Sinonasal Lymphoma Presenting as Cavernous Sinus Syndrome: Case Report and Review of the Literature

A 37-year-old man presented with a 1-week history of diplopia. He was under investigation by otorhinolaryngology for left sinonasal malignancy after imaging of the paranasal sinuses had revealed a large homogenous mass in the left nasal cavity. His visual acuity was 6/9 in each eye with no relative afferent pupillary defect. The left pupil, though was mid-dilated and unresponsive to light. He had a left-sided ptosis. Extraocular movements of the left eye were restricted in all directions of gaze and there was with limited abduction, dextroelevation and dextrodepression of the right eye. A trans-nasal biopsy revealed extranodal natural killer/T-cell lymphoma. Further imaging showed a large enhancing nasopharyngeal mass with intracranial extension to the cavernous sinuses and local infiltration together with intracranial abscesses. The patient was started on empirical intravenous antibiotics and supportive treatment. While awaiting institution of lymphoma chemotherapy, he died. The involvement of the cavernous sinus in sinonasal lymphoma represents an advanced stage. This case highlights that lymphoma should be considered in any patient presenting with a cavernous sinus syndrome and sinonasal disease.

Comparative cohorts of retinopathy of prematurity outcomes of differing oxygen saturation: real-world outcomes

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.

Facial nerve palsy in otitis externa: A red flag?

Otitis externa is an infection of the external auditory canal. It rarely results in facial palsy except in severe cases such as necrotizing otitis externa, which is a life-threatening invasive infection of the external auditory canal. Early recognition with prompt and appropriate treatment of necrotizing otitis externa is crucial to prevent more sinister complications. Here we report a case of an elderly gentleman who presented with otitis externa and developed facial palsy a month later. We identified possible problems that may have led to the complication so that such an occurrence can be prevented in the future.

Visual outcomes after Phacoemulsification with Intraocular Implantation surgeries among patients with and without Diabetes Mellitus

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.

"Mummy, my eyelids are heavy": A case series of juvenile myasthenia gravis

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.

Central corneal thickness changes and horizontal corneal diameter in premature infants: A prospective analysis

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.

Ocular perfusion pressure and ophthalmic artery flow in patients with normal tension glaucoma

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, χ², 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.

Ocular Tuberculosis Initially Presenting as Central Retinal Vein Occlusion

A 23-year-old man presented with central retinal vein occlusion. The retinal haemorrhages worsened and signs of retinal vasculitis appeared later as vision dropped from 6/60 to Counting Fingers. No signs of systemic disease were observed. Routine Mantoux test and chest radiograph were negative for tuberculosis. Fundus flourescein angiogram confirmed presence of retinal vasculitis. Both systemic and topical corticosteroid therapy were ineffective. Polymerase chain reaction analysis of vitreous fluid showed presence of Mycobacterium tuberculosis. A full 6-month course of antituberculosis therapy was given and inflammation subsided. Vision improved to 3/60. This is a rare case of ocular tuberculosis without evidence of systemic infection, presenting first as a central retinal vein occlusion.

Retinopathy of prematurity in extremely low birth weight infants in Malaysia

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.

Arterial occlusion following embolization of an orbital arteriovenous malformation. A case report

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.

The Jarisch-Herxheimer reaction in ocular syphilis

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" in a patient with anterior uveitis

"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.