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Competing Interests: The authors have no financial or conflicts of interest to disclose.

Objective: An ongoing third epidemic of retinopathy of prematurity (ROP) is contributed largely by developing nations. We describe a cohort of infants in a single neonatal unit where two limits of oxygen saturation were administered, to show real-world outcomes from trend in neonatology for higher oxygen to improve survival., Methods and Analysis: This retrospective, comparative study of prospectively collected data in an ROP screening programme included infants indicated by gestational age ≤32 weeks, birth weight <1501 g, ventilation for 7 days or requiring oxygen >1 month, who underwent dilated fundoscopic examination from age 4 weeks, every 2 weeks until full retinal vascularisation. Infants with ROP were examined weekly and treated where indicated. Data were divided into two epochs. Epoch 1 oxygen saturation targets were [88-92%], epoch 2 targets [90-95% (99%)] with allowance of increase to 20% for several hours after procedures. Outcome measures included development of ROP, treatment, mortality, sepsis and intraventricular haemorrhage., Results: A total of 651 infants underwent examination between 2003 and 2016. The incidence of ROP in epoch 1 was 29.1% and epoch 2 was 29.3% (p=0.24). ROP progression doubled in epoch 2 (5 vs 11%, p=0.006), proportion of cases treated halved (14% vs 6%, p=0.0005), sepsis was halved (78.5% vs 41.2%, p<0.0001) and intraventricular haemorrhage doubled (20.2% vs 43.8%, p=0.0001) in epoch 2. Mortality was 4% and 0% in epochs 1 and 2, respectively., Conclusion: Incidence of ROP did not differ, although ROP cases that worsened doubled with higher oxygen targets. ROP cases requiring treatment decreased, as did sepsis and mortality. Intraventricular haemorrhage cases doubled., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To report three cases of juvenile myasthenia gravis aged between 18 and 24 months with ocular symptoms as their first presentation., Method: A case series., Results: We present a case series of juvenile myasthenia gravis in a tertiary centre in Malaysia. Two of the three cases consist of a pair of twins who presented with ptosis of bilateral eyes; the first twin presented 4 months later than the second twin. These two cases were positive for anti-acetylcholine receptor antibodies and had generalized myasthenia gravis, whereas the other case was negative for receptor antibodies and was purely ocular myasthenia gravis., Conclusion: Juvenile myasthenia gravis is relatively rare in toddlers. Early diagnosis and commencement of treatment is important to slow the progression of the disease and avoiding life-threatening events.

Introduction: The aim of this study was to compare the visual outcomes of phacoemulsification with intraocular lens implantation (IOL) surgery in patients with and without diabetes mellitus (DM) in Malaysia over a 12-year period and to identify factors that may contribute to poor visual outcome., Materials and Methods: Data was retrieved from the webbased Malaysian Cataract Surgery Registry (CSR). Perioperative data for cataract surgery performed from 2007- 2018 were analysed. Inclusion criteria were age ≥40 years, phacoemulsification and IOL and senile cataract. Combined surgeries, surgeries performed by trainees and ocular comorbidities were excluded. Post-operative Best-Corrected Visual Acuity (BCVA) were compared. Factors affecting poor visual outcomes among those with DM were analysed using multivariate logistic regression to produce adjusted odds ratio (OR) for variables of interest., Results: Total number of cases between 2007-2018 was 442,858, of whom 179,210 qualified for our analysis. DM group consisted of 72,087 cases (40.2%). There were 94.5% cases in DM group and 95.0Ź from non-DM group who achieved BCVA ≥6/12 (p<0.001). Among patients with DM, advanced age (70-79 years old, OR: 2.54, 95% Confidence Interva, 95%CI: 1.91, 3.40; 80-89 years old, OR: 5.50, 95%CI: 4.02, 7.51), ≥90 years, OR: 9.77, 95%CI: 4.18, 22.81), poor preoperative presenting visual acuity [<6/18-6/60] (OR: 2.40, 95%CI: 1.84, 3.14) and <6/60-3/60 (OR: 3.00, 95%CI: 2.24, 4.02), <3/60 (OR 3.63, 95%CI: 2.77, 4.74)], presence of intraoperative complication (OR 2.24, 95%CI: 1.86, 2.71) and presence of postoperative complication (OR 5.21, 95%CI: 2.97, 9.16) were significant factors for poor visual outcome., Conclusions: Visual outcomes following phacoemulsification with IOL implantation surgery among cases with DM were poorer compared to cases without DM. Risk factors for poor visual outcomes among cases with DM were identified.

To report observations of horizontal corneal diameter (HCD) and central corneal thickness (CCT) changes in premature infants with stable optic disc cupping and intraocular pressures (IOPs). The HCD and CCT at term serve as a baseline for premature infants.Sixty-three premature infants were enrolled in a prospective case series. HCD, CCT, and IOP were measured. RetCam images of the optic discs were used to evaluate the cup-disc ratio (CDR) and read by an independent masked observer. Data were collected at between preterm (32-36 weeks) and again at term (37-41 weeks) postconceptual age. Left eye measurements were used for statistical analysis. Left eye findings were combined to construct predictive models for HCD and CCT.The mean HCD was 9.1 mm (standard deviation [SD] = 0.7 mm) at preterm and 10.0 mm (SD = 0.52 mm) at term. The mean CCT preterm was 618.8 (SD = 72.9) μm and at term 563.9 (SD = 50.7) μm, respectively. The average preterm CDR was 0.31 and at maturity was 0.33. Average IOP of preterm and term was 13.1 and 14.11 mm Hg, respectively. There was significant linear correlation between HCD with the postmenstrual age (r = 0.40, P < .01) and the head circumference (r = 0.33, P < .05). Predictive models were constructed for HCD (R = 0.52, 0.2 mm/wk) and CCT (R = 0.23, -11.4 μm/wk) with postconceptual ages.The HCD and CCT variation did not affect IOP reading over time. CCT was not correlated with birth parameters and decreased as the infant reached term. Corneal diameter correlated with gestational age at birth and head circumference.

Background: Vascular insufficiency has been reported to be a cause of normal tension glaucoma (NTG). The aim of this study was to compare ocular perfusion pressure (OPP) and ophthalmic artery flow (OAF) between patients with NTG and those without glaucoma., Methods: We considered one eye each from 31 NTG and 15 non-glaucoma control patients. Blood pressure and intraocular pressure (IOP) were measured in the sitting position, for calculation of OPP. Humphrey visual field (HVF) assessment was then carried out on NTG patients. All patients then underwent Transcranial Doppler ultrasound measurements of OAF parameters, including mean flow velocity (MFV), end diastolic velocity (EDV), peak systolic velocity (PSV) and resistive index (RI). We looked at differences in OPP and OAF parameters between the two groups, and their correlations in NTG patients. T-tests, χ (2), ANOVA and Pearson Correlation tests were performed, with p < 0.05 considered statistically significant., Results: There were no statistically significant differences in OPP between the NTG and control groups (60.5+/-8.7 mmHg and 62.9+/-10.2 mmHg respectively, p = 0.393), and also no statistically significant differences in MFV, EDV, PSV and RI (all p > 0.05). In the NTG group, there were positive correlations between OPP and both MFV (r = 0.416, p = 0.020) and EDV (r = 0.369, p = 0.041). There were no statistically significant correlations between HVF mean deviation and OPP or OAF parameters (all p > 0.05)., Conclusion: There is no difference in OPP and OAF parameters between patients with NTG and non-glaucoma controls, suggesting that vascular insufficiency or dysregulation by themselves may not account for the pathogenesis of NTG.

Purpose: To evaluate the prevalence of ocular surface disease (OSD) in glaucoma and nonglaucoma subjects using different clinical tests and to determine the effect of number of antiglaucoma medications and preservatives on OSD., Methods: This is a cross-sectional, case-comparison study at the Eye Clinic of the University of Malaya Medical Centre, Malaysia, between June 2012 and January 2013. Glaucoma subjects (n = 105) using topical antiglaucoma medications were compared with control subjects (n = 102) who were not on any topical medications. The presence of OSD was assessed using the tear film breakup time (TBUT) test, corneal staining, Schirmer test, and Ocular Surface Disease Index (OSDI) questionnaire grading., Results: The prevalence of OSD varied from 37 to 91% in the glaucoma group, depending on the type of clinical test. More subjects in the glaucoma group had corneal staining (63% vs. 36%, p = 0.004), abnormal Schirmer tests (39% vs. 25%, p = 0.049), and moderate OSDI symptoms (17% vs. 7%, p = 0.028). The percentage with abnormal TBUT increased with higher numbers of topical medications and was high with both benzalkonium chloride-containing and preservative-free eye drops (90% and 94%, respectively, both p < 0.001). Benzalkonium chloride was associated with a nearly three times higher odds ratio of showing abnormal OSDI., Conclusions: Ocular surface disease is common in those using topical antiglaucoma medications. Abnormal TBUT is associated with increasing number of eye drops and benzalkonium chloride-containing eye drops, although this also occurs with the use of preservative-free eye drops.

Purpose: The purpose of this report was to describe 2 cases of periocular infantile hemangiomas (IHs) that were successfully treated with low-dose oral propranolol alone and in combination with oral prednisolone., Methods: Two infants aged 3 months and 6 weeks, respectively, were referred for management of vision-threatening periocular IHs causing ocular displacement and obscuration of the visual axis. The first infant had a superficial left upper eyelid capillary hemangioma with extraconal extension and the second infant had a deep preseptal capillary hemangioma in the right lower eyelid with intraconal extension. Both cases were started on oral propranolol 0.5 mg/kg/day in divided doses and titrated up to 1.5 mg/kg/day as first-line therapy. The first infant was also given oral prednisolone 2 mg/kg/day during the initial first month of treatment., Results: Rapid regression in sizes of the hemangiomas was seen within the first 3 days of treatment. By 2 months of therapy, both infants had achieved normal ocular alignment. The second infant experienced a transient period of hypotension after the first dose of propranolol was started but recovered spontaneously. Both infants did not experience any adverse effects of propranolol throughout the treatment period., Conclusions: Low-dose oral propranolol is an effective first-line therapy for the management of vision-threatening IH. Dose escalation in combination with oral prednisolone after pediatric assessment might be useful in avoiding adverse effects of propranolol in young infants.

Purpose: To report a case of bilateral endogenous candida endophthalmitis treated with intravenous fluconazole., Method: A 54-year-old man with poorly controlled diabetes presented with blurring of vision in both eyes, associated with eye pain for the past 2 months. Ocular examination revealed vision RE 4/60 ph 6/24, left eye (LE) 3/60. Anterior chamber examination showed 2+ anterior chamber cells in the LE. A streak of hypopyon was also noted in the LE. Both fundi showed presence of vitritis and white opacities. Proliferative diabetic retinopathy was present bilaterally. A diagnosis of bilateral endogenous endophthalmitis was made., Result: The patient was empirically treated with intravitreal vancomycin/ceftazidime on 3 consecutive days pending culture and sensitivity result. Blood and urine samples were negative for organisms. Vitreous samples were taken at the first intravitreal. The culture and sensitivity report of the vitreous sample was positive for candida albicans, which was sensitive to fluconazole. The patient was commenced on intravenous fluconazole 400  mg daily. The patient underwent core vitrectomy in the LE. Fluconazole was continued for 4 weeks, and he showed dramatic improvement with vision 6/12 in both eyes (OU) and endophthalmitis completely resolved., Conclusion: There should be high index of suspicion of fungal endophthalmitis in patients with immune-compromised state even with no known septic foci.

Aim: To compare corneal endothelial structure and central corneal thickness (CCT) between type II diabetics and non-diabetic control patients. To look for correlations between diabetic status and corneal findings., Methods: Hospital-based, observational study. 200 eyes (from 100 type II diabetic patients and 100 controls) were included. Specular microscopy and pachymetry were used to measure endothelial cell density, size, coefficient of variation in cell area, hexagonality as well as corneal thickness. Independent t-tests were used to compare variables between diabetics and controls. Pearson correlation tests were used to evaluate correlations between corneal findings and diabetic status such as duration of diabetes, haemoglobin A1c (HbA1c) level and severity of diabetic retinopathy., Results: Endothelial cell density in the diabetic group (2541.6±516.4 cells/mm(2)) was significantly lower than that in the control group (2660.1±515.5 cells/mm(2), P<0.05). The average size of endothelial cells, standard deviation (SD) of cell size and coefficient of variation (CV) of cell area were all significantly higher in diabetics. Hexagonality was significantly lower in diabetics (41.1%±19.6%) compared to non-diabetics (45.2%±20.6%). CCT was higher in diabetics but not significant (P>0.05). Duration of diabetes, HbA1c level and severity of diabetic retinopathy were not significantly correlated with corneal endothelial findings., Conclusion: Type II diabetes causes a significant alteration in the state of the cornea including reduction in endothelial cell density and increased pleomorphism and polymegathism. Central corneal thickness is unaffected.

Purpose: To identify differences in incidence, risk factors, and outcomes of retinopathy of prematurity (ROP) between 2 birth weight categories within a cohort of extremely low birth weight (ELBW) infants in Malaysia., Methods: This was a prospective study of infants in the Special Care Nursery at the University of Malaya Medical Centre between 2003 and 2005. Outcome measures were presence or absence of ROP, most severe stage of ROP observed, and whether laser treatment was performed. Risk factors for treatment were analyzed in this cohort of treated patients, who were further divided into groups of birth weight <751 g and birth weight 751-1,000 g., Results: The study protocol identified 70 qualifying ELBW infants. Of these, 41 (58.6%) developed ROP and 23 (32.9%) required laser treatment. Mean birth weight was 806.8 g (SD +/- 142.5); mean gestation was 27.4 weeks (SD +/- 2.2). Infants with birth weight <750 g were twice as likely to require treatment (OR = 2, p = 0.038). The risk factors for laser treatment by bivariate analysis were gestation <28 weeks (OR = 1.8, p = 0.001), duration of ventilation >1 week (OR = 1.5, p = 0.012), and intraventricular hemorrhage (OR = 2.5, p = 0.010). Zone 1 ROP was observed only in infants <751 g., Conclusions: The incidence of ROP in ELBW infants in Malaysia is comparable to that seen in the ETROP and CRYO-ROP studies. Within this group, birth weight <750 g doubled the likelihood that treatment would be required.

Orbital arteriovenous malformation is a rare condition which poses a management problem in view of the complexity of the vessels involved, and the potentially blinding and life-threatening complications from the modes of treatment. Treatment requires obliteration of the abnormal vascular communication. Vision may be adversely affected by the condition itself, as well as a result of invasive treatment modalities. This case reports such a situation where the visual outcome was severely affected following embolization of the feeding vessels.

A patient with ocular syphilis is presented. She experienced deterioration in vision following the commencement of treatment due to a Jarisch-Herxheimer reaction. This is a transient febrile illness that can occur in patients after the first adequate dose of an anti-microbial drug to treat infectious diseases such as syphilis, Lyme disease and relapsing fever. However, a Jarisch-Herxheimer reaction occurring in a patient receiving treatment for ocular syphilis can be serious, resulting in the rapid loss of vision.

"Cauliflower Ears" describes the appearance of swelling of the auricular cartilage resulting in gross distortion of the auricle. The underlying pathology is inflammation of the auricular cartilage. We report a case of a patient who presented to the ophthalmology clinic with an ocular inflammation, whose subsequent diagnosis of replapsing polychondritis was clinched with the finding of "Cauliflower Ears". This case emphasizes the importance of an appropriate general examination of ophthalmic patients for early diagnosis and prompt institution of medical treatment, which may prevent life-threatening complications to the patient.