Rheumatoid arthritis (RA) is a multisystemic autoimmune disease which can be associated with visual threatening ocular manifestations. Common ocular associations with RA include necrotising scleritis and peripheral ulcerative keratitis (PUK). Optic nerve involvement otherwise is uncommon, especially as a presenting feature of RA. We report a rare case of recurrent bilateral retrobulbar optic neuritis (ON) with progressive visual deterioration as an early manifestation of seronegative RA. This case posed diagnostic and management challenges due to its unusual presentation and initially inconclusive investigations. The patient was diagnosed with seronegative RA three years after the first eye presentation. Her RA disease activity score (DAS-28) improved after treatment with a disease-modifying anti-rheumatic drugs (DMARDs), and her ON attacks have been controlled since then. However, her visual acuity, visual field and colour vision remained poor after multiple ON attacks. Multidisciplinary care is key to managing such a patient’s condition and its potential disease complications.

A white-eyed blowout fracture is an orbital floor fracture associated with restriction of ocular motility (suggestive of orbital content entrapment) but with minimal or absence of signs of soft tissue trauma. It can lead to significant patient morbidity. This case involved an 8-year-old boy with a white-eyed blowout fracture following facial trauma. He presented with binocular diplopia and a history of recurrent episodes of vomiting after the trauma and was referred to our centre for a suspected head injury. Visual acuity in both eyes was 6/9. Examination showed minimal left periorbital haematoma with left eye motility restriction on superior and medial gaze associated with pain. CT scan of the orbit showed left orbital floor fracture with minimal soft tissue entrapment. He underwent urgent open exploration of the left orbit and release of orbital tissue entrapment. Post-operatively, the left eye motility restriction improved significantly with resolution of diplopia. In conclusion, a high index of suspicion is crucial in diagnosing paediatric white-eyed blowout fractures due to lack of external ocular signs.
Diplopia

Background: A diagnosis of ankylosing spondylitis (AS) is challenging and often delayed despitebpatients being symptomatic. Low back pain is the most common initial symptom, appearing in the second and third decades of life. Acute anterior uveitis (AAU) occurs much later in the course of the disease, often when the destruction of the spine is already debilitating. Objective: Here, we report three cases of AS that were diagnosed after the patients developed AAU. Methods: A case series illustrated AAU leading to the diagnosis of AS years after the initial episode of low back pain. A comparison of the clinical presentation, diagnosis, and outcomes was also illustrated. Result: We report three cases of acute anterior uveitis (AAU)-associated AS diagnosed only after many visits to the primary health care provider with the complaint of chronic low back pain. All three patients had irreversible radiological changes upon diagnosis of AS. The AAU resolved with topical steroids, and one patient developed cataract. Conclusion: A high index of suspicion of AS in a young adult with chronic back pain before the development of AAU may prevent further functional loss and provide a better prognosis. Diagnosis of AS following AAU is not only associated with dependency but also may rob the vision of a young adult.

Herpes zoster optic neuropathy (HZON) is a rare manifestation of herpes zoster ophthalmicus (HZO). It is a potentially blinding condition. We report a case of an immunocompetent patient with HZON following keratouveitis during the course of treatment. A 33-year-old gentleman presented with left eye (LE) worsening of visual acuity (6/9 reduced to 6/24) despite on treatment for HZO keratouveitis. It was associated with pain on ocular movement and central scotoma. He was on systemic acyclovir and topical corticosteroids prior to current complaint. Fundoscopy showed left optic disc swelling with impaired optic nerve functions. Diagnosis of left optic neuritis secondary to HZO was established in view of close temporal relationship with occurrence of cutaneous herpes zoster. Systemic corticosteroids was commenced. The patient had obtained good visual outcome at two months. Early referral for ophthalmology assessment is crucial to establish diagnosis of HZON and prompt initiation of treatment may preserve vision.

The School of Medical Sciences of Universiti Sains Malaysia (USM) is the launching pad for this journal. From the school’s humble beginning at the USM Main Campus in Pulau Pinang, Malaysia, it has grown in stature at its current location in the USM Health Campus, Kubang Kerian, Kelantan, Malaysia. Commemorating its 40th anniversary, this editorial aims to recollect, although not exhaustively, the wealth of returns for the USM, as well as for the nation, which the school has managed to deliver in that period. Resolute to its vision and mission, this article highlights the outstanding accomplishments in various core aspects of the school’s academic, research and professional growth as we continually strive to train globally competitive and compassionate medical graduates, medical specialists and scientists, skilled to serve nation’s needs and broader markets worldwide. Currently guided by the Malaysian Higher Education Blueprint (2015–2025), the school shall remain ingenious in its duties in the many more years to come, as we head for a world-class trajectory.

AIM:To compare the pattern electroretinogram (PERG) and pattern visual evoked potential (PVEP) between obstructive sleep apnoea (OSA) patients and controls.METHODS: This was a prospective cross-sectional study involving 40 OSA patients and 31 control subjects in Hospital Universiti Sains Malaysia.Patients with a confirmed diagnosis of OSA who had no ocular pathology were randomly selected to participate in the study.The apnoea-hypopnoea index (AHI) was obtained from their records and used for stratification of OSA severity.Electrophysiological tests (PVEP and PERG) were performed on each patient by a trained technician in the electrophysiology laboratory of the Department of Ophthalmology, USM.The results obtained were recorded as median values.Data analysis was done using IBM Statistics Version 21.0.RESULTS: Among OSA patients, we observed a significant reduction of the PERG amplitude P50 (P<0.001) and the PVEP amplitude P100 (P<0.001) compared to the control group.OSA patients also had a significant increase in PVEP time to peak P100 (P=0.003) and time to peak N75 (P=0.004).However, no significant differences were detected in PERG time to peak between OSA patients and controls.There were likewise no significant differences in PVEP or PERG between OSA patients with different disease severity.CONCLUSION: OSA patients have significant abnormalities in PVEP amplitude and time to peak, as well as PERG amplitude.This may reflect subclinical optic nerve dysfunction in OSA.Further research is needed to determine the association between the severity of OSA and the degree of optic nerve dysfunction.

AIM: To identify factors predicting visual improvement post vitrectomy for sequelae of proliferative diabetic retinopathy (PDR).METHODS: This was a retrospective analysis of pars plana vitrectomy indicated for sequelae of PDR from Jan.to Dec.2014 in Hospital Sultanah Bahiyah,Alor Star,Kedah,Malaysia.Data collected included patient demographics,baseline visual acuity (VA) and post-operative logMAR best corrected VA at 1y.Data analysis was performed with IBM SPSS Statistics Version 22.0.RESULTS: A total of 103 patients were included.The mean age was 51.2y.On multivariable analysis,each pre-operative positive deviation of 1 logMAR from a baseline VA of 0 logMAR was associated with a post-operative improvement of 0.859 logMAR (P<0.001).Likewise,an attached macula pre-operatively was associated with a 0.374 (P=0.003) logMAR improvement post vitrectomy.Absence of iris neovascularisation and absence of post-operative complications were associated with a post vitrectomy improvement in logMAR by 1.126 (P=0.001) and 0.377 (P=0.005) respectively.Absence of long-acting intraocular tamponade was associated with a 0.302 (P=0.010) improvement of logMAR post vitrectomy.CONCLUSION: Factors associated with visual improvement after vitrectomy are poor pre-operative VA,an attached macula,absence of iris neovascularisation,absence of post-operative complications and abstaining from use of long-acting intraocular tamponade.A thorough understanding of the factors predicting visual improvement will facilitate decision-making in vitreoretinal surgery.

AIM:To evaluate if early ethambutol toxicity can be detected by comparing pre-and post-treatment anatomical and visual function using retinal nerve fiber thickness,pattern visual evoked potentials and conventional optic nerve function tests.METHODS:This was a prospective study involving 72 eyes of 36 patients treated with ethambutol according to directly observed treatment short-course(DOTS) strategy in Hospital Universiti Sains Malaysia,Kelantan,Malaysia.The visual acuity and optic nerve function tests were performed by a single investigator.Likewise,Humphrey automated perimetry,optical coherence tomography (OCT) measurement of the retinal nerve fibre layer (RNFL) and pattern visual evoked potential (PVEP) were performed by a single technician.The examinations were performed before initiating ethambutol treatment and 3mo after that.RESULTS:There was no change in visual acuity,colour vision,light brightness,red saturation and fundus findings pre and post ethambutol.However,there was a statistically significant deterioration in the mean deviation of the visual field post treatment (P=0.010).There were also significant changes on OCT and PVEP,with increased RNFL thickness in all quadrants (P＜ 0.05) and PVEP delayed P100 peak latency and amplitude (P＜0.001).CONCLUSION:Ethambutol toxicity is a known complication of tuberculosis treatment.Early detection of this toxicity may prevent severe irreversible visual loss.The use of OCT to detect RNFL thickness and PVEP to assess P100 latency and amplitude can assist in the detection of subclinical anatomical and visual function changes prior to development of abnormalities on conventional optic nerve function tests.

Background: A thymectomy is considered effective for patients with myasthenia gravis (MG). Although a few studies have described the role of a thymectomy in the treatment of MG in Asians countries, there are no published data on the application of this surgical approach for MG in Malaysia. We aimed to describe the clinical outcomes of MG patients who underwent a thymectomy and the factors affecting these outcomes. Methods: This was a retrospective study involving 16 patients with MG who underwent a thymectomy at the Hospital Universiti Sains Malaysia (HUSM) from January 2002 until December 2012, with a follow-up period ranging from 3–120 months. Results: The study consisted of 16 patients aged 22–78 years, 10 of whom were males. The overall remission/improvement rate was 87.5%, and the rate of clinical outcomes classified as unchanged/ worsened was 12.5%. Thymomamatous or non-thymomamatous MG, histology features, Osserman stage and the duration of follow-up were not significant prognostic factors. Post-operative mortality was 6.2% (1 of 16 patients died of septic shock). Conclusion: A thymectomy seems to be an effective treatment for MG, with low surgical morbidity. Patients with a lower Osserman stage and those with/without thymomas had favourable outcomes.

Migraine with aura is one of the major subtypes of migraine, and can be associated with ischaemic brain infarction. Use of oral contraceptive pills (OCPs) increases the risk of infarction in this type of migraine. Seizures and migraine also have a complex relationship, one element of which is migrainetriggered seizures. We report a case of bilateral occipital lobe infarction and migraine-triggered seizures, most likely precipitated by oral contraceptive pills (OCPs) in a patient with migraine with visual aura. OCPs, triptans and ergotamines should be used cautiously in these patients. Methods of birth control other than OCPs should be considered.