A 64-year-old Malay gentleman alleged occupational injury when a malfunctioned metal hydraulic door hit on his face while unloading sand from his tipper-truck. Post-trauma, he complained of right eye (RE) pain and total loss of vision. On examination, noted RE visual acuity was unable to be assessed and left eye (LE) was 6/24 with pinhole 6/9. No eyeball could be seen in the right socket with superior orbital rim step deformity and left periorbital haematoma. Computed tomography scan of the brain and orbit confirmed displaced right eye globe into the right anterior cranial fossa with right and left multiple orbital wall fractures. He then underwent successful right eye globe repositioning. Traumatic orbital roof fracture is a rare condition. Repositioning of the eye globe was done to salvage the eye globe for a cosmetic reason and to avoid localised inflammatory reaction at the anterior cranial fossa.

AIM:To report unusual presentation and good outcome of neuromyelitis optica(NMO) in a child.METHODS:Case Report.RESULTS: An 8-year-old girl presented with 5-day history of sudden bilateral visual deterioration followed by left lower limb weakness. Visual acuity was perception to light in both eyes. Funduscopy revealed bilateral hyperaemic swollen optic discs. MRI of brain and spine revealed enhancing white matter lesions in the right frontal lobe and spinal cord at C5 level. She was diagnosed NMO and treated with intravenous methylprednisolone and tapering doses of oral prednisolone as maintenance therapy.Symptoms gradually improved 1 month after treatment. However, she presented with similar presentation 1 week after stopping oral prednisolone. MRI of brain and spine were reviewed and showed enhancing lesion in the right frontal lobe and longitudinal segment of spinal cord from C3 to C5 level. She was promptly given intravenous methylprednisolone for 5 days followed by prolonged tapering of oral prednisolone over 6 months period. After 2 months, she was able to walk and attend activities of school. Visual acuity was improved to 6/10 in both eyes and neurological examination was normal. There was no recurrence during the next year. Final visual acuity was 6/7.5 in the the right eye and 6/10 in the left eye.CONCLUSION: The diagnosis of NMO should be kept in mind although it is unusual presentation in child presented with bilateral visual loss and unilateral lower limb weakness. Early diagnosis and treatments would yield good outcome to the patient.

AIM: To report a successful intrastromal injection of amphotericin B 5mg/L in a refractory fungal keratitis.METHODS: An interventional case report RESULTS: A 48-year-old lady presented with history of redness of the right eye for one week duration followed by decrease in vision and corneal opacity for two days. There was no histow of trauma or foreign body. Examination revealed visual acuity of 6/16 with pinhole of 6/12 of the right eye. The conjunctiva was injected with minimal eye discharge. There was a full thickness stromal abscess at the paracentral area of the cornea. It was irregular,feathery margin with few satellite lesions. There was no epithelial defect noted. Hypopyon level was also seen.The left eye was normal. A presumptive diagnosis of fungal keratitis was entertained. Despite three weeks of intensive treatment with topical amphotericin B every 2 hours and natamycin every 4 hours and antibiotic cover,the lesion showed no sign of resolution. It grew larger and a new focal lesion of stromal abscess appeared at the 12 o'clock position. We decided to proceed with an intrastromal injection of amphotericin B 5mg/L in lieu of therapeutic penetrating keratoplasty. The size of the ulcer was substantially reduced with total disappearance of hypopyon. There was no ocular toxicity observed following the intervention. Patient regained her normal visual acuity of 6/6 after 2 months of intervention.CONCLUSION: An intrastromal injection of amphotericin B 5mg/L provides an alternative method of treating refractory fungal keratitis. It is also shown to be an effective and safe procedure with promising results.

A 39 years old gentleman presented with red painful right eye.He had self-inflicted an injury to his right eye with a wooden stick and he saw a vision of an old man indicating him to do so.Clinically,the right eye was moderately proptosed,complete ophthalmoplegia and the periorbital skin was severely swollen.Imaging showed right orbital cellulitis with inferior ophthalmic vein thrombosis,bilateral cavernous sinus syndromeandimpending cavernous sinus thrombosis.No intraorbital or intraocular foreign body was reported.Despite aggressive intraven ous antimicrobials,the patient's condition was not improved.Exploration done under anesthesia exposed a huge wooden stick at the inferior fornix.Patient showed a remarkable recovery after the removal of the foreign body may occur in psychiatry patient that a possibility of selfinflicted injury.A detailhistory,examinationand appropriate investigations are mandatory to reveal the correlated clinical findings with imaging studies are the most helpful guide in managing intraorbital foreign body could potentially prevent further serious morbidity or

AIM: To report a case of cryptococcus meningitis in an immunocompetent teenager that presented early with diplopia and bilateral poor vision.METHODS:A case report RESULTS:A 17-year-old boy presented with blurring of vision in both eyes and diplopia for 3 weeks. It was associated with severe throbbing headaches, nausea and vomiting. He was also having low grade fever. On physical examination he was afebrile with no sign of meningism. His vision was 6/15 in both eyes with constricted visual field. Anterior segment was normal in both eyes. Extraocular muscles movement showed bilateral sixth nerve palsies. Fundoscopy revealed bilateral hyperaemic and slightly elevated optic disc. CT scan of the brain was normal with no evidence of intracranial mass or abnormal ventricles. Lumbar puncture revealed high opening pressure >300mmH2O. Cerebrospinal fluid(CSF) microscopically and culture showed presence of cryptococcus neoformans . This case was combinedly managed with neuro-medical team. Patient was started on intravenous Amphotericin B and fluconazole. His neurological symptoms recovered after a week. His vision was improved to 6/6 in both eyes with recovery of peripheral visual field. The diplopia improved with recovery of sixth nerve palsies in both eyes. Unfortunately, patient developed nosocomial lower respiratory tract infection and was treated for the problem.CONCLUSION: This case highlights the indolent nature of cryptococcus meningitis and the fact that the overt signs of meningism may not be present even in immunocompetent person. Diplopia may be one of the early presentations of meningitis patient.

A fourteen years old Malay boy was involved in a motor vehicle accident and suffered multiple injuries. The patient was referred to ophthalmology for right periorbital haematoma, ocular examination was normal but proptosis of right eye was detected which was later associated with increase in the intraocular pressure (IOP). Direct carotid cavernous sinus fistula (CCF) was diagnosed by angiography and treated with embolization.

A 21-year-old and an 11-year-old patients presented with severe,resistant shield ulcers failed to respond to medical treatments which included topical steroids,mast cell stabilizers and antihistamines. Both of them were treated with surgical debridement of the ulcer,supratarsal injection of triamcinolone acetonide,topical cyclosporine 0.5g/L and ketotifen fumerate 0.25g/L. The ulcers healed well after three weeks. Topical cyclosporine was discontinued after two months in both patients. They were symptom free with no recurrence for six months. Combination of surgical debridement of the ulcer,supratarsal injection of triamcinolone acetonide,topical cyclosporine 0.5g/L and ketotifen fumerate 0.25g/L are effective as the treatment option in managing patients with severe vernal shield ulcer.KEYWORDS: vernal shield ulcer; surgical debridement; supratarsal injection of triamcinolone acetonide; cyclosporine; ketotifen fumerate

A 25-year man presented with symptom of photophobia and tearing in the right eye for 2 months duration. It was associated with painless gradual reduced vision. There was a history of hammering on a metal object prior to that. Ocular examination revealed signs of mild anterior uveitis due to a retained metallic intralenticular foreign body. Conjunctiva was white. Computed Tomography (CT) scan of the orbit confirmed presence of a single intraocular foreign body. The condition is misleading and can be easily overlooked. A detailed history and clinical examination are mandatory in this misleading situation.

INTRODUCTIONRefractive error remains one of the primary causes of visual impairment in children worldwide, and the prevalence of refractive error varies widely. The objective of this study was to determine the prevalence of refractive error and study the possible associated factors inducing refractive error among primary school children of Malay ethnicity in the suburban area of Kota Bharu, Kelantan, Malaysia.

MATERIALS AND METHODSA school-based cross-sectional study was performed from January to July 2006 by random selection on Standard 1 to Standard 6 students of 10 primary schools in the Kota Bharu district. Visual acuity assessment was measured using logMAR ETDRS chart. Positive predictive value of uncorrected visual acuity equal or worse than 20/40, was used as a cut-off point for further evaluation by automated refraction and retinoscopic refraction.

RESULTSA total of 840 students were enumerated but only 705 were examined. The prevalence of uncorrected visual impairment was seen in 54 (7.7%) children. The main cause of the uncorrected visual impairment was refractive error which contributed to 90.7% of the total, and with 7.0% prevalence for the studied population. Myopia is the most common type of refractive error among children aged 6 to 12 years with prevalence of 5.4%, followed by hyperopia at 1.0% and astigmatism at 0.6%. A significant positive correlation was noted between myopia development with increasing age (P <0.005), more hours spent on reading books (P <0.005) and background history of siblings with glasses (P <0.005) and whose parents are of higher educational level (P <0.005). Malays in suburban Kelantan (5.4%) have the lowest prevalence of myopia compared with Malays in the metropolitan cities of Kuala Lumpur (9.2%) and Singapore (22.1%).

CONCLUSIONThe ethnicity-specific prevalence rate of myopia was the lowest among Malays in Kota Bharu, followed by Kuala Lumpur, and is the highest among Singaporean Malays. Better socio-economic factors could have contributed to higher myopia rates in the cities, since the genetic background of these ethnic Malays are similar.

Child ; Cross-Sectional Studies ; Female ; Follow-Up Studies ; Humans ; Malaysia ; epidemiology ; Male ; Prevalence ; Refraction, Ocular ; Refractive Errors ; complications ; epidemiology ; physiopathology ; Retrospective Studies ; Schools ; Suburban Population ; statistics & numerical data ; Vision, Low ; epidemiology ; etiology ; physiopathology ; Visual Acuity

AIM: To report a rare case of severe contact lens related fungal keratitis due to fusarium sp, which not only was successfully treated with therapeutic penetrating keratoplasty but also aided in the confirmation of diagnosis. METHODS:Case report.RESULTS: A 39-year-old private clerk Malay lady who wore extended wear soft contact lens for the past 18 years, presented with acute right eye pain and redness for 10 days duration. Ocular examination showed multiple round feathery paracentral corneal ulcers with presence of minimal hypopyon. Clinical diagnosis of presumed fungal keratitis was made. She was treated with broad spectrum topical antibiotics and antifungal agents after repeated corneal scrapping was negative either for fungi or for the bacteria. However, she developed deterioration of the right eye keratitis. Other topical and systemic antifungal agents were instituted. Unfortunately the right corneal ulcer became further deteriorating. Finally a therapeutic penetrating keratoplasty has done in order to preserve the globe and limit the infection after one and a half months of presentation. The diagnosis and the etiology agent were only confirmed based on histopathological examina-tion and polymerase chain reaction (PCR) from corneal button revealed fusarium sp.CONCLUSION:This case highlights the rare case of fusarium sp as an etiology of severe contact lens related fungal keratitis. This case also illustrates the challenge in managing fungal keratitis. Therapeutic penetrating keratoplasty is the ultimate choice in controlling further infection and perserving the globe.