Eye South East Asia

Multiple Cranial Nerve Involvement as the Initial Manifestation of Primary Central Nervous System Lymphoma

2024-02-05T09:45:03+07:00

Background: Primary central nervous system lymphoma (PCNSL) which mostly consists of B-cell lymphomas can be described as extranodal high-grade non-Hodgkin lymphoma that is limited to the central nervous system.

Case presentation: We report a case of a newly-diagnosed retroviral-positive patient who first presented with multiple cranial nerve palsy, started with left facial asymmetry for three weeks and subsequently developed symptoms involving multiple neurological foci and eye manifestations. Blood investigations revealed a markedly elevated level of lactate dehydrogenase (LDH) and cerebrospinal fluid analysis showed the presence of Oligoclonal bands. Magnetic Resonance Imaging (MRI) of the brain and orbit revealed multiple brain hyperintense T2 lesions, enlarged extraocular muscle and perineural enhancement of the optic nerve. Diagnosis of central nervous system (CNS) lymphoma was eventually confirmed by biopsy of globus pallidus that showed diffuse large B-cell lymphoma however no specific treatment was initiated due to patient succumbed to death post biopsy.

Conclusion: Diagnosing PCNSL presents a diagnostic challenge due to its diverse clinical manifestation. It requires a high level of suspicion in immunocompromised patients presented with non-specific neurological and ophthalmic symptoms. Ideally, brain biopsy should not be delayed to establish a final diagnosis and initiate treatment.

Conflict of interest: None to declare.

Fibrin Pupillary-block Glaucoma after Uneventful Phacovitrectomy in a Patient with Proliferative Diabetic Retinopathy (PDR): A Case Report

2024-02-05T09:56:46+07:00

Background: Fibrin pupillary-block glaucoma is an uncommon complication after phacoemulsification or vitrectomy. Various treatment modalities relieving fibrin pupillary-block have been reported, such as intracameral recombinant tissue plasminogen activator (rTPA), argon–neodymium: YAG (Nd:YAG) laser iridotomy, Nd:YAG laser membranotomy, and medical dilation.

Objective: To report a patient with proliferative diabetic retinopathy (PDR) who developed fibrin pupillary-block glaucoma after uneventful phacovitrectomy and was successfully treated with Nd:YAG laser membranotomy.

Methods: Retrospective case report.

Results: The patient was a 59-year-old Thai male with PDR, epiretinal membrane and tractional macular edema in his left eye. Combined phacoemulsification with pars plana vitrectomy (PPV) was performed. On postoperative day 7, the patient presented with blurred vision from corneal microcystic epithelial edema associated intraocular pressure (IOP) spike due to the presence of fibrin membrane obstructing the pupil opening and was diagnosed with fibrin pupillary-block glaucoma. Nd:YAG laser membranotomy was performed and resulted in complete resolution of pupillary block.

Conclusion:Laser Nd:YAG membranotomy provides safe and effective resolution of fibrin pupillary-block glaucom.

A Comparative Study of Pain Intensity in Patients Receiving Cooling Botulinum Toxin (BTX) and Non-cooling BTX

2023-11-15T15:06:34+07:00

Objective: To compare pain intensity in the patients who receive both cooling Botulinum toxin (BTX) injections and non-cooling BTX injections around the periocular area.

Methods: A Prospective, randomized, single-blind controlled trial study of patients who had bilateral blepharospasm or bilateral hemifacial spasm between June 2021 and October 2022. Each patient received 10 points of BTX injections around the periocular area (randomized into 5 injection points each of cooling and non-cooling BTX respectively). A visual analog scale (VAS) was used to measure the pain intensity immediately after injection at each point. Main outcome measures: pain score and complication. cooling botox: 15-18℃, non-cooling botox: room temperature 25-27℃.

Results: A cohort of 11 patients received 55 points for cooling BTX injections and 55 points for non-cooling BTX injections. The mean pain score of the cooling BTX group was 1.91 ± 1.59, while the non- cooling BTX group had a mean pain score of 1.89 ± 1.59, the difference was not statistically significant (p = 0.887). The highest pain levels in both groups were at the upper eyelids and lower (mean pain score of 2.0).

Conclusion: There was no significant difference in the pain intensity and complication between cooling BTX and non-cooling BTX injections.

Conflicts of Interest: none

Reliability and Validity of the Thai Version – The Standardized Patient Evaluation of Eye Dryness (T-SPEED)

2024-02-05T09:39:06+07:00

Objective: To evaluate the reliability and validity of the Thai version of The Standardized Patient Evaluation of Eye Dryness questionnaire (T-SPEED)

Design: Cross-sectional descriptive study

Methods: Consisting of four steps
1) Translation of the SPEED questionnaire from English to Thai by a team consisting of an ophthalmologist and a linguist, subsequently reverse-translated from Thai to English by a separate team.
2) Content and construct validity of the translated questionnaire were evaluated by a group of ten experts.
3) Reliability of the translated questionnaire was evaluated from responses of 290 volunteers aged between 18 and 80 years of age, via Google Forms. The period allowed for response was from the 1st August 2022-31st January 2023.
4) Data analysis and evaluation of reliability and validity using item analysis and Cronbach’s Alpha Coefficient.

Results: The indexes of item-objective congruence (IOC) with a mean of 0.93. Content Validity Index scores (CVI) with a mean of 0.98. Item-level Content Validity Index (I-CVI) scores ranged between 0.9 and 1.0 with a total scale-level Content Validity Index (S-CVI) of 0.99. Data suggests this questionnaire has credible validity in both congruence and content. In addition, the data also suggests that the questionnaire has a statistically significant reliability. The group of four questions regarding frequency and regarding severity of eye dryness had a Cronbach Alpha Coefficient value of 0.775 and 0.837 respectively, which may be interpreted as credible.

Conclusion: The Thai-translated version of the SPEED questionnaire has both credible validity and reliability and can be applied to the Thai population and may be particularly beneficial in screening and follow-up of Thai patients with dry eye disease.

Evaluation of the Relationship between Serum TSH Receptor Antibody and Dry Eye Syndrome in Graves’ Disease: A Cross-sectional Study

2024-02-27T15:55:28+07:00

Background: This study aimed to evaluate the relationship between serum TSH receptor antibody levels and dry eye syndrome in Graves' disease patients without graves’ orbitopathy.

Materials and Methods: This cross-sectional study encompassed 28 eyes of 14 individuals diagnosed with Graves’ disease. Serum TSH receptor antibodies were measured followed by dry eye parameters assessed via the OCULUS Keratograph® 5M specifically Non-Invasive Keratograph Break-Up Time, tear meniscus height, and redness score. Dry eye symptoms were assessed with OSDI score.

Results: The majority of Graves’ disease patients exhibit moderate severity of dry eye symptoms (Mean OSDI score = 25.05) and high TSH receptor antibody level (Mean TRAb level = 9.61). The TSH receptor antibody level shows a significant association primarily with the redness score (r = 0.410, p = 0.030). However, no significant correlations were observed between the TSH receptor antibody level and tear meniscus height, NIKBUT, or OSDI score.

Conclusion: In Graves’ disease patients without Graves orbitopathy, a correlation was observed between Serum TSH receptor antibody levels and the redness score. However, there was no correlation between TSH receptor antibody levels and other dry eye parameters or symptoms associated with dry eye syndrome.

Conflicts of Interest: no financial interest in any products or instruments mentioned in this study.

Effectiveness of Phacoemulsification with Goniosynechialysis in Angle Closure

2024-03-28T09:58:40+07:00

Objective: To study the effect of phacoemulsification with goniosynechialysis on the reduction of intraocular pressure and the medications usage in the treatment of patients with angle closure glaucoma.

Materials and Methods: Patients who underwent phacoemulsification with goniosynechialysis between January 2019 and January 2022 were included in the study. Patient histories and records were obtained from the electronic hospital database.

Results: A total of 28 patients were included in this study, 75% being female, were enrolled in the study. The distribution of left and right eyes was equal. The average age of the patients was 59.28±8.04 years, and the mean visual acuity was Logmar 0.92±0.46. The average intraocular pressure (IOP) at baseline was 25.07±12.66 mmHg, ranging from 9 to 55 mmHg. The patients were using an average of 2.86±1.33 types of glaucoma medications. After 3 months of treatment, the average number of drops of glaucoma medications used decreased from 3.93 to 1.64 drops (P= <0.001, 95%CI [1.35,3.22]). The average intraocular pressure decreased from 25.07 mmHg to 12.75 mmHg (P= <0.001, 95%CI [7.76,16.88]), and the average number of types of glaucoma medications decreased from 2.86 to 1.53 (P= <0.001, 95%CI [0.65,2.00]).

Conclusions: Phacoemulsification with goniosynechialysis has been shown to be effective in lowering intraocular pressure in patients with angle closure glaucoma. Additionally, this procedure has the potential to decrease the number and types of glaucoma medications needed for managing the condition.

Evaluating the Correlation between Pterygium SLIT2 Grading System and OCULUS Keratography

2024-04-18T13:40:40+07:00

Background: Pterygium is known to contribute to ocular discomfort and dry eye symptoms. Traditionally, its measurement has been subjective and descriptive, relying on the attending physician’s assessment. The OCULUS K5M Keratograph offers an objective measurement, reducing bias and yielding more reproducible and reliable results. This study aims to evaluate ocular surface parameters using the OCULUS K5 Keratograph in eyes affected by unilateral pterygium and to explore the correlation with SLIT2 grading.

Method: A prospective study involved 67 participants with unilateral primary nasal pterygium. Ocular surface parameters were obtained using the OCULUS K5 keratograph and compared between unilateral pterygium eyes and their respective normal eyes. The relationship between SLIT2 pterygium grading and Keratograph parameters was also investigated.

Results: Pterygium eyes showed decreased tear break up time (TBUT) (6.76 ± 4.87 vs. 8.66 ± 5.13 seconds, p = 0.001) and increased bulbar redness (1.98 ± 0.56 vs. 1.42 ± 0.44, p < 0.0011) compared to non-pterygium eyes. High-grade SLIT2 pterygium injection was associated with shorter TBUT (low grade TBUT 5.05 ± 0.70 seconds, high grade TBUT 4.44 ± 3.38, p = 0.035). SLIT2 grading correlated significantly with bulbar redness, except for Stalker’s line.

Conclusion: Pterygium eyes displayed reduced TBUT and increased bulbar redness. High-grade pterygium was associated with shorter TBUT. Bulbar redness showed significant differences in SLIT2 grading, excluding Stalker’s line. No significant variations were observed in tear meniscus height and meibomian gland dysfunction grading.

Conflicts of interest: none

Photo Integrated Experience Challenge (PIEC): An Innovative Active Learning Method for Teaching Ophthalmology Residents

2024-04-25T09:50:18+07:00

Background: Active learning has emerged as a cornerstone in medical education, promoting superior knowledge retention and social-cognitive skills compared to traditional methods. For ophthalmology residents, developing proficiency in interpreting ophthalmic images is paramount, as over 80-90% of ocular diagnoses rely on ophthalmic images from digital slit lamp and other ophthalmic devices. In light of this, we introduce the Photo Integrated Experience Challenge (PIEC), an innovative active learning method that leverages the combined strengths of ophthalmic image diagnosis, personal knowledge and experience sharing. This research aims to evaluate the advantages and effectiveness of PIEC, along with gathering student feedback on its implementation.

Methods: PIEC class is implemented every week throughout an academic year. Each session includes 5-6 residents from first year to third year and lasts for 50 minutes. Initially, first year residents initiate the discussion by sharing their existing knowledge and observations related to pre-assigned eye disease images which are shared on the monitor. Subsequently, second and third year residents expand upon the initial insights, offering additional perspectives and integrating their personal clinical experiences about the disease. Throughout the process, the instructor helps facilitate the discussion, share expert knowledge and experience about the disease from clinical practice, and synthesize key learning points at the session’s conclusion. To objectively assess knowledge acquisition, 29 participating residents completed pre- and post-course self-evaluations on each covered topic. Additionally, we employed a feedback questionnaire to evaluate student experiences and perceptions of PIEC.

Results: This research found a statistically significant increase in residents’ self-reported knowledge acquisition, as evidenced by a jump in mean scores from 52.70% to 82.60% between the pre- and post-course evaluations (p < 0.05). This improvement was particularly pronounced in the areas of disease investigation (40.96% gain) and treatment (37.02% gain). Qualitative feedback revealed that the PIEC method fostered deeper understanding, engagement, and critical thinking. Residents reported the method being fun, easy to prepare for, and less stressful than traditional lecture-based instruction. Additionally, they felt increased confidence in communication and knowledge integration.

Conclusion: PIEC effectively enhances ophthalmology residents’ critical thinking, communication skills as well as knowledge integration with clinical experience, suggesting its potential as a valuable active learning tool in medical education.

Conflicts of Interest: Authors have no conflict of interest.