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Endogenous endophthalmitis accounts for approximately 5 - 10% of all endophthalmitis cases. We report a case of a middle-aged gentleman with underlying uncontrolled diabetes mellitus who presented with fever and generalised body weakness for one week. He was diagnosed with invasive Klebsiella syndrome based on blood culture with presence of bilateral pleural effusion, liver abscess, renal impairment and sphenoidal sinusitis. The patient developed sudden bilateral painless reduced vision on day two of admission. Ocular examination revealed bilateral severe anterior chamber reaction and severe vitritis that obscured the view of the fundus. Ocular B-scan ultrasonography showed multiple loculations in the posterior segment in both eyes. There was soft tissue density with calcification in the left sphenoid sinus on computed tomography of the orbit. He was treated for bilateral endogenous endophthalmitis with multiple intravitreal antibiotic injections, but showed no improvement. Functional endoscopic sinus surgery was performed and revealed that the left sphenoid sinus was filled with fungal balls. Following drainage of sphenoidal pus, there was resolution of vitritis and fundus examination showed features of underlying fungal infection with a “string of pearls” present along the vascular arcade of both eyes. The patient was diagnosed with bilateral endogenous endophthalmitis secondary to invasive Klebsiella syndrome with coexisting fungal endophthalmitis secondary to sphenoid mycetoma. In addition to repeated intravitreal antibiotic injections, he was also treated with systemic and topical antifungal therapy. At three months post treatment, the infection resolved and his vision improved from counting fingers to 6/36 bilaterally. Key messages: A middle-aged gentleman presented with bilateral endogenous endophthalmitis secondary to invasive Klebsiella syndrome with coexisting fungal endophthalmitis secondary to sphenoid mycetoma. A high index of suspicion is required for early diagnosis of fungal endophthalmitis.

To compare tumour necrosis factor-alpha (TNF) and interleukin (IL)-6 levels in saliva between different stages of diabetic retinopathy (DR).This comparative cross-sectional study was conducted between January 2018 and November 2020. This study included diabetes mellitus (DM) patients with no DR, non-proliferative DR (NPDR), and proliferative DR (PDR). None of the patients with DM were included in the control group. Unstimulated saliva samples were then collected. TNF-α and IL-6 levels were measured.Altogether, 120 patients were included in the study (DM without DR, 33 patients; DM with NPDR, 30 patients; DM with PDR, 32 patients; non-DM, 25 patients). The mean IL-6 level in saliva was significantly higher in the DM group (0.033 ± 0.005 pg/ml) than in the non-DM group (0.027 ± 0.001 pg/ml) (p 0.001 after adjusting for covariates). There was no significant difference in the mean salivary TNF-α between patients with DM and those without DM after adjusting for covariates. The mean IL-6 in saliva was significantly higher in the NPDR (0.036 ± 0.003 pg/ml) and PDR (0.093 ± 0.023 pg/ml) groups than in the no DR group (0.027 ± 0.001 pg/ml) (p 0.001 and p 0.001, respectively). Mean TNF-α in saliva was significantly higher in the NPDR (0.086 ± 0.022 pg/ml) and PDR (0.093 ± 0.023 pg/ml) groups than in the no DR group (0.049 ± 0.011 pg/ml) (p = 0.015 and p = 0.003, respectively).There is an association between inflammatory biomarkers in saliva (IL-6 and TNF-α) and severity of DR among patients with DM, suggesting that these salivary biomarkers are potential biomarkers for screening, monitoring, and predicting the progression of DR.

BACKGROUND: Various studies suggest that oxidative stress has a role in the etiology of diabetes mellitus (DM) and its complications. Detection of antioxidant enzymes and malondialdehyde (MDA) level in ocular fluid may provide the possible biomarkers for monitoring the progression of diabetic retinopathy (DR). The aim of this study was to compare catalase, glutathione peroxidase (GPx) and MDA levels in tears among diabetic patients with and without DR. METHODS: A cross-sectional study was conducted among type 2 DM patients. The patients were divided into three groups: no DR, non-proliferative DR (NPDR) and proliferative DR (PDR). Tears samples were collected using Schirmer strips for measurement of catalase, GPx and MDA. RESULTS: A total of 171 patients were recruited in this study (no DR, 58 patients; NPDR, 57 patients; PDR, 56 patients). There was significant difference in the mean level of GPx in tears between the three groups (no DR, 658.08 ± 115.70 U/L; NPDR, 653.78 ± 87.90 U/L; PDR, 605.31 ± 107.47 U/L, respectively) before and after adjustment for covariates (p = 0.013 and p = 0.001, respectively). Bonferroni post-hoc analysis showed PDR group had significantly lower mean GPx level than in no DR (p=0.001) and NPDR (p=0.037) after adjustment for covariates. There was no significant difference of mean catalase and MDA in the tears between the three groups before and after adjustment for covariates. CONCLUSION: This study demonstrated that diabetic patient with DR is associated with low level of GPx in tears, suggesting that this antioxidant enzyme is a potential biomarker for predicting the presence of DR.

An elderly diabetic lady presented with a painful swollen right eye and blurred vision for one week, preceded by right eye redness for six months. Her right eye best-corrected visual acuity was finger counting at 1 m. There was right eye proptosis, limited extraocular muscle movements, corkscrew vessels, chemosis and elevated intraocular pressure, but no bruit. Fever was absent. Computed tomography of the brain and orbit showed thickened extraocular muscles and intraconal fat streakiness, with normal superior ophthalmic vein and concavity of the cavernous sinus. Intravenous antibiotics resulted in limited clinical improvement. The subsequent response to oral prednisolone was dramatic, with the improvement of visual acuity to 20/60 after three doses. In cases of atypical orbital cellulitis where antibiotics fail, one should consider differential diagnoses such as orbital inflammatory disease, vascular anomalies and masqueraders. We discuss the approach to the diagnosis of acute proptosis in a diabetic patient and highlight the role of corticosteroids in idiopathic orbital inflammatory disease.

Glaucoma is a known risk factor for retinal vein occlusion (RVO). There are many reported studies among primary open-angle glaucoma (POAG) patients with RVO in Caucasians. Our objective was to report the natural course of RVO in Asian patients with POAG. A retrospective record review was conducted between January 2015 and December 2016 involving five POAG patients who developed RVO while attending regular follow-up at the Hospital Universiti Sains Malaysia glaucoma clinic (Malaysia). Three readings of intraocular pressure (IOP) were taken as pre-RVO IOP. IOP at presentation of RVO was also recorded. Clinical data including RVO management and complications were documented. All POAG patients were at the severe and end stage of the disease. None of them achieved target pressure. Median IOP at presentation was 26 ± 3.8 mmHg (SD) and the majority were asymptomatic. Systemic hypertension was present in all patients. There was deterioration of visual acuity and increased number topical medication post RVO presentation. Vigilant monitoring of IOP is important in POAG patients with systemic hypertension to prevent RVO, given that RVO in POAG is like robbing someone blind twice.

A 42-year-old man presented with generalized redness in the left eye and painless blurring of vision for four days. He also had a fever and a large left leg abscess for four days prior to the onset of eye symptoms. Visual acuity of the left eye was hand movement with a positive relative afferent pupillary defect. Conjunctiva was injected with chemosis and mild corneal haziness centrally. There was a presence of whitish fibrin covering the pupil and presence of hypopyon with anterior chamber inflammatory cells. The fundoscopic view was obscured by the presence of fibrin in the pupillary area. B-scan ultrasound showed severe vitritis with multiple loculations. He was treated as left eye endogenous endophthalmitis secondary to left leg abscess. He was given multiple intravitreal antibiotic injections together with intravenous ceftazidime and gutt. moxifloxacin. The vitreous specimen did not yield any growth. Incision and drainage were done for the left leg abscess, and yellowish pus was aspirated with negative culture. Trans-pars plana vitrectomy was performed in view of poor clinical response. However, despite that, his left visual acuity dropped to non-perception of light (NPL). The vitreous specimen taken during vitrectomy finally showed non-sporulating fungal hyphae. He was started on oral fluconazole and topical amphotericin B. His left eye remains as NPL. However, his general eye condition improved.

BACKGROUND: Progression of diabetic retinopathy post cataract surgery is related to the increased level of vascular endothelial growth factor (VEGF) in ocular fluid post operatively. The aim of this study was to compare the VEGF level in tears post phacoemulsification between non-proliferative diabetic retinopathy (NPDR) and non-diabetic patients. METHODS: This was a prospective cohort study and was conducted from June 2017 to May 2019. Patients with underlying NPDR who were planned for phacoemulsification were recruited in this study. Non-diabetic patients who were planned for phacoemulsification were included as control group. Tears samples were collected using Schirmer strip two weeks prior to operation, at day (D) 7 and D30 post phacoemulsification. Tears samples were analyzed for VEGF level. RESULTS: A total of 65 patients were recruited in this study (NPDR: 32 and control: 33). There was significant increase of VEGF levels in tears from pre operation to D7 post phacoemulsification in NPDR (p

We report a case of optic disc drusen (ODD) associated with peripapillary polypoidal choroidal vasculopathy (PCV). A 62-year-old Malay lady presented with both eye ODD and the left eye associated with peripapillary subretinal hemorrhage. Ultrasound B-scan and red-free photography confirmed the optic nerve head drusen findings bilaterally. Optical coherence tomography (OCT) of the left eye showed sharply elevated peripapillary pigment epithelial detachment with subretinal fluid. The presence of peripapillary polyps with branching vascular network in indocyanine green angiography of the left eye further confirmed the diagnosis of PCV and excluded choroidal neovascularization (CNV) secondary to ODD. Subsequently, the patient was treated with a combination of verteporfin photodynamic therapy with three monthly intravitreal ranibizumab injections. Three months after the combined treatment, OCT showed completely resolved subretinal fluid. ODD can cause compression of the subretinal vessels at the optic disc that results in retinal ischemia and release of vascular endothelial growth factor, which may trigger the development of CNV or PCV. The rarity of this combination makes it interesting to study more cases of ODD with PCV. Importantly, a thorough evaluation in distinguishing the PCV from the CNV that mimics it is crucial for early detection and prompt intervention. In this case, indocyanine green angiography (ICGA) is the diagnostic method to differentiate the PCV from CNV secondary to ODD.

الملخص: علاج التهاب القزحية الأمامية المتكرر بعد العملية الجراحية أمر صعب. نقدم هنا تقريرا عن معالجة ناجحة لحالتين بالحقن التجويفي لمنشط البلازمينوجين النسيجي المركب في حالتين من حالات التهاب القزحية الأمامية المتكرر؛ حالة التهاب القزحية الأمامية المعدي وحالة '' فوت-كويناقي-هرادا''. أُصيبت سيدة في الأربعين من العمر باحمرار في العينين وضعف الرؤية لمدة أسبوعين. كان لديها التهاب القزحية الأمامية، والتهاب الأوعية الدموية، والتهاب الشبكية، وتورم القرص البصري. وكانت اختبارات الأمصال لبكتريا بارتونيلا هنسيلي وتوكسوبلازما جوندياي موجبة. تم علاجها بالكورتيكوستيرويدات العامة على المدى الطويل والمضادات الحيوية المناسبة. كانت حالتنا الثانية رجلا سليما يبلغ من العمر ٣٠ عاما ظهر لديه احمرار غير مؤلم في العينين مع ضعف في الرؤية وصداع وطنين لمدة أسبوعين. كان هناك التهاب حبيبي في العينين مع التهاب السائل الثقيل والكورويد والشبكية مع احمرار القرص البصري. وتم تشخيصه على أنه حالة '' فوت-كويناقي-هرادا'' وتم علاجه بالكورتيكوستيرويدات العامة. نتج لدى الحالتين إعتام ثانوي في عدسة العين والماء الأزرق الذي استدعي التدخل الجراحي. أدى الالتهاب المزمن المستمر إلى تكوين غشاء ليفي سميك أمام العدسة بعد جراحة استحلاب العدسة مع زراعة عدسة جديدة. بعد ذلك أُزيل الغشاء جراحيا وتلى ذلك الحقن التجويفي لمنشط البلازمينوجين النسيجي المركب بجرعة ٢٥ ميكروغرام. كان هناك تشافي للالتهاب المستمر وتحسن كبير في حدة البصر في غضون أسبوع من الحقن. لم تُسجل أي تأثيرات جانبية في العين أو في الجسم. الحقن التجويفي لمنشط البلازمينوجين النسيجي المركب مفيد في المرضى الذين يعانون من التهاب القزحية الأمامية المتكرر بعد العملية الجراحية. في معظم الحالات، يكون التدخل الجراحي مهما لتوفير رؤية يستفيد منها المريض. يجب أن يؤخذ الحقن التجويفي لمنشط البلازمينوجين النسيجي المركب في الاعتبار عند التعامل مع الالتهابات المستمرة من أسباب مختلفة. Abstract: Management of inflammation after surgery for recalcitrant anterior uveitis is challenging. Herein, we report successful treatment using intracameral injection of recombinant tissue plasminogen activator (rtPA) in two patients with recalcitrant anterior uveitis, due to infective uveitis and Vogt–Koyanagi–Harada disease, respectively. A 40-year-old woman presented with bilateral redness and vision reduction that had persisted 2 weeks. She also had bilateral anterior uveitis, vasculitis, retinitis, and optic disc swelling. Serology was positive for Bartonella henselae and Toxoplasma gondii. She was treated using long-term systemic corticosteroids and appropriate antibiotics. Our second case; a healthy 30-year-old man with bilateral eye redness and reduced vision without pain, and associated with headache and tinnitus for 1 weeks. He showed bilateral granulomatous inflammation with vitritis, choroiditis, retinitis, and hyperemic optic disc. The patient was diagnosed with Vogt-Koyanagi-Harada disease and treated with systemic corticosteroids. Both patients developed secondary cataracts and glaucoma that necessitated surgical intervention. Persistent chronic inflammation led to the formation of a thick fibrin membrane anterior to the intraocular lens (IOL) after phacoemulsification surgery with IOL implantation. This membrane was removed surgically, and intracameral injection of rtPA (25 μg) was carried out. The persistent inflammation had resolved and visual acuity had significantly improved within 1 week of intracameral rtPA injection. There were no reported ocular or systemic side effects. Intracameral rtPA is beneficial in patients with recalcitrant anterior uveitis who have undergone intraocular surgery. In most cases, surgical intervention improves the patients' vision. Intracameral rtPA should be considered in cases of persistent inflammation of varying etiology. الكلمات المفتاحية: التهاب البارتونيلا العيني, فوت-كويناقي-هرادا, منشط البلازمينوجين النسيجي المركب, التهاب القزحية الأمامية المتكرر, التهاب الشبكية, Keywords: Ocular bartonellosis, rtPA, Recalcitrant anterior uveitis, Retinitis, Vogt–Koyanagi–Harada

Introduction Ocular tuberculosis (TB) encompasses a broad spectrum of clinical manifestations affecting different structures of the eye. It is caused by Mycobacterium tuberculosis, a great ancient organism that induces various types of diseases and unfavorable outcomes if unrecognized and not well treated. Purpose To report the clinical profile of 34 ocular TB cases observed during 6 years period in Hospital Universiti Sains Malaysia (HUSM). Method A retrospective review of medical records from 34 patients diagnosed with ocular TB in HUSM from January 2011 until December 2016. Results The mean age was 43 ± 14.6 years old. Both male and female affected in about 1:1 ratio. The majority of subjects were local Malays (91.2%). Risk factors included previous contact with pulmonary TB patients (38.2%), and patients with underlying diabetes mellitus (26.5%). Most patients showed normal chest radiography (79.4%). However they had positive Mantoux test (94.1%) and raised erythrocyte sedimentation rate (ESR) value (58.8%). Uveitis was the most common ocular manifestation of ocular TB (70.6%) while the rare ocular manifestations included optic perineuritis and optic neuritis, orbital apex syndrome, orbital cellulitis, sclerokeratitis, corneal ulcer and conjunctival abscess. All patients responded well to anti-TB treatment, but visual outcome was variable. Conclusions This review shows the diverse entity of ocular TB spectrum in an endemic area. Good clinical response to anti-tuberculous therapy supported the presumed diagnosis of ocular TB in majority of the cases., Highlights • Tuberculosis (TB) causes significant morbidity and mortality and remains a major health problem despite medical advances. • Majority primary care givers and physicians are unaware of ocular TB and frequently misdiagnose ocular symptoms. • The spectrum of ocular TB is diverse, affecting different layers and contents of the orbit and the globe. • Good clinical response to anti-TB therapy supported the presumed diagnosis of ocular TB in majority of the cases. • Ocular tuberculosis is potentially blinding if unrecognized and poorly treated.

Background . Endophthalmitis post cataract surgery is rare, but the incidence and complications are higher in diabetics. Objectives . We present 3 diabetic patients who underwent cataract surgery and developed endophthalmitis postoperatively. Material and methods . This is a retrospective case series of diabetic patients who underwent cataract surgery and developed endophthalmitis postoperatively between September 2015 and August 2016. The medical records were retrieved from the system, and data was collected. Results . The patients eventually had different visual outcomes depending on the severity of endophthalmitis. Case 1. The patient developed delayed subtle postoperative endophthalmitis at 8 weeks post cataract operation, with underlying foot cellulitis and poor blood sugar control. The patient responded well to topical and systemic antibiotics and stabilization of blood sugar. Case 2. The patient presented with delayed postoperative endophthalmitis secondary to a suture abscess of the cataract wound at 7 months post implantation of an anterior chamber intraocular lens. There was complete resolution of the infection after administration of topical, intravitreal and systemic antibiotics, with a good control of blood sugar. Case 3. The patient presented with acute severe postoperative endophthalmitis with the presence of hypopyon at day 5 following cataract surgery. There were no obvious risk factors besides poor control of blood sugar, but Streptococcus mitis was isolated from the vitreous specimen. The endophthalmitis worsened in spite of topical, intravitreal and systemic antibiotics, as well as vitrectomy. Evisceration was eventually performed for the painful blind eye. Conclusions . Although endophthalmitis following cataract surgery is rare, the incidence and complications are much higher in diabetic patients.

Highlights • Herpes zoster ophthalmicus is an uncommon clinical presentation. • Concurrent hyphema and orbital apex syndrome are rare clinical sequelae. • Hyphema is postulated due to auto immune vasculitis affecting iris vessel. • Orbital apex syndrome results from occlusive vasculitis affecting vasculature of optic nerve and extraocular muscles. • This incidence probably suggests that occlusive vasculitis occurs at more than one site in the affected dermatome., Introduction Hyphema and orbital apex syndrome occurring concurrently in a patient with herpes zoster ophthalmicus have not been reported previously. We present a case with these unique findings and discuss the pathogenesis of these conditions and their management. Presentation of case A 59-year-old Malay lady with underlying diabetes mellitus presented with manifestations of zoster ophthalmicus in the left eye. Two weeks later, she developed total hyphema, and complete ophthalmoplegia suggestive of orbital apex syndrome. She was treated with combination of intravenous acyclovir and oral corticosteroids, and regained full recovery of ocular motility. Total hyphema persisted, and she required surgical intervention. Discussion Hyphema is postulated to occur due to an immune vasculitis affecting the iris vessels. Orbital apex syndrome is probably due to an occlusive vasculitis affecting the vasculature of the extraocular muscles and optic nerve, resulting from a direct invasion by varicella zoster virus or infiltration of perivascular inflammatory cells. Magnetic Resonance Imaging of the brain is essential to exclude possibility of local causes at the orbital apex area. Conclusion Herpes zoster ophthalmicus is an uncommon ocular presentation. Managing two concurrent complications; persistent total hyphema and orbital apex syndrome is a challenging clinical situation. Early diagnosis and prompt treatment are essential to prevent potential blinding situation.

Optic perineuritis (OPN) is a subtype of optic neuritis (ON) in which the inflammatory process involves meningeal sheath surrounding the optic nerve. Clinically, OPN simulates ON. However, in contrast to ON, patient with OPN shows sparing of central vision, improves dramatically with high-dose corticosteroid, are more likely to experience recurrence after stopping treatment. We report a rare case of caecocentral scotoma observed in a female with typical ON symptoms. Her magnetic resonance imaging showed features in line with OPN. She was treated with intravenous methylprednisolone 1 g/day for five days followed by slow tapering dose of oral prednisolone for one month. Her vision improved dramatically with a resolution of visual field defect. No relapses seen within two years of follow-up.

Introduction Ocular syphilis is a sight-threatening condition. It can occur at any stage of syphilis infection, which present either with acute inflammation during the primary, secondary, and early latent stages or with chronic inflammation during tertiary infection, affecting virtually every ocular structure. This study was to report on the clinical presentation of ocular syphilis that presented to eye clinic Hospital Universiti Sains Malaysia. Methodology This was a retrospective study where medical records of ocular syphilis patients who attended eye clinic in Hospital Universiti Sains Malaysia from January 2013 to June 2017 were reviewed. Results A total of 10 patients (13 eyes) with ocular syphilis were identified out of 106 cases that presented with ocular inflammation. The mean age of presentation was 69.8 ± 6.4 years and seven of them (70%) were female. All patients were Malay and human immunodeficiency virus (HIV) was negative. The ocular manifestations included panuveitis (four eyes, 30.8%), anterior uveitis (two eyes, 15.4%), posterior uveitis (seven eyes, 53.8%) and optic neuritis (two eyes, 15.4%). Seven (53.8%) eyes presented with visual acuity of worse than 6/60, five (38.5%) eyes had visual acuity between 6/15 to 6/60, and one (7.7%) eye had visual acuity of 6/12 or better. Nine patients received an intravenous benzylpenicillin regime and one patient received an intramuscular penicillin injection. Out of 13 eyes affected, 11 (84.6%) eyes had improved visual acuity of at least one Snellen line after treatment. Visual acuity of 6/12 or better increased to four (30.8%) eyes. Conclusions Posterior uveitis was the commonest presentation of ocular syphilis in HIV-negative patients. Early detection and treatment of ocular syphilis can result in resolution of inflammation and improvement of vision.

ObjectiveDetection of vascular endothelial growth factor (VEGF) levels in ocular tissue may perhaps provide insight into the role of VEGF in the pathogenesis and progression of diabetic retinopathy (DR). The aim of this study was to evaluate the levels of VEGF in tears and serum amongst type 2 diabetes mellitus (DM) patients.MethodsA comparative cross-sectional study was conducted between August 2016 and May 2018 involving type 2 DM patients with no DR, non-proliferative DR (NPDR), and proliferative DR (PDR). Tear samples were collected using no.41 Whatman filter paper (Schirmer strips) and 5 mL blood samples were drawn by venous puncture. VEGF levels in tears and serum were measured by enzyme-linked immunosorbent assay.ResultsA total of 88 type 2 DM patients (no DR: 30 patients, NPDR: 28 patients, PDR: 30 patients) were included in the study. Mean tear VEGF levels were significantly higher in the NPDR and PDR groups (114.4 SD 52.5 pg/mL and 150.8 SD 49.7 pg/mL, respectively) compared to the no DR group (40.4 SD 26.5 pg/mL, p < 0.001). There was no significant difference in the mean serum VEGF levels between the three groups. There was a fair correlation between serum and tear VEGF levels (p = 0.015, r = 0.263).ConclusionVEGF levels in tears were significantly higher amongst diabetic patients with DR compared to those without DR and were significantly associated with the severity of DR. There was a fair correlation between serum and tear VEGF levels. Detection of VEGF in tears is a good non-invasive predictor test for the severity of DR. A large cohort study is needed for further evaluation.