there are no published data on the application of this surgical approach for MG in Malaysia. We aimed to describe the clinical outcomes of MG patients who underwent a thymectomy and the factors affecting these outcomes.
Bartonella henselae is a recognized cause of neuroretinitis in cat scratch disease. Meanwhile, polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, skin changes (POEMS) syndrome with Castleman disease (evidence of lymph node hyperplasia), is a chronic debilitating condition that predisposes to various superimposed infections. B. henselae neuroretinitis implicated in POEMS syndrome has not been reported previously. A 34-year-old asymptomatic man was referred for an eye assessment. Examination showed visual acuity of 6/18 in the right eye and 6/24 in the left eye. On fundus examination, both eyes exhibited typical features of neuroretinitis (optic disc swelling and incomplete macular star). There was otherwise no vitritis or chorioretinitis. Serology for B. henselae revealed high immunoglobulin M (IgM) titer (1:96) indicative of acute disease, and positive immunoglobulin G (IgG) (1:156). He was treated with oral azithromycin for 6 weeks and a short course of oral prednisolone. Subsequently, the visual acuity in both eyes improved with resolution of macular star. However, both optic discs remained swollen.
Duane retraction syndrome (DRS) with mechanical and innervational upshoot poses a surgical challenge. We discuss a case of DRS with mechanical and innervational upshoot and its surgical management. An 11-year-old boy presented with left eye upward deviation since birth. This deviation was worst on the right gaze. His best corrected visual acuity was 6/6 OD and 6/60 OS. Refraction showed low hyperopia with low astigmatism in both eyes. Stereoacuity was absent and there was suppression on the Worth 4 dot test in the left eye. The left eye had large hypertropia of 50 prism diopter in primary gaze. Extraocular movements showed severe upshoot and narrowing of palpebral fissures on adduction and limited abduction (-2). The patient underwent Y-splitting of the left lateral rectus (LR) muscle of 10 mm, LR recession of 4 mm, and left eye superior rectus recession of 12 mm. A marked reduction in hypertropia in primary gaze was observed on day one and at two months postoperatively with residual upshoot on adduction. His left eye deviation remained stable after six months postoperatively.
We describe a rare case of a patient with systemic lupus erythematosus (SLE) with functional visual loss (FVL). A 30-year-old female had blindness in the left eye due to multiple episodes of optic neuritis with underlying SLE. She presented with blurred vision in the right eye after an upper respiratory tract infection. The visual acuity in the right eye was 6/24, while the left eye had no light perception. The right eye optic nerve function tests were within normal limits. There was a positive relative afferent pupillary defect in the left eye. Fundoscopy showed left optic atrophy, while the right fundus was normal. The patient was treated according to a diagnosis of right retrobulbar optic neuritis. However, despite a course of intravenous methylprednisolone, her right visual acuity deteriorated to light perception. A magnetic resonance imaging (MRI) scan of the brain and orbit was normal. The visual evoked potential (VEP) in the right eye was also normal. The patient was suspected of having FVL and was referred to a psychiatrist. She was diagnosed with major depressive disorder after a full psychiatric assessment.
Endogenous fungal endophthalmitis caused by an unusual fungus poses both diagnostic and therapeutic challenges. We report a case of endogenous endophthalmitis caused by a rare mold, namely Cladosporium spp., which presented with a foveal abscess. A 52-year-old male patient who was diagnosed with rectal carcinoma presented with pain, redness, and a loss of vision in the right eye. He had been experiencing the symptoms for 1 week. The patient had undergone gastrointestinal surgery 2 weeks before experiencing the eye complaint. His best-corrected visual acuity was hand movements. Fundus examination revealed a foveal abscess of around a half-disc diameter in size that simulated retinochoroiditis with vitritis. Optical coherence tomography of the macula revealed a hyperreflective lesion in the fovea, which breached the full thickness of the fovea and extended into the preretinal space. Ocular toxoplasmosis was considered. On that basis, oral trimethoprim/sulfamethoxazole was given for 1 week, although the patient's condition worsened. A vitreous tap and an intravitreal combination of vancomycin, ceftazidime, and amphotericin B were administered twice but did not improve the patient's condition. Pars plana vitrectomy was performed and the vitreous biopsy results revealed the presence of Cladosporium spp. Intravitreal voriconazole was given three times and the foveal abscess resolved into a scar. Endophthalmitis caused by Cladosporium spp. is uncommon and published case reports are extremely limited. The present case may provide insight into the variable presentation of fungal endophthalmitis and, therefore, assist with the early diagnosis and appropriate management of the condition.
Non-arteritic anterior ischemic optic neuropathy (NAION) is the most common cause of optic neuropathy in older adults and is usually associated with an altitudinal visual field defect. Binasal hemianopia is a rare visual field presentation, and most causes are due to ocular pathology instead of brain pathology. It is an infrequent finding in NAION. We report a rare presentation of binasal hemianopia visual field defect in a patient with NAION. This a case of an elderly lady with underlying uncontrolled type 2 diabetes mellitus, hypertension, and dyslipidemia who presented with a sudden onset of painless blurring of vision in the left eye. She had a similar episode of blurred vision involving the other eye two years ago. Her visual acuity was reduced in both eyes. Humphrey visual field showed a binasal field defect. Fundoscopy showed mild hyperemic optic disc swelling in the left eye and a pale disc in the right eye. The CT scan and MRI were normal. She was co-managed with the medical team to control her systemic risk factors. Although NAION is the most common cause of optic neuropathy in older adults, binasal hemianopia is a rare visual field presentation in NAION. The history and assessment from this case add important information toward diagnosing NAION.
Optic perineuritis (OPN) refers to the inflammation of the optic nerve sheath and it is a rare form of idiopathic orbital inflammatory disease. We report a rare case of bilateral OPN in an obese female teenager with idiopathic intracranial hypertension (IIH). She was initially presented with painless bilateral blurring of vision that was progressively worsening for three weeks duration. Visual acuity of both eyes was hand movement with no relative afferent pupillary defect detected. The confrontation visual field test showed central scotoma. Both anterior segments were unremarkable. Fundoscopy showed a swollen optic disc bilaterally, with extensive flame-shaped hemorrhages surrounding the disc area and dot blot hemorrhages in the posterior pole. A magnetic resonance imaging scan of the brain and orbit revealed the presence of bilateral optic nerve sheath enhancement with empty sella turcica. The patient was diagnosed with bilateral OPN with IIH. She received an initial high dose of systemic corticosteroid followed by a slow tapering dose. She was monitored by the neuromedical team for her IIH. She was followed up for about a year. The final best corrected visual acuity in the right eye was 6/36 and the left eye was 6/60. In conclusion, OPN poses challenges in diagnosis and management. This case emphasizes the importance of considering OPN in the differential diagnosis of optic nerve-related symptoms, as prompt recognition and intervention are crucial for favorable outcomes.
Introduction Ocular syphilis is a sight-threatening condition. It can occur at any stage of syphilis infection, which present either with acute inflammation during the primary, secondary, and early latent stages or with chronic inflammation during tertiary infection, affecting virtually every ocular structure. This study was to report on the clinical presentation of ocular syphilis that presented to eye clinic Hospital Universiti Sains Malaysia. Methodology This was a retrospective study where medical records of ocular syphilis patients who attended eye clinic in Hospital Universiti Sains Malaysia from January 2013 to June 2017 were reviewed. Results A total of 10 patients (13 eyes) with ocular syphilis were identified out of 106 cases that presented with ocular inflammation. The mean age of presentation was 69.8 ± 6.4 years and seven of them (70%) were female. All patients were Malay and human immunodeficiency virus (HIV) was negative. The ocular manifestations included panuveitis (four eyes, 30.8%), anterior uveitis (two eyes, 15.4%), posterior uveitis (seven eyes, 53.8%) and optic neuritis (two eyes, 15.4%). Seven (53.8%) eyes presented with visual acuity of worse than 6/60, five (38.5%) eyes had visual acuity between 6/15 to 6/60, and one (7.7%) eye had visual acuity of 6/12 or better. Nine patients received an intravenous benzylpenicillin regime and one patient received an intramuscular penicillin injection. Out of 13 eyes affected, 11 (84.6%) eyes had improved visual acuity of at least one Snellen line after treatment. Visual acuity of 6/12 or better increased to four (30.8%) eyes. Conclusions Posterior uveitis was the commonest presentation of ocular syphilis in HIV-negative patients. Early detection and treatment of ocular syphilis can result in resolution of inflammation and improvement of vision.
Background. Ocular bartonellosis can present in various ways, with variable visual outcome. There is limited data on ocular bartonellosis in Malaysia. Objective. We aim to describe the clinical presentation and visual outcome of ocular bartonellosis in Malaysia. Materials and Methods. This was a retrospective review of patients treated for ocular bartonellosis in two ophthalmology centers in Malaysia between January 2013 and December 2015. The diagnosis was based on clinical features, supported by a positive Bartonella spp. serology. Results. Of the 19 patients in our series, females were predominant (63.2%). The mean age was 29.3 years. The majority (63.2%) had unilateral involvement. Five patients (26.3%) had a history of contact with cats. Neuroretinitis was the most common presentation (62.5%). Azithromycin was the antibiotic of choice (42.1%). Concurrent systemic corticosteroids were used in approximately 60% of cases. The presenting visual acuity was worse than 6/18 in approximately 60% of eyes; on final review, 76.9% of eyes had a visual acuity better than 6/18. Conclusion. Ocular bartonellosis tends to present with neuroretinitis. Azithromycin is a viable option for treatment. Systemic corticosteroids may be considered in those with poor visual acuity on presentation.