Lens-induced glaucoma, a collateral damage during COVID-19 Pandemic

Cataract if left untreated, can lead to complications such as lens induced glaucoma and permanent visual loss. The COVID-19 outbreak resulted in movement control orders causing closure and reduction of non-COVID hospital services resulting delayed appointment dates. This study described the side effects of delayed patient appointments due to COVID-19 pandemic. A 70-year-old man presented with right eye (RE) pain and redness. There was gradual reduction in RE vision over the last year but treatment was delayed due to pandemic. In examination, visual acuity on his RE was hand movement and left eye (LE) was 6/12 (ph6/12) and near vision of N5. The right pupil was mid-dilated, reacting sluggishly with presence of relative afferent pupillary defect. Intraocular pressure (IOP) on the RE was 54 mmHg and LE was 16 mmHg. Circumciliary injection of right conjunctiva with central corneal haziness was seen. The anterior chamber was deep with the presence of 3+ cells with whitish lens material at the pupillary axis. A Morgagnian cataract with phacodonesis was present. A diagnosis of lens induced glaucoma was made. Immediate reduction of IOP included topical and systemic medication and pain relief were instituted. Intracapsular cataract extraction with anterior vitrectomy and surgical peripheral iridectomy was performed. This highlights the late presentation of a patient with mature cataract during the COVID-19 pandemic. Patient awareness and education are essential in recognising the complications of mature cataract if it is presented later. A reminder of signs and symptoms of lens induced glaucoma should be conveyed to patient when appointment is delayed

The relationship between intraocular pressure and estimated intracranial pressure in patients with normal tension glaucoma

This study aims to determine the relationship between intracranial pressure (ICP) and intraocular pressure (IOP) in patients with normal-tension glaucoma (NTG) who were already on anti-glaucoma treatment using an estimated ICP (estICP) and translaminar pressure difference (estTPD) formula. A cross-sectional comparative study consisted of 66 subjects (66 eyes) who were divided into NTG (n=33) and normal (n=33) group was conducted from 1st November 2017 until 31st May 2020 at a tertiary hospital in Malaysia. After obtaining consent from subjects, ocular and systemic data including IOP, visual field testing, axial length, central corneal thickness (CCT), peripapillary and macular retinal nerve fibre layer evaluation as well as blood pressure (BP) and body mass index (BMI) were collected. The estICP (mm Hg) was calculated as 0.44 x BMI (kg/m2) + 0.16 x diastolic blood pressure (mmHg) – 0.18 x age (years) – 1.91. The estTPD was derived from this calculated value, where estTPD (mm Hg) = IOP – estICP. Analysis showed there was no significant difference in estimated ICP between NTG and normal subjects [mean difference (95% CI): 0.37 (-1.39, 2.12), p=0.679]. The difference in estTPD between NTG and normal subjects were found to be statistically insignificant too [mean difference (95% CI): -1.24 (-2.95, 0.47), p=0.149]. The variables significant in multivariate model included best corrected visual acuity (p=0.028), retinal nerve fiber layer (RNFL) (p=0.003), average macular (p=0.002) and estTPD (p=0.008). The EstTPD was found to be protective towards NTG, which the unit increased in estTPD will decreased the odds of having NTG by 26.5% [Adj. OR (95% CI): 0.735 (0.586, 0.922), p=0.008]. In conclusion, ICP was correlated in increased in IOP. A higher TPD may be associated with a lower chance of developing NTG

Bilateral retinal vasculitis: a presumed case of ocular TB without inflammation.

A 17-year-old male student of Indonesian parentage presented with two weeks history of progressive painless bilateral visual deterioration. There was no contact with tuberculosis (TB)-infected patients and parents claimed that all immunization including BCG was completed. However, BCG scar was not apparent. Visual acuity was 6/36 and 6/60 in the right and left eyes respectively. The anterior and vitreous chambers were quiet. Funduscopic examination revealed retinal vasculitis with perivascular exudates, branch vein occlusion, neovascularization and macular oedema. Fluorescein angiography confirmed large areas of capillary non-perfusion and leaking new vessels. Mantoux test was positive and full regime anti-TB therapy was instituted. HIV screening was negative. Three days later, an immunosuppressive dose of oral steroid was started. Both eyes received intensive laser photocoagulation. Interestingly, there was no development of vitritis throughout

Therapeutic and Tectonic Penetrating Keratoplasty- All in One

A middle-aged gentleman with history of left penetrating keratoplatsy presented with left eye perforated corneal graft secondary to infective keratitis. The affected eye was blind from absolute steroid-induced glaucoma. In view of expected poor graft survival in a blind eye, globe removal was offered. However, the patient refused the treatment and request for another corneal graft. This case highlights both the possibility of good outcome of cornea graft in such a case, and also illustrates that patient’s autonomy to refuse treatment option outweighs beneficence