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Publisher: Universiti Kebangsaan Malaysia   (Total: 11 journals)   [Sort by number of followers]

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3L : Language, Linguistics, Literature     Open Access   (Followers: 28, SJR: 0.251, CiteScore: 0)
Akademika : J. of Southeast Asia Social Sciences and Humanities     Open Access   (Followers: 7)
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Journal of Surgical Academia
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ISSN (Print) 2231-7481
Published by Universiti Kebangsaan Malaysia Homepage  [11 journals]
  • Recurrent Orbital Cellulitis Secondary to the ‘Forgotten’
           Scleral Buckle: A Case Report

    • Authors: ahlina
      Abstract: Author(s):  Hor SM Noor Aniah A Mushawiahti M Malisa A Bastion MLC Issue:  Vol. 7 No. 2 : 2017 Correspondance Address:  Mae-Lynn Catherine Bastion. Department of Ophthalmology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +603-91457207 Fax: +603-91456733 E-mail: Full text:  <div> <p> <strong>Introduction</strong></p> <p> &nbsp;</p> <p> Scleral buckling with exoplant has been an effective method in treating primary rhegmatogenous retinal detachment for more than 50 years (1). Long-term complications include induced myopia, diplopia, strabismus, foreign body sensation, infection, extrusion, intrusion, anterior segment, retinal and choroidal ischaemia (1,2). Complications may present years after surgery with different clinical manifestation (1). Infection of scleral buckle remains a significant complication and can results in orbital infection. Almost all cases are resistant to antimicrobial treatment and removal of buckling elements is required for resolution (3). Anterior segment necrosis is another serious complication of scleral buckle. Wilson et al reported up to 8.2% of eyes had anterior segment necrosis while performing post mortem in eyes with scleral buckle (4).</p> <p> &nbsp;</p> <p> In this case report, we describe a case of recurrent orbital cellulitis with anterior segment ischemia induced by a forgotten and missed silicone scleral tire from previous retinal detachment surgery.&nbsp;</p> <p> &nbsp;</p> <p> <strong>Case Report</strong></p> <p> &nbsp;</p> <p> An 85-year-old woman presented with one-day history of recurrent painless eye redness, yellowish discharge and swelling of the left eye associated with one-month history of blurred vision. She was treated for left orbital cellulitis, &lsquo;choroidal detachment&rsquo; and was investigated for possible underlying malignancy in another eye center one month prior to presentation.</p> <p> &nbsp;</p></div><p> &nbsp;</p><div> <p align="center"> <img height="140" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image002.gif" width="551" /></p> <p> &nbsp;</p> <p> <strong>Figure 1</strong>: a) Anterior segment photograph of the left eye at presentation. Left conjunctiva was injected, chemosed with corneal vascularization nasally. Mucopurulent discharge with left lower lid entropion were noted. Pupil was rigid and could not be dilated beyond the size shown in the photograph; b) Rubeosis iridis was seen in left eye at the pupil margin in this slit anterior segment photograph during presentation; c) Conjunctiva injection and rubeosis iridis of left eye improved one week after removal of scleral buckle with intracameral ranibizumab.</p> <p> &nbsp;</p> <p align="center"> <img height="277" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image004.gif" width="385" /></p> <p> &nbsp;</p> <p> <strong>Figure 2</strong>: a) Hyperechoic scleral buckle indenting the globe with vitreous opacity; b) Axial and coronal view computed tomography of the orbit showed hyperdense structures (scleral buckle, arrow) encircling both globes with right pthisical bulbi; c) Encircling scleral buckle (silicone tire with Watzke sleeve) which was removed and sent for culture.</p> <p> &nbsp;</p></div><p> &nbsp;</p><p> She had underlying diabetes mellitus, hypertension, ischemic heart disease, chronic obstructive pulmonary disease and dementia. Cataract extraction was done in both eyes 15 years ago. Her right eye was blind which her family members were unsure of the cause. They were unable to provide any other past ocular or surgical history.</p><p> &nbsp;</p><p> Ocular examination revealed her right vision was no perception to light and left vision was hand movement. Her right eye was pthisical. The left eyelids were swollen with lower lid entropion and mucopurulent discharge (Fig. 1a). The conjunctiva was injected, cornea was hazy, rubeosis iridis was seen with anterior chamber cells of 3+ (moderate inflammation in between the cornea and iris). Pupil was rigid with maximum dilatation of 3 mm (Fig. 1b). Le...
      PubDate: Fri, 24 Nov 2017 03:42:51 +000
  • Antenatal Myomectomy: Is It Safe'

    • Authors: ahlina
      Abstract: Author(s):  Nor Amirawati A Anizah A Shafiee MN Issue:  Vol. 7 No. 2 : 2017 Correspondance Address:  Anizah Ali. Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +60391455960 Fax: +603-91456672 Email: Myomectomy is rarely performed in pregnancy due to risk of miscarriage or pregnancy loss, bleeding and possible hysterectomy. Myomectomy is mainly reserved for unavoidable indications such as rapidly growing fibroid or severe pain with possiblity of red degeneration for which medical treatment failed. However, good outcome had been reported in selective second trimester myomectomies. Full text:  <p> <strong>Introduction</strong></p><p> &nbsp;</p><p> The prevalence of leiomyomas during pregnancy varies from 0.3 to 15% (1). Leiomyomas mostly remains asymptomatic during pregnancy but in 10% of cases, it causes obstetric complications depending on their size, location, and number (2). Pain is the most common symptom reported however it rarely necessitates myomectomy (3). To date, limited literature exists to serve as reference with regards myomectomy in pregnancy. Available literatures are mainly restricted to case reports and retrospective studies. As such, a surgical approach is usually reserved for cases of intractable abdominal pain or persistent gastroenteric and urinary symptoms despite pharmacological treatment (4-6). Majority of the reported myomectomies were performed in second trimester for intractable pelvic pain and had excellent results. We are reporting two cases of unavoidable myomectomies in second trimester with good outcome throughout the pregnancy (7,8).</p><p> &nbsp;</p><p> &nbsp;</p><p> &nbsp;</p><p> &nbsp;</p><p> &nbsp;</p><p> <strong>Case Report</strong></p><p> &nbsp;</p><p> <em>Case 1</em></p><p> &nbsp;</p><p> A 28-year old primigravida presented with severe right iliac fossa pain and mass per abdomen at 13 weeks and 5 days period of amenorrheoa. She experienced it for 2 days prior to presentation. She had sudden onset of pain with pain score of 7/10. There were no aggravating factors and the pain was not radiating. She was unable to sit up for a long time and thus affected her daily activities. Otherwise, there were no urinary or bowel symptoms.</p><p> &nbsp;</p><p> Assessment revealed that she was in pain and distressed. She was tachycardic but remained stable and a febrile. Abdomen was soft but tender with voluntary guarding. Uterus was palpable at 16 weeks size with a right iliac fossa mass measuring 6x6 cm. The mass has normal overlying skin, regular border, firm in consistency and mobile side to side but unable</p><p> &nbsp;</p><p> &nbsp;</p><p> &nbsp;</p><p> &nbsp;</p><p> &nbsp;</p><p> to get below the mass. Vaginal examination revealed normal vulva and vagina, cervix was tubular and os closed. Uterus was at 16 weeks size bimanually and mass was attached to uterus. Other systems were unremarkable.</p><p> &nbsp;</p><p> Investigations showed she had normochromic normocytic anaemia with haemoglobin of 10.8 g/dL, white cell count was normal 7.8x109/L and normal platelet level. A pedunculated fibroid which measured 6.8x6.6cm was seen on transabdominal ultrasound. There were no complex appearance or cystic changes noted. Fetus was viable with parameters corresponded to her gestational age and placenta was posterior not low lying.</p><p> &nbsp;</p><p> Diagnosis of penduculated uterine fibroid was made. She was treated with regular intravenous opiods. However, despite adequate analgesia, her pain score was not reduced. She was then subjected for emergency laparotomy myomectomy due to intractable pain having failed medical management. Upon entry to her pelvis, uterus was noted to be enlarged to 16 weeks size with a subserosal fibroid at right posterolateral wall (Fig. 1). It measured 6 x 8cm and had paper thin stretched subserosal layer covering the tumour. Myomectomy procedure was uneventful, uterine incision was closed with vicryl 1/0. Hemostatic agent also was placed at incision site and estimated blood loss was only 200ml. Symptoms markedly improved post-operatively and she was discharged home the subsequent day. Histopathology report showed interlacing fibers of smooth muscle with spindle shaped cells, bland looking and elongated nuclei with abundant eosinophilic cytoplasm. There were also dilated and congested blood vessels ...
      PubDate: Fri, 24 Nov 2017 03:32:39 +000
  • A Dilemma in Management of Intrauterine Death in Mother with Major
           Placenta Previa

    • Authors: ahlina
      Abstract: Author(s):  Rima Anggrena D Yulianty A Nor Azlin MI Issue:  Vol. 7 No. 2 : 2017 Correspondance Address:  Rima Anggrena Dasrilsyah. Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +603-91455949 Fax: +603 91456672 E-mail: Full text:  <div> <p> <strong>Introduction</strong></p> <p> &nbsp;</p> <p> Placenta previa is a condition when the placental tissue extends over the internal cervical os. Its incidence ranged from 3.5-4.6 per 1000 birth and contributed by combination of factors due to rising number of caesarian sections and increasing maternal age (1,2,3). Placenta previa is associated with maternal and fetal morbidity and mortality. The management is complicated, especially when deals with intrauterine death. It is indeed a challenge in decision making of its management for the best interest of patient and the unborn fetus.</p> <p> &nbsp;</p> <p> <strong>Case Report</strong></p> <p> &nbsp;</p> <p> A 30-years-old housewife, gravida 3 para 2 at 33 weeks gestation with underlying gestational diabetes mellitus on diet modification with history of two spontaneous vertex deliveries, was diagnosed with placenta previa major at 28 weeks period of amenorrhea. She never had any per vaginal bleeding or abdominal pain. Unfortunately, at 29 weeks gestation, she was diagnosed with intrauterine death and opted for conservative management with weekly full blood count and coagulation profile.</p> <p> &nbsp;</p> <p> She remained well until 33 weeks gestation when she presented to emergency department with increased vaginal bleeding. On assessment, she was pale, her blood pressure was 132/74mmHg, pulse rate of 114 beats/minute and afebrile. Abdominal examination was soft and non-tender, uterus of 28 weeks size, singleton, longitudinal lie and cephalic presentation five fifth palpable. Speculum examination showed blood clots with cervical os open. Vaginal examination revealed cervical os of 3cm with bulging membrane and placental edge felt.</p> <p> &nbsp;</p> <p> She was admitted and given epidural. The labour was augmented and cervical os was fully dilated after three hours. She was encouraged to bear down after artificial rupture of membrane. However, as anticipated, there was no descend of fetal head due to placenta. In view of increased vaginal bleeding with clots, attending specialist decided to remove the placenta manually</p></div><p> &nbsp;</p><div> &nbsp;</div><p> &nbsp;</p><p> followed by delivery of the fetus.&nbsp; The placenta was removed in one piece and no true knot noted at the umbilical cord. Intravenous carbetocin was given and uterus contracted 20 weeks size. Perineum was intact and no active bleeding. The estimated blood loss was 1000ml.</p><p> &nbsp;</p><p> Patient delivered a macerated baby girl weighing 1.42kg. There was no gross abnormality seen.&nbsp; The histopathology result of the placenta sent showed uteroplacental insufficiency with placenta infarction and atheroma. There was no growth in placental swab culture.</p><p> &nbsp;</p><p> <strong>Discussion</strong></p><p> &nbsp;</p><p> There are only small numbers of reported cases of intrauterine death with placenta previa. These patients were managed differently depending on case to case basis. To date there is still no general consensus the best way to manage such cases. However, in general, placenta previa with fetal death can be managed in 3 main ways.</p><p> &nbsp;</p><p> Approximately about 85% women with intrauterine death will deliver spontaneously within 3 weeks of diagnosis (4). Theoretically, uteroplacental blood perfusion will decrease causing placental atrophy. Thus, it can reduce the blood loss during vaginal delivery (5). Unfortunately, expectant management could have disadvantages as 10% of patient may develop DIVC within one month after fetal demise (6). Therefore, women who delay in labour for periods longer than 48 hours should be advised to have DIVC testing twice weekly (2). Risk of intrauterine infection will also increase in time. Furthermore, keeping dead baby can lead to psychological stress to the mother. A Sweedish study in 1996 shows in interval of 24 hours or more from the diagnosis of death in utero to start of labour, there is increase of moderately severe anxiety or worse (7).</p><p> &nbsp;</p><p>...
      PubDate: Fri, 24 Nov 2017 03:24:58 +000
  • First Trimester Placenta Accreta: A Rare Clinical Entity and Diagnostic

    • Authors: ahlina
      Abstract: Author(s):  Ng BK Wang PY Ng WYL Mohammed F Lim PS Mahdy ZA Issue:  Vol. 7 No. 2 : 2017 Correspondance Address:  Ng Beng Kwang. Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +603-91455949 Fax: +603-91456672 E-mail:, Full text:  <div> <p> <strong>Introduction</strong></p> <p> &nbsp;</p> <p> Morbidly adherent placenta (MAP) or abnormally invasive placenta (AIP) is a potential life-threatening emergency that might lead to significant morbidity and mortality (1). It occurs in 1.32-3.27/ 1000 pregnancies and the incidence have been rising particularly with the increasing trend of caesarean sections (2,3). AIP in the first trimester is rare and more challenging due to difficulty in diagnosis (4). Therefore, most of the cases of first trimester AIP were diagnosed intra-operatively while performing surgical evacuation for miscarriages (5). We report a case of an incidental finding of placenta accreta during evacuation of product of conception (ERPOC) for missed miscarriage. Intra-operatively this was complicated with excessive bleeding requiring hysterectomy and bilateral internal iliac artery ligation.</p> <p> <strong>Case Report</strong></p> <p> &nbsp;</p> <p> A 33-year-old Gravida 4 Para 2 + 1 at 15 weeks 3 days period of amenorrhea (POA) was electively admitted for ERPOC. She had a history of surgical evacuation for incomplete miscarriage at 11 weeks of gestation and a previous lower segment caesarean section for oblique lie. She was diagnosed to have a missed miscarriage at 12 weeks POA. Trans-vaginal scan showed an intrauterine pregnancy with a fetal pole measuring 9.6 mm without fetal cardiac activity (Fig. 1). She was then admitted at 14 weeks for medical management. Misoprostol 400mg was given twice per vaginally but was unsuccessful. She opted for surgical evacuation after a week of rest.</p> <p> &nbsp;</p> <p> Intra-operatively, uterus was 8 weeks&rsquo; size and anteverted. During evacuation, there was profuse</p></div><p> &nbsp;</p><div> &nbsp;</div><p> &nbsp;</p><div> <p> vaginal bleeding after 20 cc of product of conception was removed. A decision was made for an exploratory laparotomy and hysterectomy with bilateral internal iliac ligation in view of persistent bleeding. Total estimated blood loss was 6.2 liters. She was transfused with 9 units of packed cells, 4 unit of fresh frozen plasma, 8 unit of platelet and 12 units of cryoprecipitate.&nbsp; She was nursed in the intensive care unit for 2 days without the need of inotropic support. She was discharged well on day 4 post-operatively. Histopathological examination showed products of conception confirmed with evidence of placenta accreta (Fig.2).</p> <p> &nbsp;</p> <p> <strong>Discussion</strong></p> <p> &nbsp;</p> <p> Three degrees of abnormal placental adherence can be distinguished i.e. accreta (superficial invasion), increta (invasion deeper into myometrium) and percreta (invasion into or through the uterine wall); due to a defect in the decidua basalis (6). Predisposing factors include advanced maternal age, multiparity, history of uterine surgery such as caesarean section, uterine curettage or myomectomy (2,3,7). With the advancement in radiological imaging, the diagnosis of AIP can usually be established prenatally between 18-37 weeks (7). However, diagnosis of AIP during first trimester remains challenging as typical findings of AIP might not be present and there may be a low index of suspicion as in this case.</p> <p> &nbsp;</p> <p> Several reports have described the use of ultrasonography in the first trimester to detect AIP. Presence of a well-vascularised hyperechoic lesion, loss of endometrium-myometrium interface, low resistive index and myometrium thinning near the lesion are all suggestive of AIP (6). A study by Rac et al. demonstrated that smaller anterior myometrial thickness measured in the sagittal plane significantly<br clear="all" /> improved prediction of placental invasion; whereas, distance from the gestational sac to the external os, location of the decidual basalis, presence of anechoic areas and uterine-bladder interface irregularity did not (8). Thi...
      PubDate: Fri, 24 Nov 2017 03:20:25 +000
  • Colonic Metastasis from an Invasive Lobular Carcinoma of the Breast

    • Authors: ahlina
      Abstract: Author(s):  norfaidhi akram MN Samuel T Norly S Ros’aini P Issue:  Vol. 7 No. 2 : 2017 Correspondance Address:  Norfaidhi Akram Mat Nor. Department of Surgery, Hospital Pakar Sultanah Fatimah, Jalan Salleh, 84000 Muar, Johor, Malaysia. Tel: 00-60-17-6886756 Fax: 00-60-6-9526003 E-mail: Breast carcinoma to the colon and rectum is rare type of metastatic spread. We report a case of colonic metastasis from a lobular carcinoma of the breast twelve years after the initial diagnosis. Accurate diagnosis and early treatment of systemic therapy can be done if awareness is increased. Full text:  <p> <strong>Introduction</strong></p><p> &nbsp;</p><p> Regardless of sex in Malaysia, most common cancer is breast cancer (1).&nbsp; The two most common histologic types of breast cancer are invasive ductal and lobular carcinoma. Breast cancers typically metastasize to the lungs, liver and bones. In patients with disseminated disease, few reports of colonic metastasis from breast cancer can be found (2). The risk of developing metastasis is there despite long disease free interval (3). In the present study we report a case of colonic metastasis from a lobular carcinoma of the breast twelve years after the initial diagnosis.</p><p> &nbsp;</p><p> <strong>Case Report</strong></p><p> &nbsp;</p><p> A 60-years-old lady was diagnosed with left breast invasive lobular carcinoma 12 years prior to current presentation.&nbsp; She underwent a left modified radical mastectomy with level II axillary clearance, followed by 6 cycles of chemotherapy and 15 cycles of radiotherapy.&nbsp; She also completed 5 years of hormonal therapy (tamoxifen).&nbsp; Four years ago she developed metastasis to both her ovaries.&nbsp; She was then subjected to a total abdominal hysterectomy with bilateral salpingo-oopherectomy and omentectomy.&nbsp; Following that she had another 6 cycles of chemotherapy (Doxetaxel).&nbsp; She had been well until September 2016 when she developed lower abdominal pain.&nbsp; A contrast enhanced computed tomography scan of the thorax, abdomen and pelvis revealed a long segment wall thickening involving the whole of the large bowel.&nbsp; A colonoscopy examination was done and it showed inflammed mucosa up to 20 cm from the anal verge.&nbsp; The biopsy of the colon revealed metastatic lobular breast carcinoma (Fig. 1). Following she underwent six cycles of CMF (cyclophosphamide, methotrexate, 5-flurouracil).&nbsp; Currently, she is asymptomatic from the colonic point of view at the moment.&nbsp; Literature review on the management of colonic metastasis from the breast was done and discussed.</p><p> &nbsp;</p><p> <strong>Discussion</strong></p><p> &nbsp;</p><p> Among all breast adenocarcinomas, lobular carcinoma accounts for only 8-14%.&nbsp; The metastatic pattern of lobular carcinoma is more towards unusual locations such as gastrointestinal tract, gynaecological organs and peritoneum. A PubMed review revealed a narrowed number of reports of breast cancer with metastatic spread to the colon and rectum (less than 50 cases).&nbsp;&nbsp;</p><p> &nbsp;</p><p> In reported literature, the duration from the diagnosis of breast cancer to presentation of gastrointestinal metastasis ranged from synchronous presentation to 26 years after the initial diagnosis (4). Our patient presented 12 years after the initial diagnosis. The<br clear="all" /> <img height="219" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image002.jpg" width="294" /></p><p> &nbsp;</p><p> <strong>Figure 1</strong>: Hematoxylin and eosin stain at 200x magnification showed light microscopy image showing malignant tumour cells dispersed throughout lamina propria of large intestine (yellow arrow), some of which were present in a simple file strands. The image showed fragments of colonic mucosa with no ulcer of dysplasia (red arrow). In further studies, the malignant cells are positive for CK7 and ER (3+, in 90% cells). They are negative for CK20, PR, leucocyte common antigen, TTF-1 and e-cadherin.</p><p> &nbsp;</p><p> clinical presentation is varied and non-specific.&nbsp; It is difficult to differentiate metastatic breast to colon from a primary colon or rectal cancer.&nbsp; This can make the diagnosis difficult and often unexpected.&nbsp; It may also lead to inappropriate management and chemotherapy regime.<...
      PubDate: Fri, 24 Nov 2017 03:08:32 +000
  • Lupus Nephritis with Visual Field Defect Secondary to Hypertensive
           Retinopathy: A Case Report

    • Authors: ahlina
      Abstract: Author(s):  Hor SM Norshamsiah MD Mushawiahti M Hazlita MI Issue:  Vol. 7 No. 2 : 2017 Correspondance Address:  Norshamsiah Md Din. Department of Ophthalmology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +603-91457207 Fax: +603-91456733 Email: Full text:  <div> <p> <strong>Introduction</strong></p> <p> &nbsp;</p> <p> Systemic lupus erythematosus (SLE) is an autoimmune disease with a wide range of clinical manifestation which can affect any organ in the body (1). Secondary malignant hypertension resulting from renal parenchymal lesion is part of the disease entity. Malignant hypertension may affect the eye in various ways but grade III or IV hypertensive retinopathy with ischemic retinal injury can be visually disabling. Cotton wool spots seen in grade III and IV hypertensive retinopathy indicates microinfarction of the retinal nerve fibers and neuronal loss which can<br clear="all" /> results in subsequent related scotoma (2). Hereby, we describe a case of lupus nephritis with grade 4 hypertensive retinopathy presenting with multiple peripapillary cotton wool spots which eventually causes permanent visual field defect. &nbsp;&nbsp;</p> <p> &nbsp;</p> <p> <strong>Case Report</strong></p> <p> &nbsp;</p> <p> A 23-year-old lady presented with both eye progressive painless blurring of vision for two weeks in 2011. Prior to that she had malar rash, hair loss, photosensitivity and bilateral leg swelling. The past medical and family history were insignificant.</p> <p> &nbsp;</p></div><p> &nbsp;</p><div> <p align="center"> <img height="506" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image002.gif" width="478" /></p> <p align="center"> &nbsp;</p> <p> <strong>Figure 1</strong>: a) Optic disc photo taken in year 2011 showed hypertensive retinopathy as evidenced by hyperemic swollen disc, extensive peripapillary cotton wool spots and flame shape haemorrhages; b) Optic disc photo taken in 2016 showed pink optic disc with cup/disc ratio 0.3, no neuroretinal rim thinning, scant gliosis more on right eye; c) OCT RNFL showed thinning of bilateral temporal quadrant, right nasal quadrant and left infero-nasal quadrant.</p> <p> &nbsp;</p></div><p> &nbsp;</p><div> <p> Ocular examination showed that visual acuity on the right was 6/60 and left 6/24. There was no relative afferent pupillary defect. Anterior segment and intraocular pressure were normal. Fundoscopic examination showed bilateral optic disc swelling with blurred disc margin, extensive peripapillary cotton wool spot (CWS), flame shape haemorrhages, dilated and tortous vessels and macular oedema (Fig. 1a). Systemic examination showed blood pressure of 176/111 mmHg, malar rash, discoid rash over the scalp, alopecia and vasculitic lesions over her palms.</p> <p> &nbsp;</p> <p> The blood investigation showed positive ANA/dsDNA, low C3/C4, macrocytic anemia with positive direct coomb&rsquo;s test and raised reticulocyte count. Urinalysis showed proteinuria with microscopic haematuria and renal biopsy revealed diffuse active proliferative and membranous lupus nephritis (WHO class IV &amp; V) with 56% cellular crescent. Otherwise, the renal function test was normal and computed tomography (CT) of the brain did not show features of posterior reversible encephalopathy syndrome (PRES).</p> <p> A diagnosis of SLE with grade IV hypertensive retinopathy secondary to lupus nephritis, autoimmune hemolytic anemia and discoid lupus was made. She was treated with intravenous (IV) methylprednisolone, double-filtration plamapheresis with IV immunoglobulin and IV cyclophosphamide. Subsequently, the prednisolone was tapered off and she was maintained on HCQ 200mg daily.</p> <p> &nbsp;</p> <p> She was seen in Ophthalmology clinic for screening of hydroxychloroquine toxicity. Throughout the follow up, her visual acuity remained stable at 6/9 in both eyes</p></div><p> &nbsp;</p><div> <p align="center"> <img height="759" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image004.gif" width="354" /></p> <p> <strong>Figure 2</strong>...
      PubDate: Fri, 24 Nov 2017 03:02:25 +000
  • Congenital Peritoneal Band Causing Bowel Ischaemia Post Caesarean Section:
           A Rare Occurrence

    • Authors: ahlina
      Abstract: Author(s):  Phon SE Ng BK Ng WYL Rahman RA Zainuddin AA Mahdy ZA Issue:  Vol. 7 No. 2 : 2017 Correspondance Address:  Ng Beng Kwang. Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +603-91455949 Fax: +603-91456672 E-mail:, Full text:  <div> <p> <strong>Introduction</strong></p> <p> &nbsp;</p> <p> Early post-operative small bowel obstruction is not uncommon after abdominal surgeries with significant morbidity and mortality rate of 2-5% (1). It remains challenging and puts surgeons around the world in tremendous dilemma, in terms of its diagnosis and management. There are numerous causes of bowel obstruction, including adhesions or strictures. We described a case of post caesarean section small bowel obstruction secondary to a rare congenital anomaly band.</p> <p> &nbsp;</p> <p> <strong>Case Report</strong></p> <p> &nbsp;</p> <p> A 42-year-old Gravida 2 Para 1 underwent an uncomplicated emergency lower segment caesarean section for fetal distress. Her antenatal care had been uneventful with no history of prior abdominal surgery or trauma.</p> <p> &nbsp;</p> <p> On day one post operatively, she complained of epigastric discomfort associated with vomiting. On examination, her blood pressure was 124/82 mmHg with pulse rate of 92 beats/minute. She was afebrile. Her abdomen was not distended, soft but tender upon palpation only over the incision site. The uterus was well contracted at 18 weeks&rsquo; size. There was no other mass palpable. Bowel sounds were normal. She was treated symptomatically with anti-emetics and antacids.</p> <p> &nbsp;</p> <p> However, on the following day, her abdominal pain worsened, especially over the right flank, which was</p></div><p> &nbsp;</p><div> <p align="center"> <img height="206" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image002.gif" width="393" /></p> <p> <strong>Figure 1</strong>: a) Axial CT scan showing distension of small bowel loops with diffuse wall thickening (*) and extensive mesenteric oedema (arrow); b) Saggital CT image showed abrupt tapering of the dilated small bowel in keeping with transition zone (arrow).</p> <p> &nbsp;</p> <p align="center"> <img height="188" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image004.gif" width="393" /></p> <p> <strong>Figure 2</strong>: a) Laparotomy view showing the ischaemic bowel open entering the abdominal cavity; b) Arrow showing the area of constricture due to the congenital anomaly band that loops around the affected small bowel</p> <p> &nbsp;</p></div><p> &nbsp;</p><p> associated with abdominal distension and bilious vomiting. She was tachycardic, but her blood pressure remained normotensive. On examination, the abdomen appeared grossly distended, with tenderness over the right flank.&nbsp; Rebound tenderness was positive and bowel sounds were sluggish. Blood investigations revealed leukocytosis with the total white cells of 11.6 x 10<sup>9</sup>; otherwise, serum electrolytes were within normal limits.</p><p> &nbsp;</p><p> An urgent abdominal CT scan was performed, which confirmed a marked small bowel dilatation with ascites (Fig. 1). An emergency exploratory laparotomy was performed for suspected small bowel obstruction. Intra-operatively there was 160 cm of ischemic small bowel (Fig. 2). A congenital band was found extending between the right fimbria end and the small bowel mesentery, looping over the small bowel and constricting it. The ischemic portion of small bowel was resected and primary anastomosis was performed. The patient was nursed in intensive care unit for 2 days, and was discharged home after 4 days post operatively. Histopathological examination confirmed an ischemic bowel.</p><p> &nbsp;</p><p> <strong>Discussion</strong></p><p> &nbsp;</p><p> Early post-operative small bowel obstruction (EPOSBO) is defined as temporary retu...
      PubDate: Fri, 24 Nov 2017 02:50:46 +000
  • Schwannoma of the Common Peroneal Nerve – A Rare Incidence

    • Authors: ahlina
      Abstract: Author(s):  Tan JA Levin KB Rhani SA Hisam A Issue:  Vol. 7 No. 2 : 2017 Correspondance Address:  Shaharuddin Abd. Rhani. Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +603-91457330 Fax: +603-91726473 E-mail: Full text:  <div> <p> <strong>Introduction</strong></p> <p> &nbsp;</p> <p> Schwannomas are slow growing, well capsulated, benign tumours that arise from neurilemmal cells which form the myelin sheath of peripheral nerves. It occurs more in females and usually in the fourth and fifth decade of life. It is the most common solitary nerve tumour in the body with the most common site being in the head but may also be found in the brachial plexus and the sciatic nerve. Rarely, it presents in the lower extremities, but if it does, it usually arises from the deep layers of the foot (1). Unlike Neurofibromas, Schwannomas are benign and have less than one percent chance to become malignant in the form of a neurofibrosarcoma. Patients presenting with multiple Schwannomas are usually associated with type 2 Neurofibromatosis or Schwannomatosis (2). Traditionally it is believed that Schwannomas do not breech the fascicles of the nerve, instead, it just sits on the myelin sheath. Hence, most patients are asymptomatic until a lump is noted, or when nerve irritation occurs secondary to mechanical compressive effects (3). We report a rare case of a patient presenting with a Schwannoma over the right common peroneal nerve, with the tumour found to be in continuity with the fascicles of the nerve during surgical dissection. The incidence of common peroneal nerve schwannoma is not known, however to date, there are only less than 10 known case reports in the literature since the year 1995 (1,3).</p></div><p> &nbsp;</p><div> <p align="center"> <strong><img height="214" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image002.jpg" width="382" /></strong></p> <p style="margin-left:142.5pt;"> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (a)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (b)</p> <p> <strong>Figure 1: </strong>a) Sagittal T2-weighted MRI showing a hyperintense lesion along the common peroneal nerve lying between the biceps femoris tendon and lateral head of gastrocnemius muscle (arrow); b) Lesion was not suppressed by fat suppression sequence. (arrow).</p> <p align="center"> <strong><img height="277" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image004.jpg" width="382" /></strong></p> <p> <strong>Figure 2: </strong>Biphasic tumour composed of compact areas of spindle cells (Antoni A) with palisading Verocay bodies and loosely cellular areas (Antoni B). Maginification of image: 25X</p> <p> &nbsp;</p></div><p> &nbsp;</p><p> <strong>Case Report</strong></p><p> &nbsp;</p><p> A 50-year-old gentleman was referred to the orthopaedic clinic for pain and swelling over the right popliteal fossa which was gradually increasing in size over the past 6 months. It was associated with worsening radicular pain along the anterolateral aspect of the right leg which was more severe on flexion of the knee. Other than that, he also complained of weakness over the right ankle on dorsiflexion. On examination, he was found to have a 3x2 cm lump behind the posterolateral aspect of the right knee. The lump was firm in consistency, deep to the fascia and mobile. Tinel&rsquo;s sign was positive upon tapping of the lump, there was sensory deficit over the anterolateral aspect of the leg and the ankle dorsiflexors had a muscle power of grade 3.</p><p> Magnetic resonance imaging (MRI) of the right leg revealed a well circumscribed, oval lesion located along the pathway of the common peroneal nerve. It is homogenously hypointense on T1-weighted images. and heterogeneously hy...
      PubDate: Fri, 24 Nov 2017 02:37:19 +000
  • Retinal Break Adjacent to the Optic Disc Causing Retinal Detachment in a
           Pathological Myopia

    • Authors: ahlina
      Abstract: Author(s):  Noor Aniah A Bastion MLC Mushawiahti M Issue:  Vol. 7 No. 2 : 2017 Correspondance Address:  Noor Aniah Azmi. Department of Ophthalmology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +603-91457207 Fax: 03-91456733 E-mail: Retinal detachment is one of the common complications of pathological myopia due to presence of retinal break. However, retinal break commonly occurs in the peripheral retina. This case report illustrates the rare incidence of retinal break adjacent to the optic disc, highlights the possible causes of poor visual outcome following surgical repair as well as the possible measures to treat the complications. Full text:  <div> <p> <strong>Introduction</strong></p> <p> &nbsp;</p> <p> Retinal detachment is one of the complications of pathological myopia. About 40% of retinal detachment occurs in myopic patients. Rhegmatogenous retinal detachment occurs as a result of a retinal break or lattice degeneration that is commonly associated with pathological myopia. Pathological myopia is defined as axial length more than 26 mm or refractive error of more than &ndash; 6.0 diopters. The common sites of retinal break are in the peripheral retina, however, it can also occur around the optic disc. This case report illustrates the rare incidence of retinal break adjacent to the optic disc, highlights the possible causes of poor visual outcome following surgical repair as well as the possible measures to treat the complications.</p> <p> &nbsp;</p> <p> <strong>Case Report</strong></p> <p> &nbsp;</p> <p> A 74-year-old Malay gentleman with underlying diabetes mellitus, hypertension and chronic myeloid leukemia presented with left eye blurring of vision, central scotoma and floaters for the past two months. He had no metamorphopsia and no recent ocular trauma. He is a known high myope and is bilaterally pseudophakic. His right axial length is 26.84 mm and left eye is 26.82 mm. Visual acuity of the left eye during presentation was 6/36 and N18. His intraocular pressure (IOP) and anterior segment was unremarkable. Posterior pole revealed retinal detachment surrounding the optic disc with vitreomacular traction (Fig. 1) with presence of submacular fluid detected on Optical Coherence &nbsp;</p> <p> &nbsp;</p> <p align="center"> <img height="230" src="///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image002.jpg" width="257" /></p> <p> <strong>Figure 1</strong>: Fundus photo showing retinal detachment surrounding the optic disc</p></div><p> &nbsp;</p><div> <p align="center"> <img height="132" src="///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image004.gif" width="430" /></p> <p align="center"> <strong>Figure 2</strong>: OCT image showing retinal detachment with subretinal fluid and vitreomacular traction (before surgery)</p> <p align="center"> &nbsp;</p> <p align="center"> <img height="140" src="///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image006.gif" width="431" /></p> <p align="center"> <strong>Figure 3</strong>: OCT image showing persistent subretinal fluid 3 months after surgery</p> <p align="center"> &nbsp;</p> <p align="center"> <img height="154" src="///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image008.gif" width="438" /></p> <p align="center"> <strong>Figure 4</strong>: OCT image showing reduction of subretinal fluid 10 months after surgery</p> <p> &nbsp;</p></div><p> &nbsp;</p><p> Tomography (OCT) (Fig. 2). The patient refused surgery at the time of presentation and he came back after 2 months with worsening metamorphopsia, but visual acuity remained the same. Pars plana vitrectomy with internal limiting membrane peeling, endolaser and perfluoropropane (C3F8) gas tamponade was performed. Intraoperatively, we noted that there was a small retinal break superior to the optic disc. Immediately after surgery, his visual acuity was counting finger (CF), which improved to 6/60 3 months after. On OCT, there was persistent subretinal fluid involving the fovea and retinal detachment extending to the edges of the optic disc 360...
      PubDate: Fri, 24 Nov 2017 02:24:41 +000
  • Retinal Redetachment After Pneumatic Retinopexy – The Importance of
           Case Selection

    • Authors: ahlina
      Abstract: Author(s):  Muhammad Najmi K Aida Zairani MZ Mushawiahti M Bastion MLC Amin A Issue:  Vol. 7 No. 2 : 2017 Correspondance Address:  Amin bin Ahem. Department of Ophthalmology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +603-91455981 Fax: +603-91456673 E-mail: Pneumatic retinopexy is known as one of the treatment options for a specific type of retinal detachment. It is done in an office setting and may be the most cost-effective means of retinal reattachment surgery. Location and size of the retinal break remain as the major criteria for a successful outcome. We describe a case that fulfilled all except one major criteria for pneumatic retinopexy and underwent multiple procedures but failed. Fluctuation in the resolution of the retinal detachment such as in this particular case suggested possibility of early treatment failure. Full text:  <p> <strong>Introduction</strong></p><p> &nbsp;</p><p> Pneumatic retinopexy is a procedure done to treat retinal detachment. It involves injecting expanding gas bubble into the vitreous cavity and securing retinal tear by using laser and/or cryopexy. The literature reports a variable success rate when compared to other conventional retinal reattachment surgeries. This procedure may be done in office setting thus remained as the most cost effective ways to treat retinal detachments.</p><p> &nbsp;</p><p> <strong>Case Report</strong></p><p> &nbsp;</p><p> A 58-year-old Chinese gentleman with no known medical illness, presented with two weeks history of right eye superonasal visual field defect which progressed towards the centre, associated with flashes and floaters. There was no history of ocular trauma and patient was emmetropic. Examination revealed visual acuity of 6/60 over the affected side with positive relative afferent pupillary defect. Slit-lamp examination of the right eye revealed normal anterior segment, presence of tobacco dusting with intraocular pressure of 7 mmHg. On fundal examination, there was a right eye rhegmatogeneous retinal detachment (Fig. 1) involving the macula with superior horse-shoe tear at 11 o&rsquo;clock position (2 clock-hours size). The patient underwent right eye pneumatic retinopexy with an injection of 0.4 mls of C3F8 gas (100%) followed by indirect barricade laser around the tear two days later. He was compliant to the positioning instruction which was sit up with head tilt to the left. Fundal examination a week later showed satisfactory reduction in the area of detachment and early scarring of the laser marks. However, at 2 weeks post treatment, residual retinal detachment was still present with small opening of the primary tear. In view of the positive response after the first procedure, he was subjected for a repeat pneumatic retinopexy with additional laser and injection of C3F8 0.4mls (100%) to treat the small opening of the tear. Reattachment of the macula was achieved at 1-week post procedure with residual inferior detachment.&nbsp; This was confirmed by the optical coherence tomography (OCT) (Fig. 2). Unfortunately, at 4 weeks post pneumatic treatment, the macula redetached and the area of detachment remained fairly persistent with no signs of further<br clear="all" /> <img height="262" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image002.jpg" width="294" /></p><p> &nbsp;</p><p> <strong>Figure 1</strong>: Fundus photograph of right eye showing retinal detachment with macula-off.</p><p> &nbsp;</p><p> <img height="147" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image004.jpg" width="294" /></p><p> &nbsp;</p><p> <strong>Figure 2</strong>: OCT showing macula reattachment after second pneumatic retinopexy treatment</p><p> &nbsp;</p><p> <img height="146" src="file:///C:/Users/user2017/AppData/Local/Temp/msohtmlclip1/01/clip_image006.jpg" width="294" /></p><p> &nbsp;</p><p> <strong>Figure 3</strong>: OCT showing macula re-detachment 4 weeks post pneumatic treatment</p><p> &nbsp;</p><p> resolution (Fig. 3). Eventually, 2 weeks after the redetachment, pars plana vitrectomy was performed with gas tamponade together wit...
      PubDate: Fri, 24 Nov 2017 01:49:48 +000
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