CRC HOSPITAL SHAH ALAM

NEWSLETTER

VOLUME 1, ISSUE 1 NOVEMBER 2017

In this issue:

Words from the Director HSAS 2

Words from the Head of CRC HSAS

2

Introduction to CRC 2/19

CRC HSAS EVENTS 2017 3

Ophthalmology Research Day 2017

4-12

Contributions & Achievements of HSAS

13-17

Clinical Audit 18

Clinical Research Centre,

Hospital Shah Alam, Level 2

Tel: 035526300 (ext-3304/3305)

Fax: 03 –55263217

Email: crc.hsas@gmail.com

2018

Venue:

HOSPITAL SHAH ALAM

All rights reserved. © CRC.HSAS 2017

J mResearch

1ST CRC HOSPITAL SHAH ALAM RESEARCH DAYOPHTHALMOLOGY RESEARCH DAY 2017 INCONJUNCTION WITH 6TH

SELANGOR RESEARCH WEEK17TH-18TH August 2017HOSPITAL SHAH ALAM

Officiated by:

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

Free Paper

Competition:

1st Place: Dr Faradatul Aisyah Abdul AzizSuccess Rate & Complication ofAugmented Trabeculetomy inHospital Raja Perempuan Zainab II at2 years.

2nd Place:Dr Goh Hui YinDescemet's Stripping AutomatedEndothelial Keratoplasty (DSAEK):Hospital Sungai Buloh Experience

3rd Place:Dr Nur Hanis Binti YusriThe Kuala Pilah Cluster CataractStudy: The Changing Trend in PatientDemography.

Poster Competition:

1st Place: Dr Chow Kit MayAnti Gq1b Antibody Syndrome : A Case Series

2nd Place: Dr Valarmathy VaiyavariRecurrent Corneoscleral Cyst –A Rare Occurrence

3rd Place: Dr Jacqueline TingSpontaneous Expulsive Suprachoroidal Haemorrhage In Blind

Winners

Page 4 Page 5

TOP 10 ABSTRACTS FOR ORAL COMPETITION

Comparison of smartphone wireless videography system to the conventional video recording systemfor ocular surgeryChan Jan Bond 1, Chong Wern Yih 2,3, Logeswari Krishna 4,5, Shatriah Ismail 2.

1 Department of Ophthalmology, Hospital Shah Alam, Selangor; 2 Department of Ophthalmology,Universiti Sains Malaysia Kampus Kesihatan, Kelantan; 3 Department of Ophthalmology, Hospital Klang,Selangor; 4 Department of Ophthalmology, Hospital Melaka, Melaka; 5 Department of Ophthalmology,Pusat Perubatan Universiti Malaya, Kuala Lumpur.

Introduction: To compare smartphone videography system to conventional video recording technique interms of video quality and cost effectiveness.Methodology: This is a pilot, comparative observational study, involving patients from Hospital TuankuJa’afar Seremban ophthalmology department requiring cataract surgery. Ten surgical procedures wererecorded simultaneously using both videography systems, out of which 10 seconds of the video wassampled and evaluated by 50 medical personnels (doctor vs non-doctor). Both sample videos(conventional video and smartphone) were viewed simultaneously by viewer for 10 seconds andsubsequently, the assessor graded the video using modified Absolute Category Rating (ACR) labeled as“bad”, “poor”, “fair” , “good”, and ‘excellent” and they were translated to Mean Opinion Score (MOS)ranging from 1 to 5. The cost of each videography system was calculated and compared.Result: A total of 27 doctors and 23 non-doctors participated in the study. Smartphone videography had ahigher MOS value compared to conventional one in both groups (Doctor 4.1 vs 3.47, p = 0.03 ; non-doctor4.44 vs 3.83, p <0.001) and combined group (4.22 vs 3.65, p <0.001). Smartphone videography systemwas also cheaper than the conventional.Conclusion: Smartphone videography system, offers better video quality & cost effectiveness. It can helphospitals or clinics with no conventional video recording system to record ocular surgery.

Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK): Hospital Sungai Buloh ExperienceGOH HUI YIN, K JOHN MATHEN, SHAMALA RETNASABAPATHY

Department of Ophthalmology, Hospital Sungai Buloh

Introduction: Corneal endothelial dysfunction is a significant cause of progressive blurring of vision. Overthe past decade, there has been a revolutionary change in the treatment of corneal endothelial disease.Cornea transplant surgical techniques have been refined to provide patients with faster recovery rate,lower corneal graft complications as well as better visual outcome.Methodology: This is a single centre, retrospective study conducted from December 2013 to November2016. A total of sixty eyes of fifty-seven participants with corneal conditions such as pseudophakic bullouskeratopathy, Fuch’s endothelial dystrophy and endothelial graft failure after corneal transplantunderwent DSAEK performed by nine surgeons in Hospital Sungai Buloh. The participants were followedup every six months. The outcome measures studied included best-corrected visual acuity, graftattachment success rate and its associated complications.Results: There was a significant improvement in the visual outcome of 87% of the participants. 90% ofthis surgery had a successful graft attachment rate. The remaining 10% of the participants required graftrebubbling. Nine out of the sixty eyes had primary graft failure. Three of the nine patients underwentrepeat DSAEK and one of them achieved a satisfactory visual outcome of 6/12. Only one eye wasconverted to PK as there was a perforation of the donor cornea during microkeratome dissection.Conclusion: Endothelial keratoplasty is a minimally invasive surgery that offers excellent visual outcomefor patients with corneal endothelial dysfunction. It should be considered as the surgery of choice forthese patients in a suitable healthcare setting.

Successful Use of Intravitreal Tenecteplase for Management of Submacular Haemorrhage - A Case SeriesLee WY, Teh WM, Ling KP, Haslina MADepartment of Ophthalmology, Hospital Sultanah Bahiyah, Alor Setar, Malaysia

Introduction:Tenecteplase (TNKase) is a recombinant tissue plasminogen activator (rTPA) indicated for acutemyocardial infarction. Its use in ophthalmology is off-label, but promising. This study was a retrospectiveclinical case series of six eyes treated with intravitreal TNKase (50mcg/0.1ml) for submacular haemorrhageof varying causes. We would like to share our experience and patient outcomes of using TNKase. Outcomemeasures evaluated include anatomic displacement of submacular blood, change in visual acuity, andpossible adverse events.Case Series:Six patients received intravitreal TNKase for submacular haemorrhage secondary to variousunderlying pathologies, including idiopathic polypoidal choroidal vasculopathy in four eyes, and rupturedmacroaneurysm and trauma in one eye each. In five of the six cases, TNKase was given in conjunction withintravitreal perfluoropropane pneumatic displacement. Complete resolution of blood was achieved in fivecases, while one developed a breakthrough vitreous haemorrhage. All patients either maintained orimproved on their final visual acuity, except for the one with vitreous haemorrhage requiring vitrectomy.Lesson Learnt:Intravitreal TNKase as an adjunctive therapy in displacement of submacular haemorrhage hasproven to be safe, with favourable outcome.Discussion/Conclusion:Despite the limited evidence base, we believe that intravitreal TNKase can be used inselect patients with submacular haemorrhage to achieve a favourable outcome. Further studies arewarranted to determine the efficacy and safety profiles of TNKase, as well as establish appropriate dosingregimens and other ocular routes of administration.

Pediatric Cataract Surgery in Malaysia- A Review of Visual OutcomesLIM SEE THENG1, FIONA LEE MIN CHEW2, SURIYA EH QURUT 3, IZZAIFA HASSAN3, SUNDER RAMASAMY3, JAMALIA RAHMAT3

1 Department of Ophthalmology, Universiti Kebangsaan Malaysia UKM, 2 Department of Ophthalmology, Hospital Selayang, 3 Department of Ophthalmology, Hospital Kuala Lumpur HKL

Introduction:Outcomes of pediatric cataract surgery vary with cataract complexity, ocular growth,associated ocular conditions and patient compliance to post-operative visual rehabilitation. Little is knownregarding the visual outcomes of non-traumatic pediatric cataract surgery in Malaysia. This study documentsthe visual outcomes of non-traumatic pediatric cataract surgery performed in a tertiary referral center inMalaysia.Methodology:Case notes of all patients aged 12 years and below who underwent cataract surgery fromJanuary 2010 to December 2015 in HKL were reviewed. Patients were recruited if they had primary cataractsurgery and a minimum of 6 months post-operative follow-up. Data collected included subjects’demographic details, past medical conditions and ocular examination findings. Intra-operative and post-operative ocular findings at 1, 6 months and 1 to 5 years were documented.Results: A total of 111 subjects were recruited. The mean age at diagnosis and at surgery was 29.97(SD:

32.49) months and 33.14(SD:33.47) months respectively. Males represented 55%(61/111) of subjects.Bilateral cataracts were found in 63.1%(70/111) subjects. Congenital cataract represented 78.4%(87/111) ofthe cataracts. Pre-operative mean visual acuity was 1.6 (SD: 1.07) LogMar units. Intra-operativecomplications were noted in 17% (19/111) subjects. Intraocular lens was implanted in the capsular bag for94.6%(105/111) subjects. The mean duration of follow-up was 29.71(SD: 18.78) months. At one monthreview, 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

Assalamualaikum, Salam Sejahtera.

It is of paramount important that we as clinicians understand the important

of research undertaking. Research opportunities occur every day across

our healthcare system. Health professionals, whilst in pursuit of clinical

excellence, should be involve in research undertaking. With the help of

CRC, a continuous commitment is established, that encourages and

supports every research journey. I hope HSAS can increase its research

output. I want to congratulate those whom had contribute to the outcome

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

Words from the Director of Hospital Shah Alam

Head of CRC Hospital Shah Alam

Assalamualaikum & Salam Sejahtera. It is my great pleasure to be part of

CRC Hospital Shah Alam. CRC HSAS serves as a local coordination centre

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

care by promoting and supporting the importance, quality, safety and

efficiency of clinical research. I do hope there will be an increasing trend of

Investigator Initiated Research and Investigator Sponsored Research in the

coming years. I hope many will benefit from this issue and are inspired by

the achievements of our fellow colleagues.

Dr. Hjh Nor Fariza binti Ngah

CRC Hospital Shah Alam

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

• 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

Roles

To become the leading

clinical research organisation

in Asia

To improve patients’ health

outcomes through ethical and

quality clinical research

INTRODUCTION TO CLINICAL

RESEARCH 6-8.2.17

BASIC STATISTICAL COURSE 11-12.7.17

GOOD CLINICAL PRACTICE 24-26..7.17

ORAL & POSTER PRESENTATION

WORKSHOP

22.8.17

OPHTHALMOLOGY RESEARCH DAY

In Conjunction with 6th Selangor Research Week

17-18.8.17

CLINICAL AUDIT WORKSHOP:

I. Introduction to Clinical Audit

II. Data Review and Remedial Measures

III. Presentation

16-17.2.2017

18.4.2017

12.9.2017

CLINICAL AUDIT COMPETITION

HOSPITAL LEVEL

20.9.2017

MEDICAL WRITING WORKSHOP 31.10.2017

CRC HSAS Events 2017

Page 2Page 3

TOP 10 ABSTRACTS FOR ORAL COMPETITIONVernal Keratoconjunctivitis: Remodeling Ocular Changes In Children From Hospital Universiti SainsMalaysiaTENGKU-FATISHAH AMIR 1, AMEILIA AHMAD 1, SHATRIAH ISMAIL 1

1 Department of Ophthalmology, Hospital Universiti Sains Malaysia

Introduction: To assess the remodeling ocular changes in patients with vernal keratoconjunctivitis (VKC)in Hospital Universiti Sains MalaysiaMethodology: 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 inprepubertal age with male preponderance. Itching and redness are frequently encountered symptomswith palpebral papillae was the commonest sign, followed by mucous discharge, Horner Trantas dots,limbal thicknening and lastly perilimbal conjunctival pigmentation. Majority of the patients hadpalpebral type of VKC with chronic perennial form seen in 16.7%. Ocular surface remodeling secondaryto VKC leads to various complications such as corneal scar and shield ulcer; which were found in 30% ofpatients respectively followed by peripheral corneal vascularization in 13.3%, limbal stem cell deficiencyin 6.7% and acquired ptosis in 3.3%. However none had keratoconus. Complication in related totreatments, for instance, steroid-induced glaucoma was seen in 2 patients but nil of them had developcataract.Conclusion: Smartphone videography system, offers better video quality & cost effectiveness. It canhelp hospitals or clinics with no conventional video recording system to record ocular surgery.Lesson Learnt: To emphasize that vernal keratoconjunctivitis may caused visual sequelae if not welltreated at the beginning.Discussion / ConclusionsVernal keratoconjunctivitis is a common allergic eye disease in children, in which remodeling ocularchanges is inevitable. Visual compromisation and blinding complication can be preventable byunderstanding pathogenesis which leads to effecient therapy.

Prevalence of Dengue- Related Fundus and Macular Optical Coherence Tomography (OCT) Findings among Inpatients in a Regional Referral HospitalMEE AI LOH 1, MEI FONG CHONG 1, UMI KALTHUM MN 2, HONG BEE KER 31 Department of Ophthalmology, Hospital Raja Permaisuri Bainun;

2 Department of Ophthalmology, Universiti Kebangsaan Malaysia UKM;3 Department of Internal Medicine, Hospital Raja Permaisuri Bainun

Introduction: Dengue is endemic in Malaysia. The study investigated the prevalences of dengue-related fundus and macular optical coherence tomography (OCT) findings, and the spectrum of dengue retinopathy among inpatients in a Malaysian tertiary hospital. The associations between platelet count and haematocrit level with dengue-related fundus and macular OCT findings were also investigated.Methodology: This was a cross-sectional study conducted from June to August 2015. Participants

underwent a comprehensive ocular examination. Examination included, a best-corrected distance and near visual acuities, standard black-on-white Amsler chart testing, pupillary light-reflex, fundus examination, dilated fundus photographs and OCT of the macula.Results: A total of 134 patients were included in the study. The prevalence of dengue-related fundus

findings and macular OCT findings among the patients were 35% (95% CI: 27%, 43%) and 13% (95% CI: 8%, 19%) respectively. Scotoma (p < 0.001), near vision disturbance (p = 0.04) and abnormal Amsler findings (p < 0.001) were significant associated with patients presence of macular OCT abnormalities. Out of total 268 eyes, the two most common dengue retinopathy were vessel tortuosity [53 (20%)] and yellow subretinal dot [28 (10%)]. Out of 30 eyes, diffuse retinal thickening was the most frequent OCT abnormality [22 (73%)]. Platelet count and haematocrit were not associated with abnormal fundus or macular OCT manifestation in patients suffering from dengue fever.Conclusion: The prevalences of dengue-related fundus and macular OCT findings among inpatients in our 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, presentation and recovery.Sharifah Azira binti Syed Mohd Taufik 1, Lakanakumar Thavaratnam 21 Department of Ophthalmology, Pusat Perubatan Universiti Malaya, 2 Department of Ophthalmology, Hospital Kuala Lumpur

Introduction :Optic Neuritis is a devastating condition that typically presents with sudden onset of blurringof vision. Paediatric optic neuritis defers from cases in adulthood in terms of presentation, management andrecovery.Method : We report our observation of 8 children with optic neuritis over eight months period at theNeuroopthalmology clinic, HKL. A retrospective chart analysis was conducted from October to May 2016using a computerised inpatient database.Results : The mean age was 9 years and the most common presentation was sudden onset of bilateralblurring of vision. 6 of them came with various precipitating factors including viral URTI, Sinusitis, ADEM,autoimmune while the other 2 were idiopathic. None of them were associated with multiple sclerosis unlikein adulthood. 5 patients recovered well and obtained baseline visual acuity of 6/6 both eyes after receivinghigh dose steroids. The other 3 did not, and the causes of poor visual recovery were severe demyelination,concurrent macula ischaemia and CRION. However, the patient with CRION had relatively good visual acuityof 6/9 and 6/12 but with pale optic discs due to recurrent attacks.Lesson Learnt: The main concern is its relation with demyelinating disease –in children, optic neuritis is morecommon in ADEM than in MS or NMO.Conclusion : Optic neuritis in children typically presents with sudden onset of bilateral blurring of vision. Theprecipitating factors were namely infection and ADEM. Immediate treatment with high dose steroids isnecessary to prevent relapses in order to preserve the optic nerve.

Outcome of Eyelids/Canthus Injuries in Hospital Serdang, National Oculoplastic Refferal CentreDR.LAURA JESINTHA A/P VELANKANNY1, DR. HO SHU FEN1, DR. HJH ROSNIZA AB RAZAK11 Hospital Serdang

Aim: To describe demographics, clinical characteristics and outcome of eyelids, canaliculi and medialcanthal injuries managed by Hospital Serdang, a tertiary Oculoplastic referral centreMethods: This is a 3 1h years retrospective study on all the eyelids, canaliculi and medial canthus

injuries managed in Hospital Serdang from January 2012 to June 2015. Demographic data, nature andlocation of injuries, types of procedure performed and clinical outcome were evaluated.Results: In total, there are 42 patients who underwent 49 surgical correction procedures in Hospital

Serdang. The mean age of patients was 33.7 years old, with 86% of patients were male and 88% patientswere Malay. 14 patients (33.3%) patients had eyelid injuries primarily repaired by doctors who sub-specialise in Oculoplastic. All except two achieved successful outcome in one surgical setting.

30 patients who were referred by other hospitals after failed primary repairs had secondaryrepairs. 7 patients had lateral canthal deformity successfully repaired in one setting. 7 patients hadpersistent epiphora post failed primary canalicular repair only achieved success rate of 50%. 16 patientswith cicatrical lower eyelid ectropion or lagophthalmos post primary repair were successfully repaired inone setting in 75%.

Conclusions : While most primary eyelid repair can be performed successfully by generalophthalmologists, complex eyelid injuries involving lateral or medial canthus, contiguous upper andlower eyelid margin, canaliculus or lacrimal system should be referred to Oculoplastic surgeons.Attempted primary repair or delayed referral will lead to more than one reconstructive surgery andreduced success rate as illustrated by this study.

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TOP 10 ABSTRACTS FOR ORAL COMPETITION

SUCCESS RATE AND COMPLICATION OF AUGMENTED TRABECULETOMY IN HOSPITAL RAJAPEREMPUAN ZAINAB II AT TWO YEARSFARADATUL AISYAH ABDUL AZIZ, NOR SHIDA MOHD KASSIM, NORHALWANI HUSAINDepartment of Ophthalmology, Hospital Raja Perempuan Zainab II (HRPZ II), Kota Bharu,Kelantan.

Purpose:To evaluate the success rate and complication of Mitomycin C (MMC) augmentedtrabeculectomy in glaucoma patients in HRPZ II from year 2014 to 2015.Methods: This study involved retrospective evaluation of 43 eyes of 41 patients with primaryand secondary glaucoma that underwent MMC augmented primary trabeculectomy with orwithout phacoemulsification by a single surgeon from January 2014 to December 2015. Allpatients aged between15 to 82 years old. The success of trabeculectomy is defined as IOP ≤18and ≥ 6 mmHg without medication (complete success) and qualified success is when two or less anti glaucoma medication were required. All subjects werefollowed-up for at least 2 years. Complications and further intervention were recorded.Result:From the study, 65% were male patients and most of the cases were primary openangle glaucoma which account for 56%. The total success rate was 92.1%. The IOP wassignificantly reduced with mean value of 33.87 mmHg ±11.8 preoperatively to 13.83mmHg ±4.5 at two years post-surgery (p< 0.05). Requirement of medication was significantly decreasedin number from mean value of 3.87 ± 0.78 pre operatively to 0.26 ± 0.72 after trabeculectomy(p<0.05),. There was no significant different of trabeculectomy outcome in POAG and PACG inthis study, p=0.54.Early post-operative complication was 14 % which resolved afterintervention.Conclusion: The two years outcomes of trabeculectomy in HRPZ II have shown high success

rate with significantly reduction IOP and usage of medication post-surgery.Keywords: intraocular pressure (IOP),trabeculectomy,glaucoma,complication

“THE KUALA PILAH CLUSTER CATARACT STUDY: THE CHANGING TREND IN PATIENTDEMOGRAPHY”NUR HANIS YUSRI1, PUSPHAR RAMAN1, PREMALA DEVI-S1, KHAIRUL HUSNAINI MOHD KHALID1

1Department of Opthalmology, Kuala Pilah Hospital

Purpose: To analyse the change in cataract patients’ demography over the past 5 years in theKuala Pilah Cluster HospitalMethods: 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. Thevariables studied were demographic data, comorbidities, ocular comorbidities and presentingrefracted 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 andfemale. 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 comorbiditieswere hypertension (57.3%; 70.8%) and diabetes mellitus (40.6%; 51.1%). The highest numberof cataract surgery patients were from Kuala Pilah (34%), followed by Jempol (29.6%) andTampin (25%) with a significant increase in number of cases over the year 2015-2017 inTampin (19.9% to 28.7%) and Jempol (29% to 30%). In 2010-2012 majority of patientspresented with vision better than 3/60 (34.4%) However in 2015-2017 more patientspresented 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 andTampin in 2015-2017 are due to the accessibility of treatment since the Kuala PIlah HospitalCluster Program was introduced in 2015.

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Anti GQ1b Antibody Syndrome : A Case SeriesPOH K.W.1, CHOW K.M.1, LAKANA K.T.1

1Ophthalmology Department, Hospital Kuala LumpurObjective:To exemplify the various presentations of Anti GQ1b Antibody Syndrome which isa spectrum of diseases that includes Miller-Fischer Syndrome (MFS), Guillain-Barre Syndrome (GBS), Bickerstaff’s brainstem encephalitis (BBE) and acuteopthalmoparesis without ataxia.Method:Retrospective case series of 4 patients.Results:4 patients were included in this case series. All except 1 had Anti-GQ1b antibodypositive. All had external ophthalmoplegia, with associated clinical features.Case 1 was diagnosed with MFS, due to external ophthalmoplegia, ataxia, andareflexia. Case 2 presented with limb weakness, associated with externalophthalmoplegia, ataxia, and areflexia, therefore diagnosed as a GBS variant.Case 3 was diagnosed with BBE and presented with external ophthalmoplegia,ataxia, hoarseness of voice, and pyramidal sign. Case 4 was diagnosed with acuteophthalmoparesis and presented only with external ophthalmoplegia withnegative Anti GQ1b-antibody. Case 2 and Case 3 were treated with IVIG due tothe severity of the disease, while Case 1 and Case 4 had spontaneous recovery.Those treated with IVIG resolved between 1 to 2 months, compared to those thatrecovered spontaneously within 3 to 4 months.Conclusion:Anti GQ1b Antibody Syndrome is an umbrella which encompasses MFS, GBS, BBE,and acute ophthalmoparesis. Hence, it is important to be able to delineate thedifferent clinical features of the Anti GQ1b antibody variants to ensure properdiagnosis and management.

TOP 3 ABSTRACTS FOR ORAL COMPETITION

Recurrent Corneoscleral Cyst –A Rare OccurrenceValarmathy V, Chandramalar S, SN RohaDepartment of Ophthalmology, Hospital Sg BulohIntroduction: Reporting a rare case of recurrent corneoscleral cyst with epithelial ingrowth postchildhood trauma.Method: Case report.Result: A healthy 23 year old female with previous untreated ocular trauma resulting in a cornealscar in childhood presented with painless, progressive blurring of vision in the left eye over ten years.She developed a fluid filled conjunctival cyst which ruptures spontaneously but increases in size witheach recurrence. The right eye was normal with vision of 6/6 but the left eye vision was countingfingers only. A subconjuctival clear fluid cyst was noted in the inferior half of the conjunctiva andsclera which dissected into the corneal stroma with corresponding area of thinning and bandkeratopathy. Anterior chamber was deep. The posterior segment was normal. Optical CoherenceTomography demonstrated a communication between the scleral and corneal part of the cyst.Cytology of the cyst fluid during primary exploration indicated presence of degenerated cells and wasnegative for malignancy. Sterile water was injected into the corneal cyst and intercommunicatingpassage to reduce the epithelial ingrowth and promote wall adhesion. The final visual acuity was1/60 with a better cosmetic appearance but it recurred in six months. Patient opted for intermittentdrainage if size of cyst increases against penetrating sclerokeratoplasty.Conclusions:Primary corneoscleral cyst though rare may arise post ocular trauma or surgery secondary toproliferation of anomalously situated epithelial or endothelial cells. Early imaging and placement ofsutures prevents dissection of the various ocular layers. Thus it is necessary to treat ocular traumacautiously including partial laceration wounds.

Spontaneous expulsive suprachoroidal haemorrhage in blind glaucomatous eyeJACQUELINE YL TING, PAN SHIN WEI, HUMAYUN AKHTER FAISALOphthalmology Department, Sibu Hospital.IntroductionTo describe two cases of spontaneous expulsive suprachoroidal haemorrhage (SESCH)Case ReportCase 1- A 76-years old lady presented to emergency with spontaneous left eye bleeding andhypertensive emergency. She had underlying uncontrolled hypertension, history of right eye cataractoperation, right eye angle closure glaucoma and left eye absolute glaucoma complicated with painlessleft blind eye. Ocular examination over left eye demonstrated presence of fresh bleed, expulsion oflens and prolapsed uveal contents while right eye examination was unremarkable with normalintraocular pressure (IOP). She subsequently underwent evisceration.Case 2- A 86 years old lady with no underlying medical illness presented with left eye spontaneousbleeding as well as hypertensive emergency. There was no ophthalmological history in her clinicalrecords other than history of bilateral cataract operation done in private hospital 10 years ago. Ocularexamination revealed no light perception over the affected eye and 6/18 in the other eye with normalIOP. There was prolapsed uveal contents with fresh bleeding and she underwent evisceration as well.ConclusionSESCH is a rare but serious sight threatening ocular condition associated with multiple risk factorsincluding arteriosclerosis, vascular disease, glaucoma, diabetes, intraocular malignancy and diseasedeye wall. Most cases reported involved patients with underlying glaucoma and cornea damage to acertain extent, suggesting the association between systemic factors and local ischemia of the posteriorciliary arteries. Although the exact mechanism is still debatable, thorough understanding of the riskfactors, pathophysiology and outcome may allow better management to prevent SESCH.Lesson LearntWe acknowledge that the incidence of SESCH is extremely rare and improvement in our managementis pivotal to prevent SESCH as it leads to devastating outcome.

Contribution & Achievement

Fracture-dislocation at C6-C7 level with Quadriplegia after Traditional Massage in a Patient with Ankylosing Spondylitis: A Case Report

Abilash Kumar AK, MD, Mohd Qayyumbazilin MQ, MBBS, Ahmad Zubair AH , M.Med Orth,Basir Towil BT, MS Orth

Department of Orthopaedics, Hospital Shah Alam, Shah Alam, MalaysiaDate of submission: 2 March 2017Date of acceptance: 1 June 2017

ABSTRACT

Ankylosing spinal disorders (ASD) tend to result infractures and/or dislocations after minor traumabecause of the altered biomechanical properties. Therelative risk of traumatic vertebral fractures in patientswith ankylosing spondylitis has been estimated asthree times higher than in the general population.These spine traumas, which are located at cervicallevel in 81% of patients with ankylosing spondylitis, arecomplicated by neurological lesions in 65% of patients,due to the high inherent instability of these fractures.Traditional massage is an ancient practice in manyparts of Asia. It has many benefits that are currentlyrecognized world-wide. However, it can be dangerousand even lethal if practised without adequateknowledge and skill. We report a case of C6-C7fracture-dislocation with complete neurology andneurogenic shock in a middle aged man withundiagnosed ankylosing spondylitis.

INTRODUCTION

Ankylosing Spondylitis (AS) is a seronegativespondyloarthropathy that primarily involves thevertebral column and the sacroiliac joints. It is achronic disease that typically starts before the age of30 and has a slow but steady progression. The diseasehas a characteristic caudal to rostral progression andovertime alters the strength and biomechanicalproperties of the spine through extensive remodellinginvolving ligamentous ossifications, vertebral jointfusion, osteoporosis and kyphosis 1. These changeslead to an increase in the segmental rigidity of thespine due to calcifications of soft tissue thatpredisposes to a risk of pathological fractures affectingthe spinal columns, hence resulting in spinal cord injury2. Typically, spinal fractures occur mostly in patientswith advanced age and therefore have inherentlypoorer outcome. Cervical spine fractures occur threetimes more frequently in patients with AS 3.The diagnosis of AS is based on clinical andradiographic features. The modified New York Criteriahas a high sensitivity and specificity; however, theymay not be helpful for early diagnosis of AS and theinvolvement of the sacroiliac joint remains the sine quanon for definite diagnosis.

The mean AS prevalence per 10 000 (from 36 eligiblestudies) was 16.7 in Asia 4. In this part of the world(including Malaysia), a small number of the populationtend to obtain treatment from traditional healers fortheir health problems before eventually seekingconventional professional medical advice. This hasresulted in delayed diagnosis and eventualmanagement of patients presenting in advanced stageof diseases, with challenges in treatment andprognosis.

CASE REPORT

We present a case of a 48-year old man, withundiagnosed ankylosing spondylitis who has beenpaying frequent visits to a traditional masseuse for hisneck pain from which he has been suffering for years.On his most recent visit to the masseuse, the massageproduced sharp pain at the nape of his neck andrendered him motionless.

On arrival at the emergency department, the patientwas noted to be quadriplegic. At this point of time hewas also suffering from bowel and urinaryincontinence. Examination of the upper limbsrevealed loss of power from C7 with hypoesthesia C5onwards, atonia and hyporeflexia. There was paralysisof the lower limbs, with atonia, hyporeflexia,hypoesthesia and loss of power from L2 downwards.Anal tone was lax however bulbo-cavernosus reflex(BCR) was present. He was noted to be in neurogenicshock with hypotension requiring ionotropic support.

On suspicion of a high spinal cord injury, an urgent CTof the cervical spine was done (as our facility lacks anMRI machine) (Fig. 1), The scan revealed fracture-dislocation of the C6 vertebra with facet jointsubluxation at C6/C7, retrolisthesis, significant canalstenosis, multiple facet and rib joint ankylosis andligament calcifications with syndesmophytes.Radiographic images of the spine showed the classical“bamboo spine” (Fig. 2) and destruction of thesacroilliac joints bilaterally.

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Malaysian Orthopaedic Journal 2017 Vol 11 No 2 Abilash Kumar AK, et alDoi: http://dx.doi.org/10.5704/MOJ.1707.013

I was fortunate to be given to opportunity to attend “The 2nd APTOS Symposium” in Hong

Kong on July 15 - 16, 2017. The Asia Pacific Tele-Ophthalmology Society (APTOS) was founded with

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

of living. Technological advances, when used to our advantage, can enable ophthalmologists to cut

across distance to provide quality medical services and improved accessibility of individuals, both

patients and medical practitioners alike. The objective of my trip is to widen my view on the current

advances in the field of tele- ophthalmology which has been my interest since medical school years.

Being an inventor and innovator myself, I am keen to learn more on latest imaging techniques,

artificial intelligence and tele-ophthalmology advances.

The Opening Session was featured by the

inauguration of the International Diabetic

Retinopathy Forum and 4 keynote lectures covering

deep learning, artificial intelligence, breakthroughs

in telemedicine and its applications. The rest of the

two days was filled with intensive lecturers of tele-

ophthalmology ideas and practices by doctors and

experts from all around the world such as China,

India, Japan, Australia, Singapore, Hong Kong,

United States of America, and Europe. Some of the

interesting lectures includes “Mobile Technology’s

Role in Advancing Ophthalmology” by Ms Divya

Nag from USA, the CEO of E-health Applc Inc.

describing how Apple Inc has built apps with

iPhone to help patients with Parkinson’s disease,

vision screening and health monitoring. Another

topic was “Tele-screening/Automated-screening for

Eye Diseases” by Dr Ryo Kawasaki from Japan,

describing the use of tele-ophthalmology use in

Japan for automated eye screening for the

community. “Deep Learning for Automated Retinal

Disease Assessment” was presented by Dr Varun

Gulshan from India on how artificial intelligence

performs deep learning and later being translated

to automated screening programs. Dr Yogesam

Kanasingam describes how a software is ised for

diabetic retinopathy screening in his topic “AI

Based Clinical Decision Support System for

Diabetic Retinopathy for Use by Primary Care

Medical Doctors in Australia”.

I have presented a free paper based on

an app I have built titled “REST – An Innovative

Rapid Eye Screening Test” and received

positive response from the audience. There

were medical officers from China that was

interested to us my app as a study subject and

would like to do further collaboration.

I have also presented a video presentation on

“Wireless Smartphone Videography for Ocular

Surgery System”. The presentation and

introduction of my idea to the rest of the world

has also open up a new opportunity for further

collaboration for my creation and innovations.

I have also taken the opportunity to visit

the oversea ophthalmic imaging company booth

and learn more on the new tele-ophthalmology

gadgets which is mostly not available in

Malaysia. There was portable smartphone

fundus camera, portable smartphone anterior

segment camera, artificial intelligent program for

automated diagnosis and grading. Overall the

experience of APTOS was great giving new

ideas to the world of tele- ophthalmology.

APTOS 2018 will be held in Singapore and

looking forward to look at new technologies and

advancement in ophthalmology.

by Dr. Chan Jan Bond

Ophtalmologist

Hospital Shah Alam

Dr. Chan Jan Bond with Dr Ming Guang He (President of APTOS)

Dr. Chan Jan Bond Free Paper presentation at APTOS

Asia Pacific Tele-Ophthalmology Society (APTOS) 2017 Conference – Report

The patient was transferred to a regional spinereferral centre where MRI of the cervical spineconfirmed the CT findings, with additional informationon cord compression causing cord oedema at the levelof C6, ligamentous injury, paravertebral and marrowoedema.

He was diagnosed with C6-C7 fracture dislocation withspinal stenosis and retrolisthesis with completeneurology (ASIA A) in neurogenic shock withunderlying ankylosing spondylitis. The injury wascaused by excessive hyperextension of the neck,which is a common technique practised during themassage. At the spine centre, the patient underwentposterior spinal instrumentation and fusionC4/C5/C7/T1 with laminectomy of C3-C5 (Fig. 3).

Despite our efforts, post-operative assessmentshowed no change in his neurological state whichremained at ASIA A. The patient is currentlyundergoing a spinal rehabilitation programme. Aninteresting finding in this patient was that the HLA-B27 gene tested negative despite fulfilling all points inthe Modified New York Criteria for AnkylosingSpondylitis, with radiological appearance of theclassical 'bamboo spine'' of AS. Statistic show that inthe United Kingdom, HLA-B27 is present in 90-95% ofpatients with ankylosing spondylitis 5. (Theramifications of HLA-B27, Nicholas J Sheehan)

DISCUSSIONMassage therapy is recognized as one of the oldestmethods of healing, with references in ancientmedical texts going back to 4,000 years. Hippocrates,the father of medicine, had referred to massage whenhe wrote, in the 4th century B.C.: "The physician mustbe acquainted with many things, and assuredly withrubbing."

Fig. 1: CT cervical spine: sagittal view showing

fracture-dislocation of C6 vertebra with facet joint

subluxation at C6/C7.

Traditional massage has remained a form of culturalnorm especially for a small section of the Asiancommunity for many centuries now. However at times,therapists' without knowledge on the patientsunderlying predisposing comorbid conditions andfragilities, tend to push boundaries leading tocatastrophe. It was unfortunate that this particularpatient with underlying AS went undiagnosed and hadresorted to traditional treatment without anyknowledge of this condition. A lot of emphasis has beenplaced on early detection and prevention of suchconditions and it is our role to educate and developawareness in the community to prevent furtherdisasters as in this case.

The majority of cervical spine fractures in ASD aretransdiscal extension injuries, most commonly affectingC6–C7 just as observed in our patient. ASD is prone tofracture after minor trauma due to its poor elasticity.Patients with ASD often end up with neurologicalcomplications and incomplete neurologic recovery.Most patients with such complications were oftenunable to cite a specific causative trauma. Timelyidentification of ankylosing spondylosis is instrumentalin avoiding the advanced sequelae of this catastrophicdisease.

Fig. 2: Plain

radiograph showing

“bamboo spine.”

Fig. 3: Radiograph

following posterior

spinal istrumentation and

fusion of C4/C5/C7/T1.

Page 14 Page 15

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Page 18

All research conducted in KKMHospitals MUST be registered withNMRR (www.nmrr.gov.my) and haveMREC approval.

All Publication or Presentationposter/oral MUST have DirectorGeneral of Health approval.

• NMRR User & Research

Registration

• Introduction To Clinical Research

• Good Clinical Practice

• Research Methodology

• Statistical Workshop

• Critical Appraisal

• Oral & Poster Presentation

• Medical Writing Workshop

• Consultation Research Clinic

• Statistic Consultation Clinic

• National Malaysia Research

Registration (NMRR) Online

registration

• Conduct technical review of research

protocol submitted to NMRR

• Assist in submission of research papers

for publication & presentation

• Assist in research grant application

• Conduct research training for HSAS

staffs

CLINICAL AUDIT 2017 HOSPITAL SHAH ALAM

No Projects:

1 Surgery: Transfer Time to OT for Emergency Surgery

2 Anaesthesiology: Hand Hygiene Practice in ICU

3 Pathology: An Audit on Improving Critical Value Notification by Laboratory

Personnel to Requesting Doctors

4 Ophthalmology: Clinical Audit of Post-Operative Outcome in Cataract

5 Nursing Unit: Audit Klinikal Terhadap Amalan ISBAR dikalangan Jururawat

Semasa Proses Penyerahan Tugas di Wad-Wad Hospital Shah Alam

6 Paediatric: Hypothermia in Preterm infants less than 32 weeks

7 Orthopaedic: Osteoporotic Fracture and Treatment

8 ORL: Waiting Time in ORL Clinic

9 O&G: Clinical Audit on Underestimation of Blood Loss After Vaginal

Delivery

10 Radiology: Clinical Audit on CTPA Quality 2016

11 Emergency and Trauma Department: Waiting Time in Green Zone

12 Medical: Delayed Admissions to Medical Wards

13 Pharmacy: Delay in Notification of near Expiry and Slow Moving Ward

Medications in HSAS

14 Oral Surgery: To Reduce Repetition of Intraoral Periapical (IOPA)

Radiograph at oral Surgery Department

1. Anaesthesiology 2. Pharmacy 3. Medical

1. Pharmacy 2. Oral Surgery 3. Anaesthesiology

Page 19