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CRC HOSPITAL SHAH ALAM
NEWSLETTER
VOLUME 1, ISSUE 1 NOVEMBER 2017
In this issue:
Words from the Director HSAS 2
2018
Words from the Head of CRC 2
HSAS
Venue: Introduction to CRC
CRC HSAS EVENTS 2017
2/19
3
HOSPITAL SHAH ALAM Ophthalmology Research Day
2017
4-12
Contributions & Achievements 13-17
of HSAS
Clinical Audit 18
All rights reserved. © CRC.HSAS 2017
Clinical Research Centre,
Hospital Shah Alam, Level 2
Tel: 035526300 (ext-3304/3305)
Fax: 03 –55263217
Email: crc.hsas@gmail.com
JResearch
m 1ST CRC HOSPITAL SHAH ALAM RESEARCH DAY
OPHTHALMOLOGY RESEARCH DAY 2017 INCONJUNCTION WITH 6TH
SELANGOR RESEARCH WEEK
17TH-18TH August 2017
HOSPITAL SHAH ALAM
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
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. 20.9.2017
CLINICAL AUDIT COMPETITION
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
1Ophthalmology Department, Hospital Kuala Lumpur
Kelantan.
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
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
INTRODUCTION produced sharp pain at the nape of his neck and
To describe two cases of spontaneous expulsive suprachoroidal haemorrhage (SESCH)
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
2. Typically, spinal fractures occur mostly in patients of the cervical spine was done (as our facility lacks an
including arteriosclerosis, vascular disease, glaucoma, diabetes, intraocular malignancy and diseased
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
ciliary arteries. Although the exact mechanism is still debatable, thorough understanding of the risk times more frequently in patients with AS 3. 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.
has a high sensitivity and specificity; however, they Radiographic images of the spine showed the classical
We acknowledge that the incidence of SESCH is extremely rare and improvement in our management
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
Spondylitis, with radiological appearance of the Dr. Chan Jan Bond with Dr Ming Guang He (President of
Role in Advancing Ophthalmology” by Ms Divya
classical 'bamboo spine'' of AS. Statistic show that in APTOS)
Nag from USA, the CEO of E-health Applc Inc.
the United Kingdom, HLA-B27 is present in 90-95% of I have presented a free paper based on
describing how Apple Inc has built apps with
patients with ankylosing spondylitis 5. (The an app I have built titled “REST – An Innovative
Fig. 3: Radiograph iPhone to help patients with Parkinson’s disease,
ramifications of HLA-B27, Nicholas J Sheehan) Rapid Eye Screening Test” and received
following posterior vision screening and health monitoring. Another
spinal istrumentation and topic was “Tele-screening/Automated-screening for positive response from the audience. There
DISCUSSION fusion of C4/C5/C7/T1.
were medical officers from China that was
Eye Diseases” by Dr Ryo Kawasaki from Japan,
Massage therapy is recognized as one of the oldest interested to us my app as a study subject and
describing the use of tele-ophthalmology use in
methods of healing, with references in ancient would like to do further collaboration.
Japan for automated eye screening for the
medical texts going back to 4,000 years. Hippocrates, Traditional massage has remained a form of cultural I have also presented a video presentation on
community. “Deep Learning for Automated Retinal
the father of medicine, had referred to massage when norm especially for a small section of the Asian “Wireless Smartphone Videography for Ocular
Disease Assessment” was presented by Dr Varun
he wrote, in the 4th century B.C.: "The physician must community for many centuries now. However at times, Surgery System”. The presentation and
Gulshan from India on how artificial intelligence
be acquainted with many things, and assuredly with therapists' without knowledge on the patients introduction of my idea to the rest of the world
performs deep learning and later being translated
rubbing." underlying predisposing comorbid conditions and has also open up a new opportunity for further
to automated screening programs. Dr Yogesam
fragilities, tend to push boundaries leading to collaboration for my creation and innovations.
Kanasingam describes how a software is ised for
catastrophe. It was unfortunate that this particular I have also taken the opportunity to visit
diabetic retinopathy screening in his topic “AI
patient with underlying AS went undiagnosed and had the oversea ophthalmic imaging company booth
Based Clinical Decision Support System for
resorted to traditional treatment without any and learn more on the new tele-ophthalmology
Diabetic Retinopathy for Use by Primary Care
knowledge of this condition. A lot of emphasis has been gadgets which is mostly not available in
Medical Doctors in Australia”.
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
disease.
Page 14 Page 15
Winner of best poster at Selangor Research Day &
National Conference of Clinical Research 2017
ORBITAL APEX SYNDROME : A RARE COMPLICATION OF INVASIVE
MUCORMYOCIS
QUAH WY JIN1, MOHAMMAD ISFA RIZAL2, M GUNAVATHY1
1Department of General Medicine, Shah Alam Hospital
2Department of Otorhinolaryngology, Shah Alam Hospital
Introduction: Complex ophthalmoplegia can be somewhat of a diagnostic
conundrum. Imaging plays an integral role in localizing the lesion. Amongst
the differentials, infective causes need to be ruled out especially in
immunocompromised patients.
Case Report: A 60 years old gentleman with underlying Diabetes Mellitus
(HbA1c of 14.3%) was involved in an alleged assault on the 20/5/2017. There
was no loss of consciousness and patient only suffered superficial rounds
over the trunk. 3 days later, patient started having sudden onset of visual loss
and ptosis over the left eye. CT Angiogram of the Brain was done to rule out
possible PCOM aneurysm but inadvertently, showed left cavernous sinus
thrombosis. Medical team was consulted. Examination revealed left CN II, III,
IV, V1, V2 and VI palsy which correlated with the radiological findings.
Page 16
Anticoagulation was initiated. IV methylprednisolone was started for optic
nerve compression. In view of left facial swelling/pain, ENT reviewed and
FESS revealed fungal ball debris in the left anterior ethmoid sinus with
subsequent histopathology report confirming an invasive fungal infection,
suggestive of mucormycosis. Steroids was stopped after 1 day. Surprisingly,
MRI Brain only showed left optic neuritis with no evidence of thrombosis.
Final diagnosis was left orbital apex syndrome secondary to Mucormycosis.
Anticoagulation stopped. IV Amphotericin B was started however patient
developed left endopthalmitis and was treated conservatively. Conclusion:
This was a rare and challenging case requiring an interdisciplinary
collaboration in diagnosis and management. It was a meticulous task trying to
achieve strict glycaemic control and even with prompt intervention, prognosis
was guarded in regards to the patient's eyesight.
Page 17
CLINICAL AUDIT 2017
MOH POLICIES
HOSPITAL SHAH ALAM
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
• Statistic Consultation Clinic
14 Oral Surgery: To Reduce Repetition of Intraoral Periapical (IOPA)
• 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
• Assist in submission of research papers
3. Medical
for publication & presentation
• Assist in research grant application
1. Pharmacy • Conduct research training for HSAS
2. Oral Surgery staffs
3. Anaesthesiology
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