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Fulltext Syringomyelia presenting with unilateral optic neuropathy: a case report

Ngoo QZ, Tai EL, Wan Hitam WH

Int Med Case Rep J, 2017;10:87-91.
PMID: 28352205 DOI: 10.2147/IMCRJ.S129239

PURPOSE: In this case report, we present two cases of syringomyelia with optic neuropathy.
FINDINGS: In Case 1, a 36-year-old Malay lady presented to our clinic with acute onset of blurring of vision in her left eye that she experienced since past 1 month. She was diagnosed with syringomyelia 12 years ago and was on conservative management. Her visual acuity was 6/6 in the right eye and counting fingers at 1 m in the left. There was a positive relative afferent pupillary defect in her left eye. Optic nerve functions of her left eye were reduced. Visual field showed a left inferior field defect. Her extraocular muscle movements were full. Magnetic resonance imaging of the brain and spine showed syringomyelia at the level of C2-C6 and T2-T9. Both of her optic nerves were normal. Her condition improved with intravenous and oral corticosteroids. In Case 2, a 44-year-old Malay lady presented to our clinic with a progressive central scotoma in her right eye that she experienced since past 1 month. She had previous history of recurrent episodes of weakness in both of her lower limbs from past 8 months. Visual acuity in her right and left eye was 6/9 and 6/6, respectively. The relative afferent pupillary defect in her right eye was positive. Optic nerve functions of her right eye were affected. Visual field showed a central scotoma in her right eye. Her extraocular muscle movements were full. Fundoscopy of her right eye showed a pale optic disc. Her left eye fundus was normal. Magnetic resonance imaging of the brain and spine showed syringomyelia at T3-T6. Both of her optic nerves were normal. A diagnosis of syringomyelia with right optic atrophy was performed. Her condition improved with intravenous and oral corticosteroids.
CONCLUSION: Optic neuropathy is a rare neuro-ophthalmic manifestation in patients with syringomyelia. Prompt diagnosis and timely management are essential to avoid a poor visual outcome. Intravenous corticosteroids are beneficial in the treatment of early optic neuropathy in syringomyelia.
Fulltext Evaluation of Retinal Nerve Fiber Layer Thickness and Optic Nerve Head Parameters in Obstructive Sleep Apnoea Patients

Ngoo QZ, A NF, A B, Wh WH

Korean J Ophthalmol, 2021 06;35(3):223-230.
PMID: 34120421 DOI: 10.3341/kjo.2020.0019

PURPOSE: To study the retinal nerve fiber layer (RNFL) thickness and optic nerve head (ONH) parameters in obstructive sleep apnoea (OSA) patients and their relationship with severity of the disease.
METHODS: A cross-sectional, hospital-based study. Fifty-four OSA subjects and 54 controls were recruited. Candidate that fulfil the criteria with normal ocular examinations then proceed with spectrum domain Cirrus optical coherence tomography examinations. ONH parameters and RNFL thickness were evaluated. Apnoea-hypopnoea index (AHI) of the OSA group were obtained from the medical record.
RESULTS: In OSA, mean of average RNFL thickness was 93.87 µm, standard deviation (SD) = 9.17, p = 0.008 (p < 0.05) while superior RNFL thickness was 113.59 µm, SD = 16.29, p ≤ 0.001 (p < 0.05). RNFL thickness fairly correlate with severity of the disease (AHI), superior RNFL with R = 0.293, R2 = 0.087, p = 0.030 (p < 0.05), and nasal RNFL R = 0.292, R2 = 0.085, p = 0.032. No significant difference and correlation observed on ONH parameters. In control group, mean of average RNFL thickness was 98.96 µm, SD = 10.50, p = 0.008 (p < 0.05) while superior RNFL thickness was 125.76 µm, SD = 14.93, p ≤ 0.001 (p < 0.05).
CONCLUSIONS: The mean of the average and superior RNFL thickness were significantly lower in the OSA group compare to control. Regression analysis showed RNFL thickness having significantly linear relationship with the AHI, specifically involving the superior and nasal quadrant.
Fulltext Sinonasal Lymphoepithelial Carcinoma With Aggressive Orbital Invasion

Suparmaniam S, Ngoo QZ, Wan Hitam WH, Moknasing John PA

Cureus, 2022 Nov;14(11):e31103.
PMID: 36475167 DOI: 10.7759/cureus.31103

Sinonasal lymphoepithelial carcinoma (LEC) is an extremely rare malignancy that shares some characteristics with nasopharyngeal carcinoma. In Asian populations, Epstein-Barr virus has been reported to be associated with LEC located outside of the nasopharynx. We report a rare case of sinonasal LEC with locoregional extension (brain and orbit). A 39-year-old Malay male initially presented with profound blurring of vision on the left eye (LE) and proptosis, followed by nasal symptoms of anosmia. Clinical examination revealed that the LE visual acuity was 6/36, with reduced optic nerve function with normal funduscopic findings, non-axial proptosis, and minimal limitation of extraocular movement. Subsequently, his vision worsened with perception of light in three days. Radioimaging studies showed soft tissue lesion at the ethmoid sinus with extensive local and intracranial extension. Microscopic analysis and immunohistochemistry confirmed the diagnosis of LEC. The patient was given induction chemotherapy followed by concurrent chemoradiotherapy with weekly intravenous cisplatin. Upon completing the fourth cycle of chemotherapy, the patient's ocular symptoms and general conditions worsened. Repeated imaging showed worsening intracranial extension with cerebral and cerebellar edema, and the patient succumbed to death. Sinonasal LEC is a rare malignant tumor with little mention in the literature. This case was reported to highlight the importance of a high index of suspicion for acute ocular symptoms with mass.
Fulltext Evaluation of Retinal Nerve Fiber Layer Thickness, Electroretinogram and Visual Evoked Potential in Patients with Alzheimer's Disease

Ngoo QZ, Wan Hitam WH, Ab Razak A

J Ophthalmol, 2019;2019:6248185.
PMID: 31949951 DOI: 10.1155/2019/6248185

OBJECTIVE: To study the retinal nerve fibre layer (RNFL) thickness and visual electrophysiology testing in patients with Alzheimer's disease (AD).
METHODS: A cross-sectional, hospital-based study: 25 AD subjects and 25 controls were recruited. Candidates who fulfil the criteria with normal ocular examinations were made to proceed with scanning laser polarimetry, pattern electroretinogram (PERG), and pattern visual evoked potential (PVEP) examinations of the right eye. RNFL thickness, PERG, and PVEP readings were evaluated.
RESULTS: In AD, the mean of average RNFL thickness was 45.28 μm, SD = 3.61, P < 0.001 (P < 0.05), while the superior RNFL thickness was 54.44 μm, SD = 2.85, P < 0.001 (P < 0.05) and inferior RNFL thickness was 47.11 μm, SD = 4.52, P < 0.001 (P < 0.05). For PERG, the mean P50 latency was 63.88 ms, SD = 7.94, P < 0.001 (P < 0.05) and the mean amplitudes of P50 waves were 1.79 μV, SD = 0.64, P < 0.001 (P < 0.05) and N95 waves were 2.43 μV, SD = 0.90, P < 0.001 (P < 0.05). For PVEP, the mean latency of P100 was 119.00 ms, SD = 9.07, P < 0.001 (P < 0.05), while the mean latency of N135 was 145.20 ms, SD = 8.53, P < 0.001 (P < 0.05). The mean amplitude of P100 waves was 3.71 μV, SD = 1.60, P < 0.001 (P < 0.05), whereas the mean amplitude of N135 waves was 3.67 μV, SD = 2.02, P < 0.001 (P < 0.05). RNFL thickness strongly correlates with PERG readings, with P50 latency R = 0.582, R2 = 0.339, P=0.002 (P < 0.05), amplitude of P50 wave at R = 0.749, R2 = 0.561, P ≤ 0.001 (P < 0.05), and amplitude of N95 wave at R = 0.500, R2 = 0.250, P=0.011 (P < 0.05). No significant difference and correlation were observed on PVEP readings.
CONCLUSION: The mean of the average, superior and inferior RNFL thickness were significantly lower in the AD group compared with control. There is also significant difference of PERG and PVEP parameters between AD and controls. Regression analysis showed average RNFL thickness having significantly linear relationship with the PERG parameters.
Fulltext A Triggering Event of Central Retinal Artery Occlusion With Concurrent Ischemic Stroke

Zhong Yang L, Ngoo QZ, Nilamani V, Sudarno R

Cureus, 2024 Feb;16(2):e53577.
PMID: 38445140 DOI: 10.7759/cureus.53577

We report a case of central retinal artery occlusion with concurrent ischemic stroke in a young patient. A 34-year-old Malay gentleman, an ex-smoker with underlying dyslipidemia, however, not on medication or follow-up, presented with acute, generalized, and painless right eye blurring of vision for one day. He also complained of on-and-off headaches for the past three months prior to the presentation. Visual acuity assessment demonstrated hand movement in the right eye, whereas in the left eye, it was 6/6, along with a right eye relative afferent pupillary defect. His right eye showed reduced optic nerve function and unremarkable anterior segment, with fundus examination revealing the presence of a cherry red spot, pale macula, boxcarring pattern over superior arcuate, and vascularized retina over inferior optic disc with blurred optic disc margin. The left eye examination was unremarkable. All cranial nerves were intact, except for the optic nerve. He was admitted to the ward. While in the ward, he developed a sudden onset of left-sided upper and lower limb weakness and numbness and was diagnosed with acute ischemic stroke. Blood investigations showed raised low-density lipoprotein cholesterol of 3.51 mmol/L, anti-nuclear antibody (ANA) positive, with electrocardiogram (ECG) sinus rhythm, and no atrial fibrillation. The echocardiogram was normal, and computed tomography angiography of the brain showed non-opacification at the origin and proximal part of the right ophthalmic artery, suspicious of thrombosis with distal reconstitution, with no evidence of thrombosis in the rest of neck and intracranial arteries. The patient was started on aspirin 150 mg once a day and atorvastatin 20 mg at night; subsequently, his vision improved slightly.
Fulltext A Rare Case of Isolated Abducens Nerve Palsy With Contemporaneous Thalamic Infarct

Zhong Yang L, Ngoo QZ, Viswanathan S, Sudarno R

Cureus, 2024 Mar;16(3):e56268.
PMID: 38623103 DOI: 10.7759/cureus.56268

We report a case of isolated left abducens nerve palsy accompanying a right thalamic infarct. The patient, a 43-year-old Malay male with newly diagnosed hypertension, diabetes mellitus, and dyslipidemia, initially reported binocular diplopia on left lateral gaze persisting for five weeks. Subsequently, he experienced acute left-sided body weakness and slurred speech for over one day. Clinical examination revealed restricted left eye lateral gaze (-3) with no relative afferent pupillary defect. Additionally, decreased power (4/5) was noted in the left upper and lower limbs. Brain magnetic resonance imaging (MRI) revealed restricted diffusion in the right thalamus extending to the right posterior internal capsule, left anterior cingulate gyrus, and left caudate nucleus. The patient was initiated on antiplatelet, antihypertensive, and oral hypoglycemic agents, resulting in symptom improvement. This rare neuroophthalmological finding has not been reported previously.
Fulltext Evaluation of Optic Nerve Head Parameters and Electro-Physiology Among Breast Cancer Patients on Tamoxifen

Ngoo QZ, Wan Hitam WH, Tan CL, Krishna Bhavaraju VM

Cureus, 2022 Jan;14(1):e21042.
PMID: 35155010 DOI: 10.7759/cureus.21042

Introduction To evaluate if early tamoxifen toxicity can be detected by comparing pre-and post-treatment optic nerve head parameters and visual function using Heidelberg Retinal Tomograph III (HRT III) and Pattern Visual Evoked Potential (Pattern VEP). Method This is a prospective study involving 76 eyes of 38 breast cancer patients treated with tamoxifen in Hospital Universiti Sains Malaysia, Kelantan, Malaysia. These patients were examined by a single doctor and the investigations were done by a single technician. The visual acuity, optic nerve function, visual field, optic nerve head parameters on HRT III and Pattern VEP were assessed. The examination was performed before and three months after treatment initiation. Results There was no tamoxifen ocular toxicity found three months post-treatment with tamoxifen. There was no change in visual acuity and optic nerve function post-treatment initiation. There were no statistically significant changes found in optic nerve head parameters on HRT III and P 100 peak latency and amplitude on Pattern VEP. Conclusion Ocular toxicity is a recognized complication of tamoxifen treatment. Tamoxifen optic neuropathy is a potentially irreversible, visually disabling complication. Tamoxifen ocular toxicity was not found three months after tamoxifen treatment initiation among estrogen receptor (ER)-positive breast cancer patients. No early changes in optic nerve head parameters and P 100 peak latency and amplitude changes were found after three months of treatment. A longer duration of monitoring with HRT III and Pattern VEP may be needed to adequately observe for early, subclinical changes in optic nerve head parameters and visual function among tamoxifen users.
Fulltext Endogenous Endopthalmitis in Disseminated Methicillin-Sensitive Staphylococcus aureus (MSSA) Bacteremia

Saidi NA, Ngoo QZ, Jusoh S, Ab Hamid MF, Wan Muda WN

Cureus, 2023 Feb;15(2):e34707.
PMID: 36909129 DOI: 10.7759/cureus.34707

Endogenous endophthalmitis (EE) is an ocular infection resulting from hematogenous spread from the remote primary source. Risk factors include endocarditis, bacteria meningitis, immunosuppressive state, and invasive procedures in patients with sepsis. We present a case of a 43-year-old gentleman with poorly controlled diabetes mellitus who was admitted for bilateral nasoseptal cellulitis with a right nasal wall abscess and right vocal cord palsy. At presentation, he just had preseptal cellulitis without any posterior segment involvement. He underwent incision and drainage under the Otorhinolaryngology team. Unfortunately, postoperatively he developed sepsis with a hematogenous spread of infection systemically involving his right eye (endophthalmitis) and his heart valve (infective endocarditis). Blood culture revealed Methicillin Sensitive Staphylococcus Aureus (MSSA) infection. He had six weeks of intravenous cloxacillin and three times intravitreal injections of vancomycin and ceftazidime with complete resolution of signs and symptoms. In the case of a poorly controlled diabetic patient with an extensive regional infection, the presence of ocular symptoms and signs that are suggestive of EE must be taken seriously and warrant a complete eye examination as early detection and treatment of EE is crucial for better prognosis.
Fulltext Evaluation of Anatomical and Functional Outcome of Epiretinal Membrane Surgery in Idiopathic Epiretinal Membrane Patients

Ngoo QZ, Thamotaran T, Yaakub A, Noordin Z, Mei Li JF

Cureus, 2023 Feb;15(2):e34538.
PMID: 36879699 DOI: 10.7759/cureus.34538

Objective To evaluate the anatomical and functional outcomes of an idiopathic epiretinal membrane (ERM) between the observation group and intervention group at six months postoperative. Design Prospective cohort study. Participants Patients who met the clinical diagnosis of idiopathic ERM in the age frame of 18-80 years; patients with reduced visual acuity (VA), with best corrected VA of 0.2 LogMar or worse, with symptoms of significant metamorphopsia, who visited our center from June 2021 to June 2022. Methods All idiopathic ERM patients who fulfilled the inclusion criteria were selected. The data recorded included the year of ERM diagnosis, duration of symptoms, age at diagnosis, gender, ethnicity, and presence of other ocular pathologies. Corrected VA, lens status, ERM configuration, and central subfield mean thickness (CST) in spectral domain-optical coherence tomography (SD-OCT), ellipsoid zone integrity (EZ), and disorganized retinal inner layer (DRIL) were recorded for all patients at diagnosis, as well as 3 and 6 months after diagnosis for non-operated patients. For patients who underwent surgery (pars plana vitrectomy (PPV), internal limiting membrane (ILM), and ERM peel), data were recorded similarly with additional data on the type of surgery (vitrectomy or combined phaco vitrectomy) and the development of intra or post-surgical complications. Patients receive information on the symptoms associated with ERM, treatment options, and disease progression. After counseling, the patient makes informed consent to the treatment plan. Patients are seen in the 3rd and 6th month from diagnosis. Combined phaco vitrectomy is performed if there is also significant lens opacity. Main outcome measures VA, CST, EZ, and DRIL at diagnosis and 6 months. Results Sixty subjects (30 interventional and 30 observational arms) were recruited for this study. The mean age in the intervention and observation groups was 62.70 and 64.10 years, respectively. Most ERM patients were female in the intervention group compared to males with 55.2% and 45.2% respectively. The mean pre-op CST was 410.03 μm in the intervention group compared to the pre-op CST 357.13 μm observation group. There were significantly different among groups in pre-op CST (p=0.009) using the independent T-test. Furthermore, the mean difference and 95% confidence interval in post-op CST were -69.67 (-99.17, -40.17). There were significant differences among groups in post-op CST (p<0.001) using the independent T-test. Meanwhile, there is no significant association of DRIL between both groups (p=0.23), with 95% CI of mean difference (-0.13, -0.01) using repeated measure analysis of variance (ANOVA) test. There was a significant association of EZ integrity between groups (p=<0.001), 95% CI of mean difference: (-0.13, -0.01) using a repeated measure ANOVA test. Furthermore, the mean post-op VA between pre and post-op VA was significantly different (p<0.001), with a 95% CI of mean difference (-0.85, -0.28). Finally, there is a significant factor association between the duration of ERM and post-op VA (b=.023, 95% CI .001, .05, p<0.05) with our patients. Conclusion ERM surgery has shown positive outcomes on anatomical and functional aspects with minimal safety-related risks. It is evident that a longer duration of ERM does give a minimal impact on the outcome. SD-OCT biomarkers, such as CST, EZ, and DRIL, can be used as reliable prognosticators in decision-making for surgical intervention.
Evaluation of Retinal Nerve Fiber Layer and Macular Thickness Pre- and Post-Chemotherapy With Carboplatin and Paclitaxel in Patients With Endometrial and Ovarian Cancer

Chin JJ, Wan Hitam WH, Chong MF, Lee SJ, Yew JM, Ngoo QZ

Cureus, 2023 Aug;15(8):e43943.
PMID: 37746413 DOI: 10.7759/cureus.43943

Background Carboplatin and paclitaxel are two standard chemotherapeutic agents known to cause neurotoxicity. In this study, we aim to evaluate the toxicity of these agents by measuring the peripapillary retinal nerve fiber layer (RNFL) and macular thickness in patients with endometrial and ovarian cancers who are receiving them. Methods A one-year prospective cohort study involving 28 patients who were treated intravenously with carboplatin (200-400 mg/m2) and paclitaxel (175 mg/m2) three-weekly for six cycles was conducted. RNFL and macula thickness were measured using optical coherence tomography (OCT) before the commencement of chemotherapy, after the third cycle, and one month after the sixth cycle. The main outcome measurements were the average RNFL thickness and central subfield thickness of the macula. Results The mean age of the 28 participants was 54.68 years old (standard deviation [SD] 9.03). Eleven had endometrial cancer, while 17 had ovarian cancer. The mean of the average RNFL thickness during baseline pre-chemotherapy was 96.43 µm (SD 11.39). One month after cessation of treatment, the mean RNFL thickness increased to 101.57 µm (SD 13.54). Statistical analysis showed a significant increment in the mean RNFL thickness (p ≤ 0.001), from baseline to after three cycles, and baseline to one month after six cycles of chemotherapy, except the nasal quadrant. The increment of all macular quadrants was statistically significant (p < 0.05) except for central subfield thickness. Conclusion Systemic administration of carboplatin and paclitaxel affected both the peripapillary RNFL and macula thickness. This represents early evidence of subacute subclinical retinal toxicity. OCT can be used as a screening tool to assess peri-chemotherapeutic retinal alterations.

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