Hospital Shah Alam Newsletter

CRC HOSPITAL SHAH ALAM NEWSLETTER

VOLUME 1, ISSUE 1 NOVEMBER 2017 In this issue: 2018 Words from the Director HSAS 2 Words from the Head of CRC 2 HSAS Venue: Introduction to CRC 2/19 CRC HSAS EVENTS 2017 3 HOSPITAL SHAH ALAM Ophthalmology Research Day 4-12 2017 Contributions & Achievements 13-17 of HSAS Clinical Audit 18

Clinical Research Centre, Hospital Shah Alam, Level 2 Tel: 035526300 (ext-3304/3305) Fax: 03 –55263217 Email: [email protected] 1ST CRC HOSPITAL SHAH ALAM RESEARCH DAY OPHTHALMOLOGY RESEARCH DAY 2017 INCONJUNCTION WITH 6TH SELANGOR RESEARCH WEEK 17TH-18TH August 2017 J m HOSPITAL SHAH ALAM Research Officiated by:

Datin Sri Dr. Asmah binti Samat Deputy Director of Medical Development, MOH

Winners Free Paper Competition:

1st Place: Poster Competition: Dr Faradatul Aisyah Abdul Aziz Success Rate & Complication of Augmented Trabeculetomy in 1st Place: Hospital Raja Perempuan Zainab II at Dr Chow Kit May 2 years. Anti Gq1b Antibody Syndrome : A Case Series 2nd Place: Dr Goh Hui Yin 2nd Place: Descemet's Stripping Automated Dr Valarmathy Vaiyavari Endothelial Keratoplasty (DSAEK): Recurrent Corneoscleral Cyst – Hospital Sungai Buloh Experience A Rare Occurrence 3rd Place: 3rd Place: Dr Nur Hanis Binti Yusri Dr Jacqueline Ting The Kuala Pilah Cluster Cataract Spontaneous Expulsive Study: The Changing Trend in Patient Suprachoroidal Haemorrhage In Blind Demography.

Page 4 Page 5 TOP 10 ABSTRACTS FOR ORAL COMPETITION

Comparison of smartphone wireless videography system to the conventional video recording system Successful Use of Intravitreal Tenecteplase for Management of Submacular Haemorrhage - A Case Series for ocular surgery Lee WY, Teh WM, Ling KP, Haslina MA Chan Jan Bond 1, Chong Wern Yih 2,3, Logeswari Krishna 4,5, Shatriah Ismail 2. Department of Ophthalmology, Hospital Sultanah Bahiyah, Alor Setar, Malaysia 1 Department of Ophthalmology, Hospital Shah Alam, Selangor; 2 Department of Ophthalmology, Universiti Sains Malaysia Kampus Kesihatan, Kelantan; 3 Department of Ophthalmology, Hospital Klang, Introduction:Tenecteplase (TNKase) is a recombinant tissue plasminogen activator (rTPA) indicated for acute Selangor; 4 Department of Ophthalmology, Hospital Melaka, Melaka; 5 Department of Ophthalmology, myocardial infarction. Its use in ophthalmology is off-label, but promising. This study was a retrospective Pusat Perubatan Universiti Malaya, Kuala Lumpur. clinical case series of six eyes treated with intravitreal TNKase (50mcg/0.1ml) for submacular haemorrhage of varying causes. We would like to share our experience and patient outcomes of using TNKase. Outcome Introduction: To compare smartphone videography system to conventional video recording technique in measures evaluated include anatomic displacement of submacular blood, change in visual acuity, and terms of video quality and cost effectiveness. possible adverse events. Methodology: This is a pilot, comparative observational study, involving patients from Hospital Tuanku Case Series:Six patients received intravitreal TNKase for submacular haemorrhage secondary to various Ja’afar Seremban ophthalmology department requiring cataract surgery. Ten surgical procedures were underlying pathologies, including idiopathic polypoidal choroidal vasculopathy in four eyes, and ruptured recorded simultaneously using both videography systems, out of which 10 seconds of the video was macroaneurysm and trauma in one eye each. In five of the six cases, TNKase was given in conjunction with sampled and evaluated by 50 medical personnels (doctor vs non-doctor). Both sample videos intravitreal perfluoropropane pneumatic displacement. Complete resolution of blood was achieved in five (conventional video and smartphone) were viewed simultaneously by viewer for 10 seconds and cases, while one developed a breakthrough vitreous haemorrhage. All patients either maintained or subsequently, the assessor graded the video using modified Absolute Category Rating (ACR) labeled as improved on their final visual acuity, except for the one with vitreous haemorrhage requiring vitrectomy. “bad”, “poor”, “fair” , “good”, and ‘excellent” and they were translated to Mean Opinion Score (MOS) Lesson Learnt:Intravitreal TNKase as an adjunctive therapy in displacement of submacular haemorrhage has ranging from 1 to 5. The cost of each videography system was calculated and compared. proven to be safe, with favourable outcome. Result: A total of 27 doctors and 23 non-doctors participated in the study. Smartphone videography had a Discussion/Conclusion:Despite the limited evidence base, we believe that intravitreal TNKase can be used in higher MOS value compared to conventional one in both groups (Doctor 4.1 vs 3.47, p = 0.03 ; non-doctor select patients with submacular haemorrhage to achieve a favourable outcome. Further studies are 4.44 vs 3.83, p <0.001) and combined group (4.22 vs 3.65, p <0.001). Smartphone videography system warranted to determine the efficacy and safety profiles of TNKase, as well as establish appropriate dosing was also cheaper than the conventional. regimens and other ocular routes of administration. Conclusion: Smartphone videography system, offers better video quality & cost effectiveness. It can help hospitals or clinics with no conventional video recording system to record ocular surgery.

Pediatric Cataract Surgery in Malaysia- A Review of Visual Outcomes Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK): Hospital Sungai Buloh Experience LIM SEE THENG1, FIONA LEE MIN CHEW2, SURIYA EH QURUT 3, IZZAIFA HASSAN3, SUNDER RAMASAMY3, GOH HUI YIN, K JOHN MATHEN, SHAMALA RETNASABAPATHY JAMALIA RAHMAT3 Department of Ophthalmology, Hospital Sungai Buloh 1 Department of Ophthalmology, Universiti Kebangsaan Malaysia UKM, 2 Department of Ophthalmology, Hospital Selayang, 3 Department of Ophthalmology, Hospital Kuala Lumpur HKL Introduction: Corneal endothelial dysfunction is a significant cause of progressive blurring of vision. Over the past decade, there has been a revolutionary change in the treatment of corneal endothelial disease. Introduction:Outcomes of pediatric cataract surgery vary with cataract complexity, ocular growth, Cornea transplant surgical techniques have been refined to provide patients with faster recovery rate, associated ocular conditions and patient compliance to post-operative visual rehabilitation. Little is known lower corneal graft complications as well as better visual outcome. regarding the visual outcomes of non-traumatic pediatric cataract surgery in Malaysia. This study documents Methodology: This is a single centre, retrospective study conducted from December 2013 to November the visual outcomes of non-traumatic pediatric cataract surgery performed in a tertiary referral center in 2016. A total of sixty eyes of fifty-seven participants with corneal conditions such as pseudophakic bullous Malaysia. keratopathy, Fuch’s endothelial dystrophy and endothelial graft failure after corneal transplant Methodology:Case notes of all patients aged 12 years and below who underwent cataract surgery from underwent DSAEK performed by nine surgeons in Hospital Sungai Buloh. The participants were followed January 2010 to December 2015 in HKL were reviewed. Patients were recruited if they had primary cataract up every six months. The outcome measures studied included best-corrected visual acuity, graft surgery and a minimum of 6 months post-operative follow-up. Data collected included subjects’ attachment success rate and its associated complications. demographic details, past medical conditions and ocular examination findings. Intra-operative and post- Results: There was a significant improvement in the visual outcome of 87% of the participants. 90% of operative ocular findings at 1, 6 months and 1 to 5 years were documented. this surgery had a successful graft attachment rate. The remaining 10% of the participants required graft Results: A total of 111 subjects were recruited. The mean age at diagnosis and at surgery was 29.97(SD: rebubbling. Nine out of the sixty eyes had primary graft failure. Three of the nine patients underwent 32.49) months and 33.14(SD:33.47) months respectively. Males represented 55%(61/111) of subjects. repeat DSAEK and one of them achieved a satisfactory visual outcome of 6/12. Only one eye was Bilateral cataracts were found in 63.1%(70/111) subjects. Congenital cataract represented 78.4%(87/111) of converted to PK as there was a perforation of the donor cornea during microkeratome dissection. the cataracts. Pre-operative mean visual acuity was 1.6 (SD: 1.07) LogMar units. Intra-operative Conclusion: Endothelial keratoplasty is a minimally invasive surgery that offers excellent visual outcome complications were noted in 17% (19/111) subjects. Intraocular lens was implanted in the capsular bag for for patients with corneal endothelial dysfunction. It should be considered as the surgery of choice for 94.6%(105/111) subjects. The mean duration of follow-up was 29.71(SD: 18.78) months. At one month these patients in a suitable healthcare setting. review, 60.3%(67/111) subjects achieved spherical power within 1.0D of targeted refraction. At final review, the mean visual acuity was 0.52(SD:0.47) LogMar units . Conclusions: There is room for improvement to enhance visual outcomes of pediatric cataract surgery in Malaysia. Page 6 Page 7 Words from the Director of Hospital Shah Alam Assalamualaikum, Salam Sejahtera. CRC HSAS Events 2017 It is of paramount important that we as clinicians understand the important of research undertaking. Research opportunities occur every day across INTRODUCTION TO CLINICAL 6-8.2.17 our healthcare system. Health professionals, whilst in pursuit of clinical RESEARCH excellence, should be involve in research undertaking. With the help of CRC, a continuous commitment is established, that encourages and BASIC STATISTICAL COURSE 11-12.7.17 supports every research journey. I hope HSAS can increase its research output. I want to congratulate those whom had contribute to the outcome GOOD CLINICAL PRACTICE 24-26..7.17 and continue to increase HSAS publications and presentations at not only local but the national and international arena as well. Datin Paduka Dr. Hasni binti Hanapi ORAL & POSTER PRESENTATION 22.8.17 WORKSHOP Head of CRC Hospital Shah Alam Assalamualaikum & Salam Sejahtera. It is my great pleasure to be part of OPHTHALMOLOGY RESEARCH DAY 17-18.8.17 CRC Hospital Shah Alam. CRC HSAS serves as a local coordination centre In Conjunction with 6th Selangor Research Week for research activities and training related to research. It has become a One Stop Centre to meet all the clinical research solution. Operating since May 2016, Hospital Shah Alam is committed to contribute and enhance health CLINICAL AUDIT WORKSHOP: care by promoting and supporting the importance, quality, safety and I. Introduction to Clinical Audit 16-17.2.2017 efficiency of clinical research. I do hope there will be an increasing trend of II. Data Review and Remedial Measures 18.4.2017 Investigator Initiated Research and Investigator Sponsored Research in the III. Presentation 12.9.2017 coming years. I hope many will benefit from this issue and are inspired by the achievements of our fellow colleagues. CLINICAL AUDIT COMPETITION 20.9.2017 Dr. Hjh Nor Fariza binti Ngah HOSPITAL LEVEL

CRC Hospital Shah Alam MEDICAL WRITING WORKSHOP 31.10.2017 Head Dr. Hjh Nor Fariza binti Ngah Manager Dr. Siti Sabrina binti Kamarudin Administrative Assistant Ms. Nursuhada binti Abd. Rahman Registered Nurse SN Nuramnani binti Shahrin

Vision Mission

To become the leading To improve patients’ health clinical research organisation outcomes through ethical and in Asia quality clinical research Roles • Facilitates Investigator Initiated Research (IIR) and Industry Sponsored Research (ISR) • Facilitates feasibility studies • Conduct research related trainings • Promotes research activities • Provides assistance in registration of research via NMRR • Coordinates research consultation clinic & statistical consultation clinic Page 3 Page 2 TOP 10 ABSTRACTS FOR ORAL COMPETITION Vernal Keratoconjunctivitis: Remodeling Ocular Changes In Children From Hospital Universiti Sains Malaysia TENGKU-FATISHAH AMIR 1, AMEILIA AHMAD 1, SHATRIAH ISMAIL 1 Prevalence of Dengue- Related Fundus and Macular Optical Coherence Tomography (OCT) Findings among 1 Department of Ophthalmology, Hospital Universiti Sains Malaysia Inpatients in a Regional Referral Hospital MEE AI LOH 1, MEI FONG CHONG 1, UMI KALTHUM MN 2, HONG BEE KER 3 1 Department of Ophthalmology, Hospital Raja Permaisuri Bainun; Introduction: To assess the remodeling ocular changes in patients with vernal keratoconjunctivitis (VKC) 2 Department of Ophthalmology, Universiti Kebangsaan Malaysia UKM; in Hospital Universiti Sains Malaysia 3 Department of Internal Medicine, Hospital Raja Permaisuri Bainun Methodology: Retrospective chart analysis of 30 patients with VKC seen from June 2013 to June 2014. ResultA total of 30 patients’ records were reviewed and revealed most patients were presented in Introduction: Dengue is endemic in Malaysia. The study investigated the prevalences of dengue-related prepubertal age with male preponderance. Itching and redness are frequently encountered symptoms fundus and macular optical coherence tomography (OCT) findings, and the spectrum of dengue retinopathy with palpebral papillae was the commonest sign, followed by mucous discharge, Horner Trantas dots, among inpatients in a Malaysian tertiary hospital. The associations between platelet count and haematocrit limbal thicknening and lastly perilimbal conjunctival pigmentation. Majority of the patients had level with dengue-related fundus and macular OCT findings were also investigated. palpebral type of VKC with chronic perennial form seen in 16.7%. Ocular surface remodeling secondary Methodology: This was a cross-sectional study conducted from June to August 2015. Participants to VKC leads to various complications such as corneal scar and shield ulcer; which were found in 30% of underwent a comprehensive ocular examination. Examination included, a best-corrected distance and near patients respectively followed by peripheral corneal vascularization in 13.3%, limbal stem cell deficiency visual acuities, standard black-on-white Amsler chart testing, pupillary light-reflex, fundus examination, in 6.7% and acquired ptosis in 3.3%. However none had keratoconus. Complication in related to dilated fundus photographs and OCT of the macula. treatments, for instance, steroid-induced glaucoma was seen in 2 patients but nil of them had develop Results: A total of 134 patients were included in the study. The prevalence of dengue-related fundus cataract. findings and macular OCT findings among the patients were 35% (95% CI: 27%, 43%) and 13% (95% CI: 8%, Conclusion: Smartphone videography system, offers better video quality & cost effectiveness. It can 19%) respectively. Scotoma (p < 0.001), near vision disturbance (p = 0.04) and abnormal Amsler findings (p < help hospitals or clinics with no conventional video recording system to record ocular surgery. 0.001) were significant associated with patients presence of macular OCT abnormalities. Out of total 268 Lesson Learnt: To emphasize that vernal keratoconjunctivitis may caused visual sequelae if not well eyes, the two most common dengue retinopathy were vessel tortuosity [53 (20%)] and yellow subretinal dot treated at the beginning. [28 (10%)]. Out of 30 eyes, diffuse retinal thickening was the most frequent OCT abnormality [22 (73%)]. Discussion / Conclusions Platelet count and haematocrit were not associated with abnormal fundus or macular OCT manifestation in Vernal keratoconjunctivitis is a common allergic eye disease in children, in which remodeling ocular patients suffering from dengue fever. changes is inevitable. Visual compromisation and blinding complication can be preventable by Conclusion: The prevalences of dengue-related fundus and macular OCT findings among inpatients in our understanding pathogenesis which leads to effecient therapy. country were higher compared to other countries. Furthermore, the spectrum of dengue-related fundus and macular OCT findings in our population can be varied.

Title : Optic Neuritis In Children : A case series studying paediatric optic neuritis with respect to aetiology, Outcome of Eyelids/Canthus Injuries in Hospital Serdang, National Oculoplastic Refferal Centre presentation and recovery. DR.LAURA JESINTHA A/P VELANKANNY1, DR. HO SHU FEN1, DR. HJH ROSNIZA AB RAZAK1 Sharifah Azira binti Syed Mohd Taufik 1, Lakanakumar Thavaratnam 2 1 Hospital Serdang 1 Department of Ophthalmology, Pusat Perubatan Universiti Malaya, 2 Department of Ophthalmology, Hospital Kuala Lumpur Aim: To describe demographics, clinical characteristics and outcome of eyelids, canaliculi and medial canthal injuries managed by Hospital Serdang, a tertiary Oculoplastic referral centre Introduction :Optic Neuritis is a devastating condition that typically presents with sudden onset of blurring Methods: This is a 3 1h years retrospective study on all the eyelids, canaliculi and medial canthus of vision. Paediatric optic neuritis defers from cases in adulthood in terms of presentation, management and injuries managed in Hospital Serdang from January 2012 to June 2015. Demographic data, nature and recovery. location of injuries, types of procedure performed and clinical outcome were evaluated. Method : We report our observation of 8 children with optic neuritis over eight months period at the Results: In total, there are 42 patients who underwent 49 surgical correction procedures in Hospital Neuroopthalmology clinic, HKL. A retrospective chart analysis was conducted from October to May 2016 Serdang. The mean age of patients was 33.7 years old, with 86% of patients were male and 88% patients using a computerised inpatient database. were Malay. 14 patients (33.3%) patients had eyelid injuries primarily repaired by doctors who sub- Results : The mean age was 9 years and the most common presentation was sudden onset of bilateral specialise in Oculoplastic. All except two achieved successful outcome in one surgical setting. blurring of vision. 6 of them came with various precipitating factors including viral URTI, Sinusitis, ADEM, 30 patients who were referred by other hospitals after failed primary repairs had secondary autoimmune while the other 2 were idiopathic. None of them were associated with multiple sclerosis unlike repairs. 7 patients had lateral canthal deformity successfully repaired in one setting. 7 patients had in adulthood. 5 patients recovered well and obtained baseline visual acuity of 6/6 both eyes after receiving persistent epiphora post failed primary canalicular repair only achieved success rate of 50%. 16 patients high dose steroids. The other 3 did not, and the causes of poor visual recovery were severe demyelination, with cicatrical lower eyelid ectropion or lagophthalmos post primary repair were successfully repaired in concurrent macula ischaemia and CRION. However, the patient with CRION had relatively good visual acuity one setting in 75%. of 6/9 and 6/12 but with pale optic discs due to recurrent attacks. Conclusions : While most primary eyelid repair can be performed successfully by general Lesson Learnt: The main concern is its relation with demyelinating disease –in children, optic neuritis is more ophthalmologists, complex eyelid injuries involving lateral or medial canthus, contiguous upper and common in ADEM than in MS or NMO. lower eyelid margin, canaliculus or lacrimal system should be referred to Oculoplastic surgeons. Conclusion : Optic neuritis in children typically presents with sudden onset of bilateral blurring of vision. The Attempted primary repair or delayed referral will lead to more than one reconstructive surgery and precipitating factors were namely infection and ADEM. Immediate treatment with high dose steroids is reduced success rate as illustrated by this study. necessary to prevent relapses in order to preserve the optic nerve. Page 9 Page 8 TOP 10 ABSTRACTS FOR ORAL COMPETITION TOP 3 ABSTRACTS FOR ORAL COMPETITION SUCCESS RATE AND COMPLICATION OF AUGMENTED TRABECULETOMY IN HOSPITAL RAJA PEREMPUAN ZAINAB II AT TWO YEARS FARADATUL AISYAH ABDUL AZIZ, NOR SHIDA MOHD KASSIM, NORHALWANI HUSAIN Anti GQ1b Antibody Syndrome : A Case Series Department of Ophthalmology, Hospital Raja Perempuan Zainab II (HRPZ II), Kota Bharu, POH K.W.1, CHOW K.M.1, LAKANA K.T.1 Kelantan. 1Ophthalmology Department, Hospital Kuala Lumpur Objective: Purpose:To evaluate the success rate and complication of Mitomycin C (MMC) augmented To exemplify the various presentations of Anti GQ1b Antibody Syndrome which is trabeculectomy in glaucoma patients in HRPZ II from year 2014 to 2015. a spectrum of diseases that includes Miller-Fischer Syndrome (MFS), Guillain- Methods: This study involved retrospective evaluation of 43 eyes of 41 patients with primary Barre Syndrome (GBS), Bickerstaff’s brainstem encephalitis (BBE) and acute and secondary glaucoma that underwent MMC augmented primary trabeculectomy with or opthalmoparesis without ataxia. without phacoemulsification by a single surgeon from January 2014 to December 2015. All Method: patients aged between15 to 82 years old. The success of trabeculectomy is defined as IOP ≤18 Retrospective case series of 4 patients. and ≥ 6 mmHg without medication (complete success) and q Results: ualified success is when two or less anti glaucoma medication were required. All subjects were 4 patients were included in this case series. All except 1 had Anti-GQ1b antibody followed-up for at least 2 years. Complications and further intervention were recorded. positive. All had external ophthalmoplegia, with associated clinical features. Result:From the study, 65% were male patients and most of the cases were primary open Case 1 was diagnosed with MFS, due to external ophthalmoplegia, ataxia, and angle glaucoma which account for 56%. The total success rate was 92.1%. The IOP was areflexia. Case 2 presented with limb weakness, associated with external significantly reduced with mean value of 33.87 mmHg ±11.8 preoperatively to 13.83mmHg ± ophthalmoplegia, ataxia, and areflexia, therefore diagnosed as a GBS variant. 4.5 at two years post-surgery (p< 0.05). Requirement of medication was significantly decreased Case 3 was diagnosed with BBE and presented with external ophthalmoplegia, in number from mean value of 3.87 ± 0.78 pre operatively to 0.26 ± 0.72 after trabeculectomy ataxia, hoarseness of voice, and pyramidal sign. Case 4 was diagnosed with acute (p<0.05),. There was no significant different of trabeculectomy outcome in POAG and PACG in ophthalmoparesis and presented only with external ophthalmoplegia with this study, p=0.54.Early post-operative complication was 14 % which resolved after negative Anti GQ1b-antibody. Case 2 and Case 3 were treated with IVIG due to intervention. the severity of the disease, while Case 1 and Case 4 had spontaneous recovery. Conclusion: The two years outcomes of trabeculectomy in HRPZ II have shown high success Those treated with IVIG resolved between 1 to 2 months, compared to those that rate with significantly reduction IOP and usage of medication post-surgery. recovered spontaneously within 3 to 4 months. Keywords: intraocular pressure (IOP),trabeculectomy,glaucoma,complication Conclusion: Anti GQ1b Antibody Syndrome is an umbrella which encompasses MFS, GBS, BBE, “THE KUALA PILAH CLUSTER CATARACT STUDY: THE CHANGING TREND IN PATIENT and acute ophthalmoparesis. Hence, it is important to be able to delineate the DEMOGRAPHY” different clinical features of the Anti GQ1b antibody variants to ensure proper NUR HANIS YUSRI1, PUSPHAR RAMAN1, PREMALA DEVI-S1, KHAIRUL HUSNAINI MOHD KHALID1 diagnosis and management.

1Department of Opthalmology, Kuala Pilah Hospital

Purpose: To analyse the change in cataract patients’ demography over the past 5 years in the Kuala Pilah Cluster Hospital Methods: A retrospective analysis of hospital record of patients underwent cataract surgery. Total of 2539 patient’s data was reviewed between the year 2010-2012 and 2015-2017. The variables studied were demographic data, comorbidities, ocular comorbidities and presenting refracted vision. Results: The mean age of patients undergoing cataract surgery was similar in both groups; 66.8 and 66.7 in Groups 1 and 2 respectively. with equal number of patients being male and female. Majority of patients consists of Malay (63.5%; 61.8%) followed by Chinese (24.0%; 24.9%) and Indian (12.1%; 12.9%) in Groups 1 and 2 respectively. The common comorbidities were hypertension (57.3%; 70.8%) and diabetes mellitus (40.6%; 51.1%). The highest number of cataract surgery patients were from Kuala Pilah (34%), followed by Jempol (29.6%) and Tampin (25%) with a significant increase in number of cases over the year 2015-2017 in Tampin (19.9% to 28.7%) and Jempol (29% to 30%). In 2010-2012 majority of patients presented with vision better than 3/60 (34.4%) However in 2015-2017 more patients presented earlier with vision more than 6/18 (43.5%) as compared to the year 2010-2012 (34.4%). Conclusion: The noticeable changes in patient’s data was an increase in cataract patients presenting earlier (vision better that 3/60). The increasing trend of patients from Jempol and Tampin in 2015-2017 are due to the accessibility of treatment since the Kuala PIlah Hospital Cluster Program was introduced in 2015. Page 10 Page11 Contribution & Achievement Recurrent Corneoscleral Cyst –A Rare Occurrence Valarmathy V, Chandramalar S, SN Roha Malaysian Orthopaedic Journal 2017 Vol 11 No 2 Abilash Kumar AK, et al Department of Ophthalmology, Hospital Sg Buloh Doi: http://dx.doi.org/10.5704/MOJ.1707.013 Introduction: Reporting a rare case of recurrent corneoscleral cyst with epithelial ingrowth post childhood trauma. Fracture-dislocation at C6-C7 level with Quadriplegia after Traditional Massage in a Patient with Ankylosing Method: Case report. Spondylitis: A Case Report Result: A healthy 23 year old female with previous untreated ocular trauma resulting in a corneal Abilash Kumar AK, MD, Mohd Qayyumbazilin MQ, MBBS, Ahmad Zubair AH , M.Med Orth, scar in childhood presented with painless, progressive blurring of vision in the left eye over ten years. Basir Towil BT, MS Orth She developed a fluid filled conjunctival cyst which ruptures spontaneously but increases in size with Department of Orthopaedics, Hospital Shah Alam, Shah Alam, Malaysia each recurrence. The right eye was normal with vision of 6/6 but the left eye vision was counting ABSTRACT Date of submission: 2 March 2017 fingers only. A subconjuctival clear fluid cyst was noted in the inferior half of the conjunctiva and Date of acceptance: 1 June 2017 sclera which dissected into the corneal stroma with corresponding area of thinning and band Ankylosing spinal disorders (ASD) tend to result in The mean AS prevalence per 10 000 (from 36 eligible keratopathy. Anterior chamber was deep. The posterior segment was normal. Optical Coherence fractures and/or dislocations after minor trauma studies) was 16.7 in Asia 4. In this part of the world Tomography demonstrated a communication between the scleral and corneal part of the cyst. because of the altered biomechanical properties. The (including Malaysia), a small number of the population Cytology of the cyst fluid during primary exploration indicated presence of degenerated cells and was relative risk of traumatic vertebral fractures in patients tend to obtain treatment from traditional healers for negative for malignancy. Sterile water was injected into the corneal cyst and intercommunicating with ankylosing spondylitis has been estimated as their health problems before eventually seeking passage to reduce the epithelial ingrowth and promote wall adhesion. The final visual acuity was three times higher than in the general population. conventional professional medical advice. This has 1/60 with a better cosmetic appearance but it recurred in six months. Patient opted for intermittent These spine traumas, which are located at cervical resulted in delayed diagnosis and eventual drainage if size of cyst increases against penetrating sclerokeratoplasty. level in 81% of patients with ankylosing spondylitis, are management of patients presenting in advanced stage Conclusions: complicated by neurological lesions in 65% of patients, of diseases, with challenges in treatment and due to the high inherent instability of these fractures. prognosis. Primary corneoscleral cyst though rare may arise post ocular trauma or surgery secondary to Traditional massage is an ancient practice in many proliferation of anomalously situated epithelial or endothelial cells. Early imaging and placement of parts of Asia. It has many benefits that are currently sutures prevents dissection of the various ocular layers. Thus it is necessary to treat ocular trauma recognized world-wide. However, it can be dangerous CASE REPORT cautiously including partial laceration wounds. and even lethal if practised without adequate knowledge and skill. We report a case of C6-C7 We present a case of a 48-year old man, with Spontaneous expulsive suprachoroidal haemorrhage in blind glaucomatous eye fracture-dislocation with complete neurology and undiagnosed ankylosing spondylitis who has been JACQUELINE YL TING, PAN SHIN WEI, HUMAYUN AKHTER FAISAL neurogenic shock in a middle aged man with paying frequent visits to a traditional masseuse for his Ophthalmology Department, Sibu Hospital. undiagnosed ankylosing spondylitis. neck pain from which he has been suffering for years. Introduction On his most recent visit to the masseuse, the massage To describe two cases of spontaneous expulsive suprachoroidal haemorrhage (SESCH) INTRODUCTION produced sharp pain at the nape of his neck and rendered him motionless. Case Report Ankylosing Spondylitis (AS) is a seronegative Case 1- A 76-years old lady presented to emergency with spontaneous left eye bleeding and spondyloarthropathy that primarily involves the On arrival at the emergency department, the patient hypertensive emergency. She had underlying uncontrolled hypertension, history of right eye cataract vertebral column and the sacroiliac joints. It is a was noted to be quadriplegic. At this point of time he operation, right eye angle closure glaucoma and left eye absolute glaucoma complicated with painless chronic disease that typically starts before the age of was also suffering from bowel and urinary left blind eye. Ocular examination over left eye demonstrated presence of fresh bleed, expulsion of 30 and has a slow but steady progression. The disease incontinence. Examination of the upper limbs lens and prolapsed uveal contents while right eye examination was unremarkable with normal has a characteristic caudal to rostral progression and revealed loss of power from C7 with hypoesthesia C5 intraocular pressure (IOP). She subsequently underwent evisceration. overtime alters the strength and biomechanical onwards, atonia and hyporeflexia. There was paralysis Case 2- A 86 years old lady with no underlying medical illness presented with left eye spontaneous properties of the spine through extensive remodelling of the lower limbs, with atonia, hyporeflexia, bleeding as well as hypertensive emergency. There was no ophthalmological history in her clinical involving ligamentous ossifications, vertebral joint hypoesthesia and loss of power from L2 downwards. records other than history of bilateral cataract operation done in private hospital 10 years ago. Ocular fusion, osteoporosis and kyphosis 1. These changes Anal tone was lax however bulbo-cavernosus reflex examination revealed no light perception over the affected eye and 6/18 in the other eye with normal lead to an increase in the segmental rigidity of the (BCR) was present. He was noted to be in neurogenic IOP. There was prolapsed uveal contents with fresh bleeding and she underwent evisceration as well. spine due to calcifications of soft tissue that shock with hypotension requiring ionotropic support. Conclusion predisposes to a risk of pathological fractures affecting SESCH is a rare but serious sight threatening ocular condition associated with multiple risk factors the spinal columns, hence resulting in spinal cord injury On suspicion of a high spinal cord injury, an urgent CT including arteriosclerosis, vascular disease, glaucoma, diabetes, intraocular malignancy and diseased 2. Typically, spinal fractures occur mostly in patients of the cervical spine was done (as our facility lacks an eye wall. Most cases reported involved patients with underlying glaucoma and cornea damage to a with advanced age and therefore have inherently MRI machine) (Fig. 1), The scan revealed fracture- certain extent, suggesting the association between systemic factors and local ischemia of the posterior poorer outcome. Cervical spine fractures occur three dislocation of the C6 vertebra with facet joint 3 ciliary arteries. Although the exact mechanism is still debatable, thorough understanding of the risk times more frequently in patients with AS . subluxation at C6/C7, retrolisthesis, significant canal factors, pathophysiology and outcome may allow better management to prevent SESCH. The diagnosis of AS is based on clinical and stenosis, multiple facet and rib joint ankylosis and Lesson Learnt radiographic features. The modified New York Criteria ligament calcifications with syndesmophytes. We acknowledge that the incidence of SESCH is extremely rare and improvement in our management has a high sensitivity and specificity; however, they Radiographic images of the spine showed the classical may not be helpful for early diagnosis of AS and the “bamboo spine” (Fig. 2) and destruction of the is pivotal to prevent SESCH as it leads to devastating outcome. involvement of the sacroiliac joint remains the sine qua sacroilliac joints bilaterally. non for definite diagnosis. Page 13 The patient was transferred to a regional spine Asia Pacific Tele-Ophthalmology Society referral centre where MRI of the cervical spine (APTOS) 2017 Conference – Report confirmed the CT findings, with additional information on cord compression causing cord oedema at the level I was fortunate to be given to opportunity to attend “The 2nd APTOS Symposium” in Hong of C6, ligamentous injury, paravertebral and marrow Kong on July 15 - 16, 2017. The Asia Pacific Tele-Ophthalmology Society (APTOS) was founded with oedema. a view to advancing and promoting the use of tele-ophthalmology in the Asia Pacific region and beyond. We witness and experience how technologies have revolutionized and transformed our way He was diagnosed with C6-C7 fracture dislocation with of living. Technological advances, when used to our advantage, can enable ophthalmologists to cut spinal stenosis and retrolisthesis with complete across distance to provide quality medical services and improved accessibility of individuals, both neurology (ASIA A) in neurogenic shock with patients and medical practitioners alike. The objective of my trip is to widen my view on the current underlying ankylosing spondylitis. The injury was advances in the field of tele- ophthalmology which has been my interest since medical school years. caused by excessive hyperextension of the neck, Being an inventor and innovator myself, I am keen to learn more on latest imaging techniques, which is a common technique practised during the artificial intelligence and tele-ophthalmology advances. massage. At the spine centre, the patient underwent Fig. 2: Plain The Opening Session was featured by the posterior spinal instrumentation and fusion radiograph showing “bamboo spine.” inauguration of the International Diabetic C4/C5/C7/T1 with laminectomy of C3-C5 (Fig. 3). Retinopathy Forum and 4 keynote lectures covering deep learning, artificial intelligence, breakthroughs Despite our efforts, post-operative assessment in telemedicine and its applications. The rest of the showed no change in his neurological state which two days was filled with intensive lecturers of tele- remained at ASIA A. The patient is currently ophthalmology ideas and practices by doctors and undergoing a spinal rehabilitation programme. An experts from all around the world such as China, interesting finding in this patient was that the HLA- India, Japan, Australia, Singapore, Hong Kong, B27 gene tested negative despite fulfilling all points in United States of America, and Europe. Some of the the Modified New York Criteria for Ankylosing interesting lectures includes “Mobile Technology’s Dr. Chan Jan Bond with Dr Ming Guang He (President of Spondylitis, with radiological appearance of the Role in Advancing Ophthalmology” by Ms Divya APTOS) classical 'bamboo spine'' of AS. Statistic show that in Nag from USA, the CEO of E-health Applc Inc. the United Kingdom, HLA-B27 is present in 90-95% of describing how Apple Inc has built apps with I have presented a free paper based on patients with ankylosing spondylitis 5. (The iPhone to help patients with Parkinson’s disease, an app I have built titled “REST – An Innovative ramifications of HLA-B27, Nicholas J Sheehan) Fig. 3: Radiograph following posterior vision screening and health monitoring. Another Rapid Eye Screening Test” and received spinal istrumentation and topic was “Tele-screening/Automated-screening for positive response from the audience. There fusion of C4/C5/C7/T1. DISCUSSION Eye Diseases” by Dr Ryo Kawasaki from Japan, were medical officers from China that was Massage therapy is recognized as one of the oldest describing the use of tele-ophthalmology use in interested to us my app as a study subject and methods of healing, with references in ancient Japan for automated eye screening for the would like to do further collaboration. Traditional massage has remained a form of cultural medical texts going back to 4,000 years. Hippocrates, community. “Deep Learning for Automated Retinal I have also presented a video presentation on norm especially for a small section of the Asian the father of medicine, had referred to massage when Disease Assessment” was presented by Dr Varun “Wireless Smartphone Videography for Ocular community for many centuries now. However at times, he wrote, in the 4th century B.C.: "The physician must Gulshan from India on how artificial intelligence Surgery System”. The presentation and therapists' without knowledge on the patients be acquainted with many things, and assuredly with performs deep learning and later being translated introduction of my idea to the rest of the world underlying predisposing comorbid conditions and rubbing." to automated screening programs. Dr Yogesam has also open up a new opportunity for further fragilities, tend to push boundaries leading to Kanasingam describes how a software is ised for collaboration for my creation and innovations. catastrophe. It was unfortunate that this particular diabetic retinopathy screening in his topic “AI I have also taken the opportunity to visit patient with underlying AS went undiagnosed and had Based Clinical Decision Support System for the oversea ophthalmic imaging company booth resorted to traditional treatment without any Diabetic Retinopathy for Use by Primary Care and learn more on the new tele-ophthalmology knowledge of this condition. A lot of emphasis has been Medical Doctors in Australia”. gadgets which is mostly not available in placed on early detection and prevention of such Malaysia. There was portable smartphone conditions and it is our role to educate and develop fundus camera, portable smartphone anterior awareness in the community to prevent further segment camera, artificial intelligent program for disasters as in this case. automated diagnosis and grading. Overall the experience of APTOS was great giving new The majority of cervical spine fractures in ASD are ideas to the world of tele- ophthalmology. transdiscal extension injuries, most commonly affecting APTOS 2018 will be held in Singapore and C6–C7 just as observed in our patient. ASD is prone to looking forward to look at new technologies and fracture after minor trauma due to its poor elasticity. advancement in ophthalmology. Patients with ASD often end up with neurological by Dr. Chan Jan Bond complications and incomplete neurologic recovery. Ophtalmologist Most patients with such complications were often Hospital Shah Alam unable to cite a specific causative trauma. Timely Fig. 1: CT cervical spine: sagittal view showing identification of ankylosing spondylosis is instrumental fracture-dislocation of C6 vertebra with facet joint in avoiding the advanced sequelae of this catastrophic subluxation at C6/C7. Dr. Chan Jan Bond Free Paper presentation at APTOS Page 14disease. Page 15

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Page 16 Page 17 CLINICAL AUDIT 2017 HOSPITAL SHAH ALAM MOH POLICIES

No Projects: All research conducted in KKM 1 Surgery: Transfer Time to OT for Emergency Surgery Hospitals MUST be registered with NMRR (www.nmrr.gov.my) and have 2 Anaesthesiology: Hand Hygiene Practice in ICU MREC approval. 3 Pathology: An Audit on Improving Critical Value Notification by Laboratory All Publication or Presentation Personnel to Requesting Doctors poster/oral MUST have Director General of Health approval. 4 Ophthalmology: Clinical Audit of Post-Operative Outcome in Cataract 5 Nursing Unit: Audit Klinikal Terhadap Amalan ISBAR dikalangan Jururawat WORKSHOP & TRAINING Semasa Proses Penyerahan Tugas di Wad-Wad Hospital Shah Alam • NMRR User & Research Registration 6 Paediatric: Hypothermia in Preterm infants less than 32 weeks • Introduction To Clinical Research 7 Orthopaedic: Osteoporotic Fracture and Treatment • Good Clinical Practice 8 ORL: Waiting Time in ORL Clinic • Research Methodology 9 O&G: Clinical Audit on Underestimation of Blood Loss After Vaginal • Statistical Workshop Delivery • Critical Appraisal 10 Radiology: Clinical Audit on CTPA Quality 2016 • Oral & Poster Presentation 11 Emergency and Trauma Department: Waiting Time in Green Zone • Medical Writing Workshop 12 Medical: Delayed Admissions to Medical Wards OUR SERVICES 13 Pharmacy: Delay in Notification of near Expiry and Slow Moving Ward Medications in HSAS • Consultation Research Clinic 14 Oral Surgery: To Reduce Repetition of Intraoral Periapical (IOPA) • Statistic Consultation Clinic • National Malaysia Research Radiograph at oral Surgery Department Registration (NMRR) Online registration • Conduct technical review of research 1. Anaesthesiology protocol submitted to NMRR 2. Pharmacy • 3. Medical Assist in submission of research papers for publication & presentation • Assist in research grant application 1. Pharmacy • Conduct research training for HSAS 2. Oral Surgery staffs 3. Anaesthesiology Page 18 Page 19