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A 60-year-old female with known seropositive rheumatoid arthritis and other co-morbids, presented with right eye hypertensive retinopathy and exudative macroaneurysms. Over the years, she developed vitreous haemorrhage, macula oedema and full thickness macula hole. Fluorescein angiography showed macroaneurysms and ischaemic retinal vasculitis. Initial diagnosis was thought to be hypertensive retinopathy with macroaneurysms and retinal vasculitis secondary to rheumatoid arthritis. Laboratory investigations did not support other causes for macroaneurysms and vasculitis. Hence, delayed diagnosis of IRVAN syndrome was made after detailed review of clinical findings, investigations, and angiographic evidence. Our understanding of IRVAN continues to evolve in the face of challenging presentations. To our knowledge, this is the first reported case of IRVAN associated with rheumatoid arthritis.

Purpose: Ozurdex had shown promising anatomical and functional outcomes in managing refractory Irvine-Gass syndrome over the years. Burgeoning usage of Ozurdex has prompted the study of its related complications, particularly the anterior chamber migration of the implant. Methods: Literature reviews on the anterior chamber migration of the Ozurdex via PubMed, EBSCO, and TRIP databases were searched from 2012 to 2020. The predisposing factors, outcomes, and management of such cases were evaluated. Results: A total of 54 articles consisting of 105 cases of anterior migration of Ozurdex were included in this analysis. The vitrectomized eye and compromised posterior capsule were highly associated with this complication. About 81.9% of the cases had cornea edema upon presentation, with 31.4% of them ending up with cornea decompensation despite intervention. Although there was high intraocular pressure reported initially in 22 cases, only 2 cases required glaucoma filtration surgeries in which they had preexisting glaucoma. Numerous techniques of repositioning or surgical removal of the implant were described but they were challenging and the outcomes varied. Conclusions: A noninvasive method of manipulating the Ozurdex into the vitreous cavity via the "Trendelenburg position, external pressure with head positioning" maneuvers is safe yet achieves a favorable outcome. Precaution must be taken whenever offering Ozurdex to the high-risk eyes. Prompt repositioning or removal of the implant is crucial to deter cornea decompensation. Clinical Trial Registration number: NMRR-22-02092-S9X (from the Medical Research and Ethics Committee (MREC), Ministry of Health, Malaysia).

Aim: To determine the common causes and visual outcome after treatment among uveitis and scleritis patients., Methods: This is a retrospective cohort observational study. All consecutive clinical records of patients with newly diagnosed uveitis and scleritis over a 4-year period, from Jan. 1, 2017 to Dec. 31, 2020, were analysed. Data was collected at the presentation and included a follow-up period of one year., Results: A total of 288 patients were recruited during the study period. Anterior uveitis was the most common anatomical diagnosis (50.0%) followed by panuveitis (25.0%), scleritis (13.5%), posterior uveitis (6.9%), and intermediate uveitis (4.5%). Viral Herpes was the most common cause of infectious cases, while Vogt-Koyanagi-Harada (VKH) disease and human leucocyte antigen (HLA) B27 spondyloarthropathy were the leading causes of identifiable non-infectious cases. Majority of patients presented with unilateral, non-granulomatous uveitis with an absence of hypopyon. Anatomical locations like posterior uveitis and panuveitis, and visual acuity worse than 3/60 at presentation were the factors associated with poor visual outcomes ( P <0.05). About 60% of patients had an identifiable cause for the uveitis and scleritis, with nearly equal distribution of infectious ( n =85, 29.5%) and non-infectious causes ( n =84, 29.2%). About 14.5% of patients were clinically blind at 1y of follow-up. The most common complication in our uveitis patients was glaucoma (47.5%), followed by cystoid macula oedema (18.9%) and cataract (13.9%)., Conclusion: Uveitis and scleritis are important causes of ocular morbidity. They are potentially blinding diseases which can have a good outcome if diagnosed and treated early., Competing Interests: Conflicts of Interest: Seow ST, None; Tajunisah I, None; Lee FY, None; Lott PW, None; Reddy SC, None., (International Journal of Ophthalmology Press.)

Objective: To report a rare complication of oculomotor and trochlear nerve neuritis following botulinum toxin injection for masseter hypertrophy., Case Presentation: A previously healthy 31-year-old man presented with a two-week history of left eye (OS) ptosis and diplopia, following botulinum toxin injection over the masseter area for masseter hypertrophy at an aesthetic centre. He had no proptosis or facial asymmetry. Visual acuity was 6/6 in the right eye (OD) and 6/9 in the OS. There was anisocoria, with pupils measuring 3 mm in the OD and 5 mm in the OS but no relative afferent pupillary defect. OS appeared hypertropic in primary gaze with impaired intorsion. Extraocular movement of the OS was restricted in all gazes, except for laevoversion; that of the OD was normal. This was associated with diplopia in all gazes except on laevoversion. Both eyes' anterior and posterior segment examinations were otherwise unremarkable. Besides the oculomotor and trochlear nerve, the other cranial nerves and neurological examinations were normal. Investigations including blood and cerebrospinal fluid, magnetic resonance imaging and angiography of the brain, were normal. Our impression was left oculomotor and trochlear nerve neuritis secondary to botulinum toxin injection. He was started on oral prednisolone 1 mg/kg daily and tapered by 5 mg per week. His condition improved gradually with no residual ptosis or anisocoria after three months. Extraocular movements normalised except for minimal residual restriction on depression., Conclusion: Oculomotor and trochlear nerve neuritis can occur following botulinum toxin injection over the masseter area. Healthcare professionals should be aware of this potential complication before offering the injection., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Infectious crystalline keratopathy (ICK) is a rare corneal disease. ICK has been recognised in patients with immunocompromised cornea or post penetrating keratoplasty. Here we report a case of ICK in an apparently healthy cornea., Case Description: A 25-years old Chinese female, with no history of systemic or ocular disease, presented to the eye clinic with one-month history of right eye (RE) blurring of vision with foreign body sensation. On examination, there were dense white crystalline needle-like projections over inferior paracentral corneal stroma with intact epithelium. There was also presence of lower eyelid epiblepharon with lashes rubbing against the diseased area. Corneal scraping cultures were suggestive of bacterial infection. Patient responded well with corneal epithelium debridement, intensive topical antibiotics and epiblepharon correction to prevent further microtrauma., Conclusions: The only contributing factor for ICK in our patient was trichiasis from epiblepharon. Repetitive microtrauma caused by the eyelashes lead to direct penetration and inoculation of normal ocular flora into the corneal stroma. Clinicians need to be vigilant in ruling out other possible causes such as lid abnormalities when managing an ICK patient without apparent risk factors.

Background and Objectives: To investigate the prevalence of areas of dark without pressure (DWOP) and angioid streaks (AS) in patients with sickle cell disease (SCD)., Patients and Methods: This was a consecutive series of 77 adults with SCD., Results: DWOP appeared as multiple patches in 35 of the affected eyes and as a single lesion in 3 eyes. OCT finding demonstrated the ellipsoid layer was hyporeflective in DWOP. AS were identified in six cases (3.9%) and were bilateral in five cases. The prevalence of AS was higher with increasing age, being 67% in the patients older than age 45 years., Conclusion: The prevalence of DWOP in adults with SCD is 25% in this study, which is higher than previously reported, and the prevalence of AS is around 4%, which is midway between prior estimates. Recognition of the clinical examination and imaging features of DWOP reduce the need for additional investigation. [ Ophthalmic Surg Lasers Imaging Retina . 2021;52:620-622.] .

Background: Penicillin is the conventional treatment for all stages of syphilis, including ocular and neurosyphilis, according to the recommendations by the Centre for Disease Control and Prevention Sexually Transmitted Disease. This case series highlighted three cases of ocular syphilis which showed prompt treatment response as early as 24 h after the adjunctive intravitreal ceftazidime injection., Methods: Case Series., Results: In case 1, there was significant improvement in the vision and vitritis after 24 h of a single intravitreal ceftazidime injection. In case 2, the patient achieved his best vision after a total of three intravitreal injections in his left eye and one in his right eye. In case 3, there was a further resolution of perivascular sheathing and retinal haemorrhages seen 1 week after a single intravitreal ceftazidime injection., Conclusion: The efficacy of intravitreal ceftazidime injection as a local adjunctive therapy in ocular syphilis treatment is noteworthy. It can be considered in cases which show suboptimal or slower treatment response despite early commencement of systemic penicillin to prevent devastating ocular sequelae.

Hemolacria is a rare condition that causes a person to produce tears that are partially composed of blood. It can be a presenting feature of certain ocular and systemic conditions. Here, the authors describe an interesting case of a 12-year-old boy with an underlying beta-thalassemia trait, who presented with a 2-day history of bilateral blood-stained tears, and an episode of epistaxis. Ocular examination was normal, and syringing showed no nasolacrimal duct blockage. Systemic examination was unremarkable. Laboratory investigations confirmed type 2 von Willebrand disease. Management of hemolacria remains a clinical challenge given the rare occurrence of the disease. In this case report, the authors discuss the differential diagnosis and management approach to hemolacria., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

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.

Aims: To investigate the prevalence of sickle cell maculopathy (SCM), and associations with age, sex, genotype, proliferative sickle cell retinopathy (PSR) stage, and the impact on visual acuity., Methods: Age, sex, and visual acuity were recorded and spectral domain OCT and ultra-wide-field images of the macula and retina were reviewed in a consecutive series of 74 adults with sickle cell disease., Results: The median age was 37 years (range 19-73 years) and 36 cases (48.6%) were male. SCM was present in at least 1 eye of 40 cases (54.1%) or in 67 of all eyes (42.3%). SCM prevalence was 54.8%, 62.5%, and 25% for the HbSS, HbSC, and HbS/BThal or other genotypes, respectively. SCM was observed in 41 (39.4%) of the eyes with PSR stages 0, 1, and 2, and in 21 (51.2%) of the eyes with PSR stages 3, 4, and 5, respectively. Mild visual impairment or worse was present in 3 eyes (4.8%) with SCM but this was secondary to other pathology., Conclusion: SCM is a frequent finding in the eyes of adults with sickle cell disease. The prevalence is similar for the HbSS and HbSC genotypes and is not related to the PSR stage. High-contrast distance visual acuity is typically preserved., (© 2020 S. Karger AG, Basel.)

A 33-year-old man presented with a four-day history of redness and blurring of vision of the right eye. A clinical diagnosis of adenoviral keratitis was made with a differential of microsporidia epithelial keratitis. The patient subsequently developed nummular keratitis which was resistant to topical steroids. He continued to develop multiple recurrences of the condition. Treatment with tacrolimus ointment was started as the patient had an elevated intraocular pressure due to prolonged steroid use. Tacrolimus ointment showed a favourable outcome in the management of recurrent nummular keratitis.