Embong Zunaina

Neuroretinitis in ocular bartonellosis: a case series.

We report a case series of neuroretinitis in ocular bartonellosis and describe the serologic verification for Bartonella henselae. This is a retrospective interventional case series of four patients who presented in the ophthalmology clinic of Hospital Universiti Sains Malaysia from June 2012 to March 2013. All four patients had a history of contact with cats and had fever prior to ocular symptoms. Each patient presented with neuroretinitis characterized by optic disc swelling with macular star. Serology analysis showed strongly positive for B. henselae in all of the patients. All patients were treated with oral azithromycin (except case 4, who was treated with oral doxycycline), and two patients (case 1 and case 3) had poor vision at initial presentation that warranted the use of oral prednisolone. All patients showed a good visual outcome except case 3. Vision-threatening ocular manifestation of cat scratch disease can be improved with systemic antibiotics and steroids.

Rapid anterior capsular contraction after phacoemulsification surgery in a patient with retinitis pigmentosa

A decrease in the anterior capsule opening after cataract surgery has been observed in eyes with weakened lens zonules. It commonly occurs in diabetes mellitus, uveitis, pseudoexfoliation syndrome, high myopia, and elderly patients. Herein, we report the case of a middle-aged man with advanced retinitis pigmentosa who developed a rapid contraction of the anterior capsule after an uneventful phacoemulsification surgery that resulted in severe visual loss during the early postoperative period.

Purtscher-like retinopathy following valsalva maneuver effect: case report

IntroductionPurtschers retinopathy is a rare condition that is noted in cases related to various types of trauma. The characteristic finding in the fundus is the presence of multiple Purtscher flecken. Purtscher-like retinopathy has a similar presentation in the fundus, but without an association with trauma.Case presentationA 43-year old Malay man presented with a sudden onset of central foggy vision in the left eye after holding his breath for two minutes while catching a falling object. It was not associated with floaters, flashes of light, or head trauma. His vision in the right eye was 6/6, and in his left eye it was finger counting. He had bilateral temporal sub-conjunctival hemorrhages. An examination of his left fundus revealed multiple white cotton wool spots and dot-blot retinal hemorrhages with diffuse retinal edema at the posterior pole. His right fundus was noted to have only mild temporal peri-papillary edema associated with a few dot-blot hemorrhages. Fundus fluorescein angiography showed good arterial perfusion and no evidence of leaking or neo-vascularization. A diagnosis of Purtscher-like retinopathy was made, and the patient was treated with indomethacin tablets for six weeks. At his six-week follow-up examination, his left eye visual acuity had improved to 6/12. His bilateral sub-conjunctival hemorrhage had resolved. His left fundus showed residual multiple cotton wool spots and reduced retinal edema.ConclusionsTreatment with non-steroidal anti-inflammatory drugs seems to be effective in reducing edema in patients with Purtscher-like retinopathy.

Successful treatment of syphilitic uveitis in HIV-positive patients

We report successful treatment of syphilitic uveitis in a case series of three Human immunodeficiency virus (HIV)-positive patients at Malaysia’s Selayang Hospital eye clinic. All three patients with syphilitic uveitis were male, aged from 23 to 35 years old, with a history of high-risk behaviors. Of the patients, two presented with blurring of vision and only one patient presented with floaters in the affected eye. Ocular examination revealed intermediate uveitis (case 1 and case 3) and panuveitis (case 2). Each patient showed a high Venereal Disease Research Laboratory (VDRL) titer at presentation and they were also newly diagnosed as HIV positive with variable CD4 counts. All three patients responded well to a neurosyphilis regimen of intravenous penicillin G. At 3 months posttreatment, there was reduction in VDRL titer with improvement of vision in the affected eye. Diagnosis of syphilis needs to be ruled out in all cases of uveitis. All syphilitic uveitis cases should have HIV screening and vice versa, as syphilis is one of the most common infectious diseases associated with HIV-positive patients. Early detection and treatment are important for a good visual outcome.

Serological IgG avidity test for ocular toxoplasmosis

Background The purpose of this study was to evaluate the immunoglobulin (Ig) G avidity of serological toxoplasmosis testing in patients with ocular inflammation and to determine the clinical manifestations of ocular toxoplasmosis. Methods A retrospective review of all patients presenting with ocular inflammation to the Hospital Universiti Sains Malaysia, Kelantan, Malaysia between 2005 and 2009 was undertaken. Visual acuity, clinical manifestations at presentation, toxoplasmosis antibody testing, and treatment records were analyzed. Results A total of 130 patients with ocular inflammation were reviewed retrospectively. The patients had a mean age of 38.41 (standard deviation 19.24, range 6–83) years. Seventy-one patients (54.6%) were found to be seropositive, of whom five (3.8%) were both IgG and IgM positive (suggestive of recently acquired ocular toxoplasmosis) while one (0.8%) showed IgG avidity ≤40% (suggestive of recently acquired ocular toxoplasmosis) and 65 patients (50.0%) showed IgG avidity >40% (suggestive of reactivation of toxoplasmosis infection). Chorioretinal scarring as an ocular manifestation was significantly more common in patients with seropositive toxoplasmosis (P = 0.036). Eighteen patients (13.8%) were diagnosed as having recent and/or active ocular toxoplasmosis based on clinical manifestations and serological testing. Conclusion Ocular toxoplasmosis is a clinical diagnosis, but specific toxoplasmosis antibody testing helps to support the diagnosis and to differentiate between reactivation of infection and recently acquired ocular toxoplasmosis.

Antiphospholipid syndrome in lupus retinopathy.

Systemic lupus erythematosus (SLE) is a chronic, multisystem, autoimmune disease that can affect any part of the human body including the eyes. Common blinding ocular manifestations include central retinal artery occlusion (CRAO), central retinal vein occlusion (CRVO), severe vaso-occlusive retinopathy, and optic nerve involvement. Antiphospholipid syndrome (APS) in lupus is usually associated with large vessel occlusions and needs prompt treatment with anticoagulant. We are reporting two cases of APS in SLE patients that presented with CRVO (case 1) and vaso-occlusive lupus retinopathy (case 2). Both cases were positive for antiphospholipid antibody (APA) and were treated with immunosuppression, anticoagulant, and laser treatment. Thus, screening for APA is vital in SLE patients with lupus retinopathy, as prompt treatment with anticoagulants is important to prevent further vascular thrombosis, which worsens the visual prognosis.

Cerebral venous sinus thrombosis presenting with diplopia in pregnancy: a case report

IntroductionCerebral venous sinus thrombosis is a rare condition. The most frequent symptoms and signs are headache, focal seizures with or without secondary generalization, unilateral or bilateral paresis and papilledema. We report a case of transverse sinus and superior sagittal sinus thrombosis that presented with diplopia in a pregnant woman.Case presentationA 34-year-old Malay woman, gravida 3 para 2 at 8 weeks of pregnancy, was admitted for hyperemesis gravidarum, presented with sudden onset of diplopia, blurring of vision and headache. A magnetic resonance scan of her brain showed the presence of cerebral edema with no space occupying lesion, but magnetic resonance venography ultimately revealed right transverse sinus and superior sagittal sinus thrombosis. The patient was treated with anticoagulation for 1 year, after which the patient recovered fully.ConclusionDue to its diverse and varied neurological presentation, cerebral venous sinus thrombosis should be considered in almost any brain syndrome.

Intraocular nematode with diffuse unilateral subacute neuroretinitis: case report

BackgroundLive intraocular nematode is a rare occurrence. Nematode can migrate actively within the eye, creating visual symptoms and damaging ocular tissue.Case presentationA 26-year old man presented with painless reduced vision of the left eye for one week duration. It was associated with floaters. Visual acuity on the left eye was hand movement. Anterior segment examination was normal with normal intra-ocular pressure. Fundus examination showed a live nematode lying subretinally at the macular area with macular oedema and multifocal chorioretinal lesions at peripheral retina. There was no vitritis, vasculitis or any retinal hemorrhage. Systemic examination revealed normal findings and laboratory studies only showed leucocytosis with normal eosinophil count and negative serum toxocara antibody. The diagnosis of introcular nematode with diffuse unilateral subacute neuroretinitis was made. He was treated with oral anti-helminths and a course of oral steroid at a reducing dose. The nematode had died evidenced by its immobility during the treatment and finally disintegrated, leaving macular oedema with mottling appearance and mild hyperpigmentation. Multifocal chorioretinal lesions had also resolved. However despite treatment his visual acuity during follow-up had remained poor.ConclusionsCases of intraocular nematode, though not commonly encountered, continue to present the ophthalmologist with the problem of diagnosis and management and hence poorer prognosis to the patient.

Choroidal neovascularization secondary to Best's vitelliform macular dystrophy in two siblings of a Malay family.

Best’s vitelliform macular dystrophy complicated with choroidal neovascularization is rare in children. We report three children from a Malay family of five siblings with Best’s vitelliform macular dystrophy, in which two of them subsequently developed choroidal neovascularization. The possible pathogenesis of this rare condition is described and highlighted in this report.

Intravitreal triamcinolone versus laser photocoagulation as a primary treatment for diabetic macular oedema - a comparative pilot study

BackgroundDiabetic macular oedema is the leading causes of blindness. Laser photocoagulation reduces the risk of visual loss. However recurrences are common and despite laser treatment, patients with diabetic macular oedema experienced progressive loss of vision. Stabilization of the blood retinal barrier introduces a rationale for intravitreal triamcinolone treatment in diabetic macular oedema. This study is intended to compare the best corrected visual acuity (BCVA) and the macular oedema index (MEI) at 3 month of primary treatment for diabetic macular oedema between intravitreal triamcinolone acetonide (IVTA) and laser photocoagulation.MethodsThis comparative pilot study consists of 40 diabetic patients with diabetic macular oedema. The patients were randomized into two groups using envelope technique sampling procedure. Treatment for diabetic macular oedema was based on the printed envelope technique selected for every patient. Twenty patients were assigned for IVTA group (one injection of IVTA) and another 20 patients for LASER group (one laser session). Main outcome measures were mean BCVA and mean MEI at three months post treatment. The MEI was quantified using Heidelberg Retinal Tomography II.ResultsThe mean difference for BCVA at baseline [IVTA: 0.935 (0.223), LASER: 0.795 (0.315)] and at three months post treatment [IVTA: 0.405 (0.224), LASER: 0.525 (0.289)] between IVTA and LASER group was not statistically significant (p = 0.113 and p = 0.151 respectively). The mean difference for MEI at baseline [IVTA: 2.539 (0.914), LASER: 2.139 (0.577)] and at three months post treatment [IVTA: 1.753 (0.614), LASER: 1.711 (0.472)] between IVTA and LASER group was also not statistically significant (p = 0.106 and p = 0.811 respectively).ConclusionsIVTA demonstrates good outcome comparable to laser photocoagulation as a primary treatment for diabetic macular oedema at three months post treatment.Trial RegistrationISRCTN05040192 (http://www.controlled-trial.com)