The hidden salmon patch: ocular lymphoma mistaken as Vogt Koyanagi disease

Ocular inflammation from various causes may have similar clinical presentation thus careful clinical evaluations are mandatory particularly when the disease appear to be resistant to treatment. This paper reports a case of ocular lymphoma which was initially treated as Vogt Koyanagi Harada disease at a different centre. A 65-year-old Sudanese man complained of gradual worsening left eye vision. Careful ocular and slit lamp examination revealed a conjunctival lesion with choroidal infiltration as well as exudative retinal detachment. Computed tomography scan (CT scan) showed left eye axial proptosis, and a homogenous enhancing mass at the posterior coat of the globe. Tissue biopsy of the conjunctival lesion revealed marginal Zone B cell (MALT type), low grade, non-Hodgkin’s lymphoma. AS the ocular signs and symptoms progressed, chemotherapy was initiated. The proptosis, exudative retinal detachment, disc hyperemia and swelling improved after chemotherapy. The post treatment CT scan showed reduction of the posterior ocular coat mass. The possibility of malignant lymphoma should be considered in patients with resistant uveitis despite administration of corticosteroid. Ocular lymphoma is an indolent tumour with good prognosis. Careful ocular examination, adequate imaging studies followed by early surgical biopsy will contribute to early diagnosis

Presumed tuberculous keratopathy: a rare presentation of “serpiginious-like” keratic precipitates in a unilateral anterior uveitis case

A 43-year-old lady with no underlying medical illness was referred for chronic recurrent unilateral anterior uveitis. She had no previous ocular trauma or surgical intervention to the eye. Upon presentation, she was found to have unilateral anterior uveitis with a very unusual “serpiginious-like” pattern of keratic precipitate. Initial investigations revealed no infective cause and patient was commenced on topical and oral steroids. Unfortunately, her ocular symptoms worsened and developed steroid induced glaucoma. A repeat infective screening revealed positive results for tuberculosis. Patient has since responded very well to treatment with antitubercular agents with complete resolution of the inflammation and good visual recovery. In this case report, we wish to emphasize that ocular tuberculosis presentation is highly variable and in such cases its best to employ a high index of suspicion to initiate the right treatment timely. An infective etiology should promptly be suspected in patients who are not showing response to topical or systemic steroids. Even in an immunosuppressed state, ocular tuberculosis may remain unilateral throughout the course of the disease, as seen in the patient. Injudicious use of steroid can make a simple anterior granulomatous uveitis progress to florid granulomatous uveitis with confluent keratic precipitates

An orbital solitary fibrous tumor: report of two cases with different presentation

Solitary fibrous tumour (SFT) is a rare spindle-cell neoplasm that can occur in the orbit. We report two cases of orbital SFT in a 35-year-old female and a 28-year-old male with different presentations. First patient presented with slowly progressive left lateral upper lid mass which is firm in consistency and non tender. Patient had non axial proptosis as the mass compressed the globe inferonasally. There was also funduscopy evidence of choroidal folds superotemporally. There is slight impairment of vision on the left eye comparing to right eye. Meanwhile, the second patient presented with a painless diffuse swelling of left upper eyelid. It was soft in consistency, non fluctuate and no opening or pus discharge noted. There is mild mechanical ptosis, however there was no proptosis and no evidence of compression into the globe nor visual impairment.Computed tomography (CT) imaging revealed a well circumscribed and contrast enhanced soft tissue mass intraorbital extraconal mass in both cases. However in the first case, the tumour was at the level of lacrimal gland with compression of the globe, while in second case, it was superior and posterior to the left lacrimal gland with no globe compression. Both patients underwent complete resection of their tumors. The histological findings showed alternating hypercellular and hypocellular areas composed of bland spindle cells with a fibrous stroma. The strong immunoreactivity for CD34 supported the diagnosis of orbital SFT. There was no recurrence at the 2nd and 3rd year follow-up visits for both patients. SFT should be considered as one of the differential diagnosis of an orbital tumor. The combination of CT scan, histologic findings and immunohistochemical staining provide accurate diagnosis. En bloc excision of the tumour is the mainstay of treatment

Do pathogens from corneal scraping show their true colours better in bactec bottles?

Identification of causative organisms of clinically suspected microbial keratitis is very important so that appropriate targeted antimicrobial treatment can be offered to patients. The current routine method of corneal scraping specimens on to multiple agar culture plates for microbiological study is not really providing encouraging result. Our trial of modified technique of using BACTEC broth for three clinically suspected microbial keratitis cases worked 100% to identify the causative organisms in cases of microbial keratitis

Lupus nephritis with visual field defect secondary to hypertensive retinopathy: a case report

A 23-year-old lady presented with both eye progressive painless blurring of vision for two weeks in 2011. Prior to that she had malar rash, hair loss, photosensitivity and bilateral leg swelling. Ocular examination showed that visual acuity on the right was 6/60 and on the left was 6/24. Both optic disc were swollen with extensive peripapillary cotton wool spot (CWS), flame shape haemorrhages, dilated and tortuous vessels with macular oedema. Systemic examination revealed blood pressure of 176/111 mmHg, malar rash and alopecia. Diagnosis of grade 4 hypertensive retinopathy secondary to SLE was made. The diagnosis was confirmed by positive ANA/ dsDNA, low C3/ C4 and renal biopsy showed lupus nephritis. She was treated with oral prednisolone, hydroxychloroquine and cyclosporin A. Throughout the monitoring for hydroxychloroquine toxicity, vision over both eyes were 6/9, but serial visual fields showed non-progressive left superior and inferior scotoma while right eye showed inferior scotoma. The intraocular pressure was normal with pink optic disc and cup disc ratio of 0.3. Optical coherence tomography (OCT) showed temporal and nasal retinal nerve fiber layer thinning bilaterally. However, macula OCT, fundus fluorescein angiography and autofluorescence were normal. The visual field defect was concluded secondary to CWS indicating microinfarction of the retinal nerve fiber secondary to previous hypertensive retinopathy. Non-progressive visual field defects may occur after the appearance of CWS in hypertensive retinopathy and it should not be overlooked when diagnosing glaucoma or hydroxychloroquine toxicity

Hemangioblastoma in the setting of Von Hippel Lindau disease: a case report

A 21-year-old Chinese gentleman with no known medical illness, presented with a history of right painless blurring of vision with central scotoma of two weeks duration. He also had a history of multiple episodes of seizures prior to presentation. Visual acuity was 1/60 with unremarkable anterior segment findings and no relative afferent pupillary defect. Fundus examination of the right eye revealed dilated and tortuous retinal veins with multiple retinal capillary hemangiomas and sub retinal hard exudates at the macula with edema. A diagnosis of Von Hippel Lindau disease was made when a posterior fossa mass suggestive of hemangioblastoma with obstructive hydrocephalus was seen on computed tomography of the brain. Craniotomy with nodule excision was performed. The retinal capillary hemangiomas were treated with the combination of laser photocoagulation and intravitreal Ranibizumab injections. Visual acuity subsequently improved to 6/36

Orbital cellulitis from untreated conjunctival wound

Orbital cellulitis is a potential blinding condition resulting from infection of the orbital contents, including the optic nerve. It may be fatal in cases with extension into the optic canal and subsequently the brain. Common aetiologies include extension of infection from paranasal sinusitis or preseptal cellulitis. This case report depicts the unusual occurrence of orbital cellulitis following a trivial superficial conjunctiva laceration wound from a motor-vehicle accident. Aggressive treatment with systemic antibiotics resulted in good visual outcome. All wound on or around the globe must be diligently treated to prevent such detrimental complication

Patterns of polypoidal choroidal vasculopathy among a multiracial population in a Malaysian hospital

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

Ocular syphilis: resurgence of an old disease in modern Malaysian society

Letter to the edito

Development of a Wireless and Ambulatory Posture Monitoring System

The wireless and ambulatory posture monitoring system monitors the movement and posture change of the human body with respect to the g-line. It is crucial to monitor the posture health of the ophthalmologist who spends a prolonged period on the static sitting posture while operating on the slit lamp which leads to any painful experience. The motivation of the proposed system is to improve the ergonomics of the ophthalmologist on their working environment and reduce any occupational potential hazard which may prompt Work-Related Musculoskeletal Disorders (WMSDs). The proposed system also induced a wireless system by using XBee wireless units to reduce the use of the wire that may tangle on the study subject which causes any uncomfortable experience to the study subject during the human trial. Inertial Measurement Unit (IMU) sensor which consists of an Accelerometer, a Gyroscope and a Magnetometer is used to measure the angle of deviation of the body segment with respect to the g-line. The data is tabulated and presented into the graphical method to identify and extract the properties of the graph on each different static sitting posture which later are used for posture recognition