Choroidal metastasis from renal cell carcinoma presenting with exudative retinal detachment

A 42-year-old Chinese man, known case of renal cell carcinoma with lung metastasis, was referred to Universiti Kebangsaan Malaysia Medical Centre for left eye blurring of vision for one month duration, which was worse upon waking up in the morning and cleared up after 1-2 hours. On examination, visual acuities were 6/6 in both eyes. No relative afferent pupillary defect. Left fundus showed inferonasal retinal detachment without macular involvement. No retina break, no retinitis and no choroidal lesion seen. Right eye examination was normal. Optical coherence tomography (OCT) of left eye showed subretinal fluid temporal and inferior to optic disc. Fundus fluorescein angiography (FFA) left eye showed hypofluoresence in early phase but hyperfluorescence with pin point leakage in late phase over inferonasal quadrant. Indocyanine green (ICG) showed early hypofluoresence with late pin point hyperfluoresence in the same quadrant. A clinical diagnosis of exudative retinal detachment due to choroidal metastasis secondary to renal cell carcinoma was made. The patient was planned for cyber-knife radiotherapy of his left eye but unfortunately we lost the follow up. High index of suspicion and relevant investigation are needed for patients with visual complaints and history of renal cell carcinoma to diagnose choroidal metastasis

Retinal nerve fibre layer thickness changes after pan-retinal photocoagulation in diabetic retinopathy

Diabetic retinopathy is a disease involving microangiopathic changes in response to chronic hyperglycaemia and pan retinal photocoagulation (PRP) is currently the mainstay of treatment for proliferative retinopathy. In the present study, we evaluated the effect of pan retinal photocoagulation (PRP) on retinal nerve fibre layer (RNFL) thickness in patients with diabetic retinopathy using optical coherence tomography (OCT). This was a prospective longitudinal study. Patients with Type 2 diabetes mellitus with proliferative diabetic retinopathy (PDR) or very severe non-(N)PDR requiring laser treatment were included in the study. PRP was performed by a single trained personnel. Peripapillary RNFL located 3.4 mm around the optic disc was evaluated using time-domain OCT. Examination was performed before treatment, and 2 and 4 months after laser treatment. In total, 39 subjects (39 eyes) were recruited into this study. Twenty-nine patients had PDR and 10 had very severe NPDR. Mean age was 54.97 ± 8.38 years. Male and female genders were almost equally distributed with 18 males and 21 females. Median thickness of average RNFL at baseline was 108.8 um (interquartile range [IQR] 35.3). At two months post-procedure, average RNFL thickness significantly increased to 117.4 (IQR 28.6; P = 0.006). Although, other quadrants revealed a similar trend of increasing thickness at two months but it was not significant. At 4 months post-laser treatment, RNFL thickness in all quadrants reduced to baseline levels with insignificant changes of thickness compared to prior to laser treatment. There was also no significant association between changes in RNFL thickness and HbA1c levels (P = 0.77). In conclusion, PRP causes transient thickening of the RNFL which recovers within 4 months post-laser treatment. At the same time, poor sugar control has no direct influence on the RNFL changes after PRP

Retinal nerve fiber layer thickness post-laser treatment in diabetic retinopathy: argon versus pattern scanning laser

Conventional argon laser causes transient thickening of retinal nerve fibre layer (RNFL). The effect of pattern scanning laser (PASCAL) has not been well described. We compared the immediate changes in peripapillary RNFL thickness post-panretinal photocoagulation between conventional argon lasers and PASCAL in patients with diabetic retinopathy changes. A total of 32 subjects were recruited. There were 16 patients in the argon group and 16 patients in PASCAL group. Diabetic patients were recruited from Ophthalmology Clinic, Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Complete eye examinations and fundus photographs were performed at baseline prior to laser treatment, and post-laser treatment at two and four months. RNFL thickness was measured using time domain optical coherence tomography. Both groups were comparable with respect to clinical characteristics and demographics. There was no significant difference in average RNFL thickness between the two groups prior to treatment (p= 0.323). RNFL post-laser treatment for patients receiving conventional argon laser remained unchanged with no significant differences in all quadrants at any time-point (two and four months). However, for the PASCAL group, significant thickening occurred at four months for average RNFL and the inferior quadrant (p <0.05). The other quadrants similarly demonstrated increasing thickness at four months but this did not reach statistical significance. Transient RNFL thickening occurs in both conventional and PASCAL laser patients. The PASCAL laser induces a greater increase in RNFL thickness than the argon laser group. Important events, such as laser eye treatments and even type of laser used, are worthy of consideration when evaluating RNFL

Bilateral compressive optic neuropathy secondary to tuberculum sella meningioma in pregnancy

A 37-year-old primigravida in her second trimester presented with bilateral painless progressive visual loss. Her vision was hand motion in both eyes. Both pupils were dilated with sluggish reaction to light. Both fundus appeared myopic with bilateral optic atrophy. Magnetic resonance imaging (MRI) of the brain revealed a suprasellar mass with optic chiasm compression and bilateral optic nerve atrophy. As the mass has compromised her vision, a semi-emergency craniotomy and excision of tumour was performed. Histopathological examination confirmed the diagnosis of low grade meningothelial meningioma. Both mother and foetus were well after the surgery. However, post-operatively her vision remained poor due to optic nerve atrophy

Retinal break adjacent to the optic disc causing retinal detachment in a pathological myopia

Retinal detachment is one of the common complications of pathological myopia due to presence of retinal break. However, retinal break commonly occurs in the peripheral retina. This case report illustrates the rare incidence of retinal break adjacent to the optic disc, highlights the possible causes of poor visual outcome following surgical repair as well as the possible measures to treat the complications

Intra-operative phacoemulsification conversion to extracapsular cataract extraction: risk factors and visual outcome

Phacoemulsification (PEA) is currently the procedure of choice for most cataract extraction. However, intra-operative complications may require the procedure to be converted to extracapsular cataract extraction (ECCE). We have evaluated the indications for conversion and visual outcomes in cases converted from phacoemulsification to ECCE. A retrospective review was performed on 33 eyes in which phacoemulsification was initiated and then converted to ECCE. The main parameters evaluated were indications for conversion and visual outcomes at 3 months. Thirty-three cases out of 1448 operations were identified from January 2013 to February 2014.The incidence of PEA converted to ECCE was 2.2%. The indications for ECCE conversion were posterior capsular rupture (PCR) in twenty-two cases, combined capsulorhexis extension with PCR in three cases, capsulorhexis extension and zonular dialysis in two cases respectively. Combined zonular dialysis with PCR, corneal toxicity, Descemet’s tear and obscured edge of capsulorhexis had one case each. Twenty-six (78%) cases had gain in vision, one (3%) case had unchanged vision and six (18%) cases had worsening of vision. The incidence of complicated phacoemulsification surgery requiring intra-operative conversion to ECCE was low in our study (2.2%). Seventy-eight percent of cases achieved final VA of 6/12 or better. Therefore, early recognition of complications and timely intra-operative conversion of PEA to ECCE may result in good visual outcome

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

Evaluation of outer retinal layers in diabetic macula edema treated with intravitreal ranibizumab

Anti-vascular endothelial growth factor (VEGF) reduces choroidal thickness by choroidal hypoperfusion in diabetic macula oedema (DME) patients. Indirect effect of anti-VEGF towards outer retinal layers (ORL) which supplied by choroidal circulation has not been well described. We evaluate the ORL thickness between retinal pigment epithelium (RPE) with inner-segment-outer-segment photoreceptor junction (IS/OS) and RPE with external limiting membrane (ELM) in pre- and postintravitreal Ranibizumab (IVR) treated eyes with central foveal diabetic macula edema. A total of 60 eyes (40 patients) were analysed. ORL thickness measured with optical coherence tomography at pre- and post-injection day 1, week 4 and week 6. Mean thickness of RPE-IS/OS was statistically significant over time (p=0.023) but not for RPE-ELM (p=0.216). Thickness ratio between RPE-IS/OS and RPE-ELM and central subfoveal thickness (CST) both showed statistically significant result over time with p=0.038 and p=0.000, respectively. We observed an initial reduction of ORL thickness at day 1 followed by increased in thickness at week 4 with subsequent reduction at week 6 was observed. ORL is an aspect that can be explore and emphasized further in patients considered for IVR injections. The long-term effects of IVR to the ORL however could not be concluded due to short follow up period

Mental health state of low vision patients using the hospital anxiety and depression scale and the depression, anxiety and stress scale

Mental health status of low vision (LV) patients is not a routine evaluation. This study was carried out to determine the mental health status among LV patient using Depression Anxiety Stress Scale (DASS-21) and Hospital Anxiety and Depression (HAD) Scale questionnaires. A total of 100 LV patients were recruited in this cross-sectional study. Standard LV assessment and mental health screening using DASS-21 and HAD Scale questionnaires were administered. The mean age of the subjects was 62.77+9.15 years old. There were 63% Malays, followed by 26% Chinese and 11% Indians. The mean visual acuity of the subjects was 0.45+0.24 LogMAR. Results showed the mean score for depression and anxiety for HAD scale questionnaire were 3.11+3.35 and 2.85+3.21, respectively. The mean score for depression, anxiety and stress for DASS questionnaire were 4.83+6.90, 3.58+3.79 and 6.18+6.92, respectively. The mean scores fell into the normal range classification of severity on both HAD scale and DASS. The HAD Scale showed that 12% of the subjects experienced depression and 8% experienced anxiety while the DASS showed that 7% had depression, 17% had anxiety and 24% experienced stress. These findings illustrate that the mental health of the LV patients can be affected due to visual impairment. In conclusion, the mental health status of LV patients can be screened objectively using DASS-21 and HAD Scale questionnaire. Understanding the mental health status of LV patients will enable us to provide better LV assessment and rehabilitation

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