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持續醫學進修專訊

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Common Infections In The Context Of An Acute Red Eye: A Primary Care Physician’s Guide

Dr. SHIH, Kendrick Co Ms. SIT Hui Kei, Gladys Dr. NG Lap Ki, Alex

Editorial 3

Spotlight 4Common Infections In The Context Of An Acute Red Eye: A Primary Care Physician’s Guide

Cardiology 12A Man With Blood Pressure Difference Between Two Arms

Dermatology 14Rapid Growth Of A Warty Nodule

Answer Sheet 15CME Notifications 16Meeting Highlights 20CME Calendar 23

Contents

The Hong Kong Medical Association is dedicated to providing a coordinated CME programme for all members of the medica l profess ion. Under the HKMA CME Programme, a CME registration process has been created to document the CME efforts of doctors and to provide special CME avenues. The Association strives to foster a vibrant environment of CME throughout the medical profession. Both members as well as non-members of the Association are welcome to join us. You may contact the HKMA Secretariat for details of the programme.

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Co-editorDr. CHENG Chi Man 鄭志文醫生Dr. HO Hung Kwong, Duncan 何鴻光醫生Dr. LAM Ho 林賀醫生Dr. MAK Siu King 麥肇敬醫生Dr. WONG Bun Lap, Bernard 黃品立醫生

CardiologyDr. CHAN Kit 陳杰醫生Dr. CHEN Wai Hong 陳偉康醫生Dr. LEE Pui Yin 李沛然醫生Dr. LI Siu Lung, Steven 李少隆醫生Dr. TAM Chor Cheung 譚礎璋醫生Dr. WONG Shou Pang, Alexander 王壽鵬醫生

Cardiothoracic SurgeryDr. CHENG Lik Cheung 鄭力翔醫生Dr. CHIU Shui Wah, Clement 趙瑞華醫生Dr. CHUI Wing Hung 崔永雄醫生Dr. LEUNG Siu Man, John 梁兆文醫生

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DermatologyDr. CHAN Hau Ngai, Kingsley 陳厚毅醫生Dr. HAU Kwun Cheung 侯鈞翔醫生

EndocrinologyDr. LEE Ka Kui 李家駒醫生Dr. LO Kwok Wing, Matthew 盧國榮醫生

ENTDr. CHOW Chun Kuen 周振權醫生

Family MedicineDr. LAM King Hei, Stanley 林敬熹醫生Dr. LI Kwok Tung, Donald, SBS, JP 李國棟醫生

GastroenterologyDr. NG Fook Hong 吳福康醫生

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General SurgeryDr. LAM Tzit Yuen, David 林哲玄醫生Dr. LEUNG Ka Lau 梁家騮醫生

Geriatric MedicineDr. KONG Ming Hei, Bernard 江明熙醫生Dr. SHEA Tat Ming, Paul 佘達明醫生

HaematologyDr. AU Wing Yan 區永仁醫生Dr. MAK Yiu Kwong, Vincent 麥耀光醫生

Hepatobiliary SurgeryDr. CHIK Hsia Ying, Barbara 戚夏穎醫生Dr. LIU Chi Leung 廖子良醫生

Medical OncologyDr. TSANG Wing Hang, Janice 曾詠恆醫生

NephrologyDr. CHAN Man Kam 陳文岩醫生Dr. HO Chung Ping, MH, JP 何仲平醫生Dr. HO Kai Leung, Kelvin 何繼良醫生Dr. LAM Man Fai 林萬斐醫生Dr. LEE Hoi Kan, Achillers 李海根醫生

NeurologyDr. FONG Chung Yan, Gardian 方頌恩醫生Dr. TSANG Kin Lun, Alan 曾建倫醫生

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Obstetrics and GynaecologyDr. CHAN Kit Sheung 陳潔霜醫生

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Orthopaedics and TraumatologyDr. IP Wing Yuk, Josephine 葉永玉醫生Dr. KONG Kam Fu 江金富醫生Dr. POON Tak Lun 潘德鄰醫生Dr. TANG Yiu Kai 鄧耀楷醫生

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Respiratory MedicineDr. LEUNG Chi Chiu 梁子超醫生Dr. WONG Ka Chun 黃家進醫生Dr. WONG King Ying 黃琼英醫生Dr. YUNG Wai Ming, Miranda 容慧明醫生

RheumatologyDr. CHAN Tak Hin 陳德顯醫生Dr. CHEUNG Tak Cheong 張德昌醫生

UrologyDr. CHEUNG Man Chiu 張文釗醫生Dr. KWOK Ka Ki 郭家麒醫生Dr. KWOK Tin Fook 郭天福醫生Dr. YEUNG Hip Wo, Victor 楊協和醫生

Vascular SurgeryDr. TSE Cheuk Wa, Chad 謝卓華醫生

HKMA SecretariatMs. Jovi LAM 林偉珊女士Miss Irene GOT 葛樂詩小姐Mr. Jeff CHENG 鄭嘉信先生

持續醫學進修專訊HKMA CME Bulletin

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EDITORIALI received a call from council to contact a member doctor shortly before Christmas last year. He was admitted to Asian World Expo Facility for COVID-19 infection. His clinic staff and family members are quarantined in another venue. He was worried about his condition due to old age and high viral load.

As a medical practitioner living in the pandemic for a year, we are familiar with the risk factors in COVID-19 infection. I was worried about his health condition and risk factors too. Due to physical constrains, I can only communicate with him via phone calls and instant messaging. I have made step to better the communication by 2Cs.

– Clarity– Compassion

Clarity of information is up most important in COVID-19 pandemic. His worry of high fatality rate due to old age and high viral load is a common quote in daily media reports. Then how exactly fatality rate is calculated? There are three types: 1. infection fatality risk (IFR): Death rate ÷ number of actual infections. 2. Symptomatic case fatality risk (sCFR): Death rate ÷ number of infected and symptomatic cases. 3. Hospitalisation fatality risk (HFR): Death rate ÷ number of hospitalised cases for treatment.

As the pandemic goes on, this is difficult to estimate the cumulative deaths and cumulative confirmed infection in first definition. If we only record hospitalised case in definition 3, we will be failed to address milder cases not requiring hospitalisation and all asymptomatic cases. Therefore, definition 2 of death rate in symptomatic cases is more relevant to our member with symptomatic infection.

The HKU team reported our local mortality rate among symptomatic COVID19 patients is 1.4% which is lower than the report of 3.4% globally by WHO. I assured him to have trust in our public healthcare system that has a proven track record on treatment outcomes.

Compassion literally means suffering together. When we feel and understand the on-going progress of covid-19 infection, compassion give us the courage and wisdom to go through it. It gives support to sufferer and ease his suffering. It is a powerful tool that give us strengths to face the uncertainty in the circumstances like he finds himself transferred to hospital. Life is full of uncertainties. After two week of chit chat, we become friends. I was so happy to kwon his discharge from hospital eventually. He was so grateful to our concerns.

We know the pandemic is still going on around the world. Vaccination seems to be one of the most efficient strategies to combat this virus. Hope we can stick to the principles of clarity and compassion when we disseminated COVID-19 info to our community.

Stay healthy

Dr. MAK Siu KingCo-editor, Hong Kong Medical Association CME Bulletin

4 HKMA CME Bulletin 持續醫學進修專訊 February 2021

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Introduction

Acute red eye is perhaps the most common ophthalmic complaint encountered in the primary care setting. The causes of a red eye can range from non-sight-threatening ones like conjunctivitis, subconjunctival hemorrhage, dry eye, and episcleritis, to sight-threatening ones like infectious keratitis, uveitis, scleritis and acute angle closure glaucoma. For sight-threatening causes, timely intervention by an ophthalmologist may prevent or minimize the risk of permanent visual loss. This article aims to focus on the infective causes of acute red eye, as they are commonly encountered in the primary care or emergency care settings. The first part of the article will be on the differential diagnosis of acute red eye, and we will outline red flags in the history and physical examination that point towards a clinical diagnosis of sight-threatening causes. In the second part we will focus on conjunctivitis which is probably the most common causes of acute red eye. In the third part, we will discuss infectious keratitis. Prompt recognition of the salient symptoms and signs of infective keratitis and urgent referral to an ophthalmologist for further management is key to preventing long-term complications, including blindness due to corneal scarring. According to the World Health Organization (WHO), corneal scarring is the 4th common cause of blindness globally behind cataract, glaucoma and age-related macular degeneration (1).

I: Differential Diagnoses of Acute Red Eye

The acute red eye is a common presentation to primary care physicians and emergency rooms, accounting for about 2-3% of all visits to primary care (2). Although the sign is often acute and alarming to the patient, it may not always represent sight-threatening disease. It is thus important as a physician to be able to recognize the signs and symptoms suggestive of a sight-threatening cause that would trigger a prompt referral to an ophthalmologist.

The causes of an acute red eye can be divided based on location and etiology. Table 1 summarizes the common causes o f r ed eye by l oca t i on and the i r r espec t i ve characteristic features. In general, conditions affecting the eyelids, conjunctiva and episclera are non-sight threatening, whereas conditions affecting the cornea, sclera and anterior segment are considered sight-threatening.

History

First and foremost, it is important to enquire about a preceding history of ophthalmic or periorbital trauma, as well as the mechanism, velocity, and penetrating force of injury. A low velocity injury with little to no penetrating force, for example a fingernail scratch or an accidental finger poke, may result in subconjunctival hemorrhage or a corneal abrasion. The damage is l imited to the ocular surface and wil l recover even without treatment. Conversely, a missile injury with stray particle, during drilling or hammering, has high velocity and high penetrating force. Regardless of the presenting symptoms, such patients should be immediately referred to emergency services for plain radiograph imaging and ophthalmic consultation. For non-traumatic causes of red eye, the alarming symptoms to look for are pain, blurring of vision and photophobia. Sight-threatening conditions including infectious keratitis, acute angle closure glaucoma, and scleritis, are all painful conditions. Blurring of vision in the presence of red eye suggests that either the cornea and/or anterior chamber is compromised. Photophobia or light sensitivity, in the context of a red eye, suggests uveitis. This is due to the inflammatory process extending into the anterior chamber of the eye, which causes cil iary spasm, and is exacerbated by pupil constriction in response to light.

Common Infections In The Context Of An Acute Red Eye: A Primary Care Physician’s Guide

Dr. SHIH, Kendrick CoMBBS, MRes(Med), MRCSEd, FCOphthHK, FHKAM (Ophthalmology)Department of Ophthalmology, Li Ka Shing Faculty of Medicine, University of Hong Kong

Ms. SIT Hui Kei, GladysDepartment of Ophthalmology,

Li Ka Shing Faculty of Medicine, University of Hong Kong

Dr. NG Lap Ki, AlexMBBS, FRCSEd, FRCS (Glasg), FCOphthHK, FHKAM (Ophthalmology)Hong Kong Ophthalmic Associates

5HKMA CME Bulletin 持續醫學進修專訊 February 2021

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Physical examination

For signs, it is important to look for impairment in visual acuity (with the help of a portable near Snellen chart), corneal haze and abnormal pupillary responses. Checking the visual acuity is an important, objective documentation of sight-threatening disease. The latter two signs signify a pathological process that extends beyond the ocular surface into the anterior segment of the eye. In anterior uveitis, anterior chamber inflammation causes adhesion between the iris and anterior lens surface, and this is termed posterior synechiae, which will result in a small and irregular pupil. In acute angle closure glaucoma, the elevated intraocular pressure causes ir is ischemia, resulting in a fixed and dilated pupil. If equipment such as a non-contact tonometry is available, measuring the intraocular pressure (IOP) can also aid the detection of acute angle closure glaucoma, where the IOP is often 2-3 times higher than the other eye. Apart from these signs, the pattern of redness also differs and may be detected with careful observation. In sight-threatening diseases, like keratitis, uveitis and acute glaucoma, the conjunctival injection/hyperaemia will extend to involve the perilimbal vessels. This is termed circumlimbal conjunctival injection, or ciliary flush. Conversely in conjunctivitis and episcleritis, the perilimbal vessels are usually spared from hyperaemia or injection. This is because the peri l imbal vessels are deep vessels, and thus their involvement signifies a pathology that involves the anterior segment, rather than just the ocular surface.

Table 1. Differential diagnoses of acute red eye, divided by location, and characteristic features

Location Differential diagnosis Features

Conjunctiva Viral conjunctivitis – Preceded by upper respiratory tract symptoms including fever, sore throat, runny nose (the most common cause is adenovirus, other causes include enterovirus, herpes simplex virus)

– Red eye with perilimbic sparing– Watery discharge, itching– Crusting and pseudomembrane– Burning and foreign body

sensation, gritty discomfort– Normal vision (unless complicated

by corneal involvement)– White lymphoid follicles in tarsal

conjunctiva can be present– Enlarged pre-auricular lymph

nodes may be found– Infection begins with one eye then

spread easily to the other


Bacterial conjunctivitis – Red, sticky eye with perilimbic sparing

– Purulent discharge, often foul smelling

– Common pathogens: Staphylococcus Streptococcus, Hemophilus

– Burning and foreign body sensation

– Visual disturbance due to discharge should clear upon blinking

– Papillae in tarsal conjunctiva can be present

– Common in elderly patient with poor hygiene

Allergic conjunctivitis – Itchy eye with temporary relief after rubbing

– Conjunctival injection with chemosis

– Watery discharge– Papillae in tarsal conjunctiva can

be present– Other atopic features including

allergic rhinitis, asthma, eczema

Subconjunctival hemorrhage

– Bright red, flat discoloration on sclera

– Self-limiting within 7-14 days– Otherwise normal-no eye pain,

photophobia, visual loss– Idiopathic in nature but can be

associated with coagulopathy, hypertension, conjunctivitis, eye rubbing or straining

Cornea Infective keratitis – Perilimbic/ciliary injection– Acute onset of severe, sharp pain

with foreign body sensation and photophobia (severity depends on causative agent)

– Blurry vision with corneal opacity, corneal infiltrate or ulcer

– Can be associated with hypopyon (presence of pus in anterior chamber)

– Sight threatening– See separate section in main text

Corneal abrasion – History of trauma– Extreme pain and tearing; difficult

to open eye– Limbal/ciliary flushing classically at

meridian of lesion– Fluorescein stain up-taking


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Episclera/Sclera

Scleritis – Sectoral or diffuse injection of deep scleral plexus mesh with deep persistent violaceous hue

– Severe, constant boring pain, worse at night or early morning and radiates to face and periorbital region

– Tender eye on palpation, watery eye

– Often associated with systemic diseases such as rheumatoid arthritis and Wegener’s granulomatosis

– Potentially blinding– Complications include scleral

melting, corneal melting, posterior scleritis

– Systemic treatment including oral steroid often required

Episcleritis – Sectoral or diffuse injection of superficial radial vessels which blanches with 2.5% phenylephrine

– Not as painful as scleritis, palpation well-tolerated

– No discharge or visual loss– Rarely associated with systemic

diseases– Responds to topical steroids

Anterior Segment

Acute anterior uveitis – Ocular pain, photophobia, blurring of vision

– Circumlimbal conjunctival injection– Other signs include keratitis

precipitates, anterior chamber cells, flare (slit lamp required)

– Posterior synechiae (adhesion between iris and lens), resulting in small and irregular pupil

– Can be associated with systemic diseases including ankylosing spondylitis or other seronegative spondyloarthropathies, SLE, rheumatoid arthritis, Bechet’s disease, syphilis, tuberculosis

Acute angle closure glaucoma (AACG)

– Severe eye pain, unilateral periorbital headache with nausea and vomiting

– Blurred vision, haloes around lights

– Signs include fixed, mid-dilated pupil; corneal haze/odema and ciliary flush

– Very high intraocular pressure, often over 50 mmHg

II. Conjunctivitis

Conjunctivitis is inflammation of the outermost layer of the eye (termed bulbar conjunctiva) and the inner surface of the eyelids (termed tarsal conjunctiva). They are most commonly caused by infections, either viral or bacterial, or as an allergic response (allergic conjunctivitis). The two most prominent symptoms of conjunctivitis include conjunctival injection and discharge. Although in most cases the diseases are non-sight threatening, the treatment strategy is different, and therefore differentiating them is important.

Epidemic keratoconjunctivitis (EKC)

Epidemic keratoconjunctivitis (EKC) is a highly contagious viral conjunctivitis caused by the adenovirus. Adenoviruses can survive in the environment for hours and are highly virulent, often causing outbreaks of pink eye. A positive contact history with patients with red eye and/or preceding upper respiratory tract infection symptoms may point to viral conjunctivitis. Patients typically present with a follicular conjunctivitis (where follicles can be detected on tarsal conjunctiva) with copious watery discharge. This discharge is clear but very sticky. Oftentimes, the patient will report waking up in the morning with his/her eyes matted shut from excessive sticky discharge. One eye is usually affected first, followed by the other eye several days later. Another typical feature is a presence of palpebral, tender pre-auricular lymph nodes. Although usually affecting the conjunctiva, EKC can be complicated with membranous/pseudomembranous conjunctivitis, with a rough membrane forming on the tarsal conjunctiva, which in turns causes mechanical trauma to the cornea and leads to secondary keratopathy. The virus can also directly affect the cornea causing a multifocal epithelial keratitis. For treatment, EKC is self-limiting, although episodes can extend for up to 2-3 weeks. Topical steroids can be used to reduce the ocular symptoms. Patients should be counselled regarding hand hygiene and contact precautions, as the infection is highly-contagious. In a minority of causes, after the acute episode has subsided, a subepithelial keratitis, which is thought to be an immune response to the viral antigen, can cause persistent mild blurring of vision, photophobia and tearing. In these cases, prolonged topical steroid treatment will be required.

Bacterial conjunctivitis

Bacterial conjunctivitis is typically seen in individuals with poor eyelid hygiene or poor hygienic habits, and is especially common in the elderly. Contaminated materials, such as contact lens or cosmetics, can also cause a bacterial infection.


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The discharge is often purulent, and dried up discharge can cause crusting of the lashes. The bacteria involved are usually Streptococcus pneumoniae, Haemophilus influenzae and Staphyloccocus aureus. However, bacterial culture is usually not required as a one-week course of topical antibiotics, targeting gram positive bacteria, and lid hygiene, will usually suffice. Individuals with other ocular surface diseases, such as dry eye disease, or blepharitis, are more prone to bacterial infection. To prevent recurrence, meticulous lid hygiene and treating underlying blepharitis may be required.

COVID-19

In the context of the ongoing Coronavirus Disease 2019 (COVID-19) pandemic, it is important to remember that conjunctivitis is one of the possible presentations of infection. In a study of hospitalized patients in Spain, up to 11% of subjects with COVID-19 presented clinically with conjunctivitis (3). Earlier this year, Hui et al from the University of Hong Kong demonstrated that the Severe Acute Respiratory Syndrome Coronovirus-2 (SARS-CoV2) can readily invade and proliferate in live human conjunctiva tissue (4). Furthermore, it has been shown that SARS-CoV2 is detectable in the tears of up to 25% of COVID-19 patients with moderate-to-severe disease (5). Thus, the ocular surface is both an important portal for entry and disease transmission. It is thus important to avoid eye rubbing or touching during the pandemic to minimize disease spread. There is currently no evidence to suggest whether patients with COVID-19 who initially present with conjunctivitis fare better or worse in terms of morbidity and mortality.

Allergic conjunctivitis

Allergic conjunctivitis is an important differential diagnosis of conjunctivitis, as it is also very common, and the signs and symptoms can be rather similar to the infective causes. Allergic conjunctivitis can be seasonal or perennial (chronic, year round). During history taking, the physician should check for the presence of additional differentiating symptoms apart from conjunctival redness and discharge, such as the presence or absence of itchiness. Allergic conjunctivitis is characterised by the presence of itchiness and the strong urge for eye rubbing. Symptoms of allergic rhinitis also often co-exist. The discharge associated with allergic conjunctivitis is typically mucoid in appearance, and the presence of papillae on the tarsal conjunctival surface, visible on eversion of the eyelids, is another typical sign. In children, forceful blinking may be seen in place of eye rubbing. The treatment involves the use of cold compress, allergen avoidance, use of topical anti-histamine/mast cell stabilizer combination eyedrops, or topical steroids in more severe cases.

III. Infectious Keratitis

Different from conjunctivitis which is usually self-limiting, infection of the cornea, or infectious keratitis, is much more serious and can be potentially blinding. Common risk factors include contact lens wear, trauma, presence of ocular surface disease, or previous eye surgery. There should be a high level of suspicion in all cases of acute red eye that is also painful and affects vision. The approach on infectious keratitis is as follow:

1. History Taking

History taking focuses on identifying the 1) risk factors, and 2) characteristic clinical symptoms of infectious keratitis.

History taking for important risk factors involve identifying a mode of entry of the micro-organism. The cornea is protected by a densely packed epithelium, joined by tight junctions. Only very few micro-organisms can penetrate an intact cornea epithelium, thus a breach in the ocular surface is required for infection to occur. This is most often a result of accidental trauma (such as a fingernail scratch), eye surgery, and wearing soft contact lens. If there is a history of eye trauma by plant or vegetable matter, fungal keratitis could be possible, although it is very uncommon in Hong Kong. Patients with long-standing ocular surface disease, such as dry eye disease, have micro-erosions in the cornea epithelium, which also facilitates micro-organism entry and causes infection. Another important risk factor is long-term steroid use, particularly in the form of topical application of eyedrops. This results in a suppressed local cellular immunity, making it easier for micro-organisms, particularly fungi, to infect the cornea.

Symptoms of infectious keratitis include acute red eye, eye pain, photophobia and blurring of vision. The cornea is densely innervated by pain-sensitive fibres, and thus eye pain is typically described as sharp and severe in infectious keratitis. Blurring of vision is due to the presence of infiltrates (see later paragraph) and corneal haze. In some cases, there can be an associated anterior chamber inflammation, causing ciliary body spasm and resulting in photophobia. The severity of symptoms is dependent on the microbial agent, with bacteria causing the most acute and severe symptoms. Fungal keratitis tends to be slower in progression but persistent, while viral keratitis is subacute in onset, with less severe eye pain due to concurrent cornea nerve damage.

2. Physical Examination

The hallmark of infective keratitis is the presence of corneal infiltrate(s), which is a whitish, fluffy lesion on the cornea (Figure 1). Infiltrates can be detected even without a slit lamp, and often also noticed by the patients themselves. The area of infiltrate represents the presence and accumulation of


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white blood cells in the cornea, signifying an inflammatory response to the micro-organism. The area of infiltrate often has an epithelial defect (therefore, infectious keratit is is often also termed ‘Corneal Ulcer’. The two terms are often used inter-changeably). The epithelial defect can be stained with fluorescein dye and easily visualised using a direct ophthalmoscope under the cobalt blue filter (Figure 2 & 3). If the infiltrate is not promptly treated, the white blood cells secrete enzymes including matrix metalloproteinases, which can cause melting and thinning of the cornea stroma. (6)(7) In severe cases, this can result in corneal perforation, which is a surgical emergency. The cornea infection is also often associated with an anterior chamber reaction, with presence of anterior chamber cells and flare. When severe, the cells accumulate as pus at the most dependent part of the anterior chamber, and a ‘fluid level’ can be seen. This is also known as a hypopyon.

Figure 1

Figure 2

Figure 3

3. Investigations

Investigations are focused on obtaining a microbiological diagnosis. While empirical therapy based on clinical impression remains the mainstay, it is important to obtain a microbiological diagnosis together with culture and sensit iv ity test ing, especially in severe cases, or when the response to initial treatment is suboptimal. To obtain culture, corneal scarping is performed under topical anaesthesia using a 15-blade, and is then sent for smear and culture. For suspected herpes simplex keratitis, an eye swab can be obtained and placed in viral transport medium for polymerase chain reaction (PCR) testing.

Bacterial Keratitis

Amongst the different causes of infectious keratitis, bacterial keratitis is the most acute in onset, and is most symptomatic. It is also the most common cause of infective keratitis, particularly in contact lens users. Therefore, an acute presentation of infective keratitis, especially associated with contact lens use, is considered bacterial in origin until proven otherwise.

In the 2018 ACSIKS (Asia Cornea Society Infectious Keratitis) Study, which is a prospective multi-centre study of infectious keratitis in Asia, the most common bacteria identified from corneal scrapings were Pseudomonas aeruginosa (10.7%), Streptococcus pneumonia (6.3%), Proprionibacterium acnes and coagulase negative Staphyloccus. The high prevalence of Pseudomonas aeruginosa-related infective keratitis is a direct result of widespread use of soft contact lenses, often associated with improper or unhygienic handling. Streptococcus pneumonia is a commensal of the upper respiratory tract making infection of the ocular surface common. Proprionibacterium and coagulase negative Staphylococcus are commensals of the human skin. Similarly, in a 2015 study published by our group on Hong Kong retrospective data from the prior 10 years, Pseudomonas aeruginosa and coagulase negative Staphyloccocus were the commonest isolated micro-organisms in culture positive cases (8). Amongst the organisms,


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Pseudomonas is by far the most virulent, with potential to rapidly spread throughout the cornea. Therefore, the mainstay of empirical antibiotic therapy must include effective cover for Pseudomonas, such as a fluoroquinolone.

The principle of management of bacterial keratitis is empirical treatment with a broad-spectrum topical antibiotics, such as a third or fourth-generation fluoroquinolone. The type of treatment is determined by the size of the ulcer and whether it involves the visual axis. For small ulcers not involving the visual axis, fluoroquinolone monotherapy, in the form of levofloxacin 0.5% solution or moxifloxacin 0.5% solution initially hourly and then tapered according to clinical response. For large ulcers that involve the visual axis, combination therapy using fortified antibiotics is key to achieving control of the infection as fast as possible. A fortified antibiotic is a specially prepared, high concentration antibiotic. Commonly used fortified antibiotics include levofloxacin 1.5% solution, a third-generation cephalosporin such as ceftazidime 5% solution, aminoglycoside such as gentamicin 1.4% solution or amikacin 2.5% solution, and vancomycin 5% solution. Apart from 1.5% levofloxacin which is commercially available, the other fortified antibiotics are usually prepared by hospital pharmacy. The eyedrops are initially applied hourly for at least 48-72 hours, and then tapered according to clinical response. It is important to bear in mind that fortified antibiotics are toxic to the ocular surface and should only be used when needed and for as short of a duration as possible. In the study by our group, isolated Pseudomonas aeruginosa from culture positive cases remains 100% susceptible to fluoroquinolones in Hong Kong. However, there are reports of emerging antibiotic resistance in Pseudomonas in recent epidemiological studies (9). The ACSIKS Phase 2 study, currently underway, will shed more light on antimicrobial resistance data from Asia. The Steroid for Cornea Ulcers trial (SCUT trial) demonstrated that there was no visual benefit to adding topical steroids in the management of bacterial keratitis (10). Therefore, the adjunct use of topical steroid is not recommended for bacterial keratitis.

If a bacterial keratitis is not promptly controlled, it can cause corneal melting and even perforation. In this situation, corneal transplant (termed therapeutic keratoplasty) will be required to control the infection. However, a corneal transplant in the emergency setting is usually associated with a poor long term graft survival. The long term complication after bacterial keratitis is form corneal scarring. If the corneal scar is small and does not involve the visual axis, vision will not be directly affected. However, the scar can increase astigmatism and changes in refractive error. In contrary, if the corneal scar is large and involves the visual axis, the vision can be severely impaired. Treatment include excimer laser ablation with phototherapeutic keratectomy, or corneal transplant, to regain vision.

Fungal Keratitis

As reported by the ACSIKS study, fungus was the second most common microbe identified in cases of culture positive infective keratitis in Asia. The most common two isolated fungal species

were Fusarium and Aspergillus flavus. However, the majority of these cases were from India and China, reflecting the high incidence of fungal infections in rural areas of the countries. Fungal keratitis is rare in Hong Kong. The main risk factors include ocular trauma with plant matter, long-term topical steroid use, and significant ocular surface disease. However it is still important to remember a recent outbreak of fusarium keratitis associated with a specific contact lens solution (ReNu with MoistureLoc) in 2006 (11). While fungal keratitis progresses slower than bacterial keratitis, the infection is deeper situated and tends to be harder to eradicate. Therefore, prolonged therapy is the mainstay. The mainstay of treatment for fungal keratitis is topical anti-fungal preparations, and these include Natamycin, Voriconazole and Amphotericin B (12) (13)(14)(15).

Viral Keratitis

Herpes simplex virus (HSV) kerat i t is is a very common infection of the eye, and the most common cause of viral keratitis is reactivation of latent HSV-1. Primary infection of the eye by HSV-1 tends to present in the form of a self-limiting conjunctivitis with the presence of vesicles around the upper and lower eyelids. Latent HSV-1 infection is common in Asia with most of the population being exposed by early adulthood. In a 2007 nation-wide survey study in Taiwan of health subjects, overall seroprevalence of HSV-1 was 63.2%, with prevalence increasing with age. Only 19.2% of subjects less than 5 years of age were seropositive, while more than 95% of subjects over the age of 30 were seropositive. Therefore, aging is the most important risk factor for HSV-1 seropositivity. Some study reported that HSV is present in the trigeminal ganglion of nearly 100% of patients greater than age 60 at autopsy. Reactivation of latent HSV-1 occurs in immunocompetent patients without definite precipitating factors. However, it has also been noted to occur as a result of physical or emotional stress. During reactivation, the cornea is the commonest site of involvement, but HSV can cause affect the sclera, uvea, retina and even cranial nerves. The most common long term sequalae of herpetic keratitis is cornea scarring, as well as corneal hypoesthesia. The loss of sensation is due to corneal nerve damage, and can further result in neurotrophic keratopathy. Corneal scarring due to HSV keratitis is one of the commonest non-traumatic cause of unilateral corneal blindness in developed regions including Hong Kong.

The clinical presentation of HSV keratitis is different from bacterial or fungal causes, and depends on which layer of cornea is involved. The most common form of herpes simplex keratitis is epithelial keratitis, with the classical dendritic ulcer/lesion. This is characterised by a branching lesion with terminal bulbs. The lesion readily takes up fluorescein stain. If treated injudiciously with topical steroids, the branching lesion can quickly expand into a large circular ulcer, called a geographical ulcer. For such cases, topical anti-viral therapy, such as acyclovir 3% ointment or ganciclovir 0.15% gel five times per day, as guided by the Herpetic Eye Disease Study (HEDS Study), remains the mainstay of treatment (16).


Spotlight

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Apart from dendritic ulcer, the deeper layers of the cornea can also be involved, such as stromal keratitis and disciform keratitis. In these cases, the addition of oral acyclovir 400 mg five times a day (or alternatively valacyclovir 1000 mg three times a day) will be needed, as well as topical steroid therapy (17, 18). In patients with recurrent herpetic keratitis, the intake of long-term oral acyclovir (acyclovir 400 mg twice a day) has been shown to reduce the risk of recurrence by half, as demonstrated by the HEDS II study (19).

Apart from HSV, another common cause of viral keratitis is due to herpes zoster virus (HSV) which occurs as a complication of Herpes Zoster Ophthalmicus.

IV: Summary

Acute red eye is a very common eye complaint. It is important to identify the alarming symptoms and signs that point towards a sight-threatening cause. Infective causes remain a very common cause. If the infection is limited to the conjunctiva, the vision is usually unaffected. However, if the cornea is involved, these cases must be promptly treated to long-term complications, including cornea scarring and perforation. Thus, for pr imary care physicians, the most important action is identifying salient features of infective keratitis in a patient presenting with a red eye and referring to an ophthalmologist as soon as possible for prompt confirmation and management.

References

1. Whitcher JP, Srinivasan M, Upadhyay MP. Corneal blindness: a global perspective. Bull World Health Organ. 2001;79(3):214-21.

2. Pflipsen M, Massaquoi M, Wolf S. Evaluation of the Painful Eye. Am Fam Physician. 2016;93(12):991-8.

3. Güemes-Villahoz N, Burgos-Blasco B, García-Feijoó J, Sáenz-Francés F, Arriola-Villalobos P, Martinez-de-la-Casa JM, et al. Conjunctivitis in COVID-19 patients: frequency and clinical presentation. Graefe’s Archive for Clinical and Experimental Ophthalmology. 2020;258(11):2501-7.

4. Hui KPY, Cheung MC, Perera R, Ng KC, Bui CHT, Ho JCW, et al. Tropism, replication competence, and innate immune responses of the coronavirus SARS-CoV-2 in human respiratory tract and conjunctiva: an analysis in ex-vivo and in-vitro cultures. Lancet Respir Med. 2020;8(7):687-95.

5. Arora R, Goel R, Kumar S, Chhabra M, Saxena S, Manchanda V, et al. Evaluation of SARS-CoV-2 in Tears of Patients with Moderate to Severe COVID-19. Ophthalmology. 2020.

6. Dalmon C, Porco TC, Lietman TM, Prajna NV, Prajna L, Das MR, et al. The clinical differentiation of bacterial and fungal keratitis: a photographic survey. Invest Ophthalmol Vis Sci. 2012;53(4):1787-91.

7. Leck A, Burton M. Distinguishing fungal and bacterial keratitis on clinical signs. Community Eye Health. 2015;28(89):6-7.

8. Ng AL, To KK, Choi CC, Yuen LH, Yim SM, Chan KS, et al. Predisposing Factors, Microbial Characteristics, and Clinical Outcome of Microbial Keratitis in a Tertiary Centre in Hong Kong: A 10-Year Experience. J Ophthalmol. 2015;2015:769436.

9. Subedi D, Vijay AK, Willcox M. Overview of mechanisms of antibiotic resistance in Pseudomonas aeruginosa: an ocular perspective. Clin Exp Optom. 2018;101(2):162-71.

10. Srinivasan M, Mascarenhas J, Rajaraman R, Ravindran M, Lalitha P, Glidden DV, et al. Corticosteroids for bacterial keratitis: the Steroids for Corneal Ulcers Trial (SCUT). Arch Ophthalmol. 2012;130(2):143-50.

11. Chang DC, Grant GB, O’Donnell K, Wannemuehler KA, Noble-Wang J, Rao CY, et al. Multistate outbreak of Fusarium keratitis associated with use of a contact lens solution. Jama. 2006;296(8):953-63.

12. Prajna NV, Krishnan T, Mascarenhas J, Rajaraman R, Prajna L, Srinivasan M, et al. The mycotic ulcer treatment trial: a randomized trial comparing natamycin vs voriconazole. JAMA Ophthalmol. 2013;131(4):422-9.

13. Prajna NV, Lalitha P, Rajaraman R, Krishnan T, Raghavan A, Srinivasan M, et al. Changing Azole Resistance: A Secondary Analysis of the MUTT I Randomized Clinical Trial. JAMA Ophthalmol. 2016;134(6):693-6.

14. Prajna NV, Radhakrishnan N, Lalitha P, Austin A, Ray KJ, Keenan JD, et al. Cross-Linking–Assisted Infection Reduction: A Randomized Clinical Trial Evaluating the Effect of Adjuvant Cross-Linking on Outcomes in Fungal Keratitis. Ophthalmology. 2020;127(2):159-66.

15. Prajna NV, Krishnan T, Rajaraman R, Patel S, Srinivasan M, Das M, et al. Effect of Oral Voriconazole on Fungal Keratitis in the Mycotic Ulcer Treatment Trial II (MUTT II): A Randomized Clinical Trial. JAMA Ophthalmol. 2016;134(12):1365-72.

16. Asbell PA. Ganciclovir Ophthalmic Gel in the Treatment of Herpes Simplex Keratitis. Journal-Ganciclovir Ophthalmic Gel in the Treatment of Herpes Simplex Keratitis.

17. Wilhelmus KR, Gee L, Hauck WW, Kurinij N, Dawson CR, Jones DB, et al. Herpetic Eye Disease Study: A Controlled Trial of Topical Corticosteroids for Herpes Simplex Stromal Keratitis. Ophthalmology. 1994;101(12):1883-96.

18. Barron BA, Gee L, Hauck WW, Kurinij N, Dawson CR, Jones DB, et al. Herpetic Eye Disease Study: A Controlled Trial of Oral Acyclovir for Herpes Simplex Stromal Keratitis. Ophthalmology. 1994;101(12):1871-82.

19. Wilhelmus KR, Beck RW, Moke PS, Dawson CR, Barron BA, Jones DB, et al. Acyclovir for the prevention of recurrent herpes simplex virus eye disease. New England Journal of Medicine. 1998;339(5):300-6.

CMEQUESTIONS:Q&A

Complete Spotlight, 1 CME Point will be awarded for at least five correct answersSelf-Assessment

Questions:Q&AAnswer these on page 15 or make an online submission at: www.hkma.org.Please indicate whether the following statements are true of false.

1. In acute red eye, if there is significant eye pain, the cause is usually sight-threatening

2. Epidemic keratoconjunctivitis (EKC) is highly contagious3. A broad-spectrum antibiotic eyedrop is necessary to treat a

viral conjunctivitis4. Most cases of COVID-19 infections present with an acute red

eye5. Conjunctiva is a possible entry site for COVID-196. The most common cause of infectious keratitis in young

patients is contact lens wear7. Contact lens – related infectious keratitis can be caused by

Pseudomonas aeruginosa infection8. If untreated, a bacterial keratitis can cause corneal melting and

perforation, requiring corneal transplant.9. Fungal keratitis is the second most common cause of corneal

infection in Hong Kong10. Most HSV keratitis are recurrent in nature, and can involve the

different layers of the cornea

Answer to January 2021Spotlight – Infertility1.T 2. F 3. T 4. F 5. T 6. T 7. F 8. T 9. T 10. F

Cardiology

12 www.hkma.orgHKMA CME Bulletin 持續醫學進修專訊 February 2021

A Man With Blood Pressure Difference Between Two Arms

A 65 years old gentleman with known history of hypertension and hyperlipidemia, presented with one-month history of dizziness. He also noted to have left arm numbness for one week. He attended to one neurologist’s clinic due to worrisome of stroke. Physical examination found no any neurological deficit. However, there was significant difference of blood pressure between two arms: 145/70 mmHg in right arm vs 110/65mmHg in left arm.

The content of the February 2021 Cardiology Series is provided by:Dr. CHEUNG Shing Him, Gary

MBBS, MRCP, FHKCP, FHKAM (Medicine), Specialist in Cardiology二月臨床心臟科個案研究之內容承蒙張誠謙醫生提供。Complete Cardiology case,

0.5 CME POINT will be awarded for at least 2 correct answers in total

Q&A Please answer ALL questionsAnswer these on page 15 or make an online submission at: www.hkma.org.

1. Which of the following is the possible cause of

blood pressure difference between two arms?

a) Coarctation of aortab) Subclavian artery stenosisc) Aortic dissectiond) Aneurysm of aortae) All of the above

2. Which of the following is the most suitable

investigation for this patient?

a) Doppler ultrasoundb) CT aortogramc) Echocardiogramd) Electrocardiograme) Repeat blood pressure measurement by another

machine.

3. The Picture 1 shows the diagnostic angiogram

of this patient. What is the diagnosis of this

patient?

a) Coaratation of aortab) Right subclavian artery stenosisc) Left subclavian artery stenosisd) Aortic dissectione) Carotid artery stenosis

4. Which of the following is the option for curative

treatment for this patient?

a) Intra-thoracic bypass surgeryb) Regular anaerobic exercise of both armsc) Percutaneous endovascular stenting of

subclavian arteryd) Oral anticoagulatione) Percutaneous endovascular stenting of thoarcic

aorta

Cardiology

13www.hkma.org HKMA CME Bulletin 持續醫學進修專訊 February 2021

January Answers

Explanation Answers: 1. A 2. B 3. C

The European Society of Cardiology recently updated their guidelines on the management of atrial fibrillation in 2020 and put forth an “Atrial Fibrillation Better Care (ABC) holistic pathway that aims to streamline care for patients suffering from AF across all healthcare levels. The message is represented in the abbreviation ‘A’ for anticoagulation/avoid stroke, ‘B’ for better symptom management (via rate or rhythm control strategies), ‘C’ for cardiovascular and comorbidity optimization.

Avoiding stroke in AF patients via anti-thrombotic therapy is a fundamental aspect of AF management and an ever-increasing clinical problem that general practitioners will encounter in view of an aging population and a lifetime risk of 1:3 to 1:7 (depending on ethnicity) in developing AF.

First published in 2001, the CHADS2 score was found to be most accurate at predicting future stroke risk in patients who were at high risk. However, patients who scored a CHADS2 of 0 (and were not recommended for anti-thrombotic therapy) were not as low risk as once thought. In 2012, a study of the Danish National Patient Registry which contained a cohort of patients with non-valvular AF a more refined CHA2DS2-VASc score was applied. It identified a group of patients in whom had a CHADS2 score of 0 but a CHA2DS2-VASc score of 3, translating into a 3.2% annual risk of stroke. The CHA2DS2-VASc score was found to be more inclusive of some common stroke risk factors/modifiers that were missed by the original CHADS2 score. Subsequently, numerous validation studies have shown CHA2DS2-VASc to be just as good as CHADS2 at predicting high risk patients but also doing a better job at risk stratifying low risk patients, in particular the ones who do not require anti-thrombotic therapy. The CHA2DS2-VASc score is now used in routine clinical practice to estimate stroke risk in patients with AF. Anti-thrombotic therapy (via a direct oral anticoagulant) is recommended for stroke prevention when the CHA2DS2-VASc score is ≥2 (in men) or ≥3 (in women). Anti-thrombotic therapy is not recommended when the CHA2DS2-VASc is 0 (in men) or 1 (in women). For scores of 1 (in men) or 2 (in women), treatment should be prescribed on an individualized basis to be based on net clinical benefit and the patient’s preference and values.

Regarding the choice of anti-thrombotic therapy, RCTs have already demonstrated non-inferiority of the 4 commercially available direct (also termed novel) oral anticoagulants (DOACs) apixaban, dabigatran, edoxaban and rivaroxaban compared to warfarin for stroke prevention. Furthermore, there is ample evidence in the literature regarding greater efficacy and safety of the direct oral anticoagulants compared to warfarin, especially so in Asians. Apart from AF patients who have either 1) a mechanical heart valve or 2) moderate to severe mitral stenosis, all are recommended a direct oral anticoagulant for stroke prevention in preference to a vitamin-K antagonist (i.e. Warfarin).

Anti-platelet agents (either aspirin monotherapy or in combination with clopidogrel) are NOT recommended as anti-thrombotic therapy for stroke prevention in AF if a patient is either unfit for or refuses an anticoagulant (i.e. a DOAC or Warfarin). Ample evidence exists now in the literature showing aspirin to be ineffective for stroke prevention compared with no antithrombotic therapy. Aspirin + Clopidogrel is more effective vs. aspirin monotherapy alone but still less effective than warfarin with similar risks for major bleeding.

The content of the January 2021 Cardiology Series is provided by:Dr. CHEUNG Ling Ling

MBBS(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in Cardiology Dr. Karl CHAN

MBBS (HK), MRCP (UK) 一月臨床心臟科個案研究之內容承蒙張玲玲醫生及陳斯畧醫生提供。


Dermatology

www.hkma.org

Dermatology Series for February 2021 is provided by:Dr. KWAN Chi Keung, Dr. TANG Yuk Ming, William,

Dr. CHAN Hau Ngai, Kingsley, Dr. LEUNG Wai Yiu and Dr. NG Shun ChinSpecialists in Dermatology & Venereology

二月皮膚科個案研究之內容承蒙關志強醫生、鄧旭明醫生、陳厚毅醫生、梁偉耀醫生及吳順展醫生提供。

Q&A Please answer ALL questionsAnswer these on page 15 or make an online submission at: www.hkma.org.

A 48-year-old gentleman complained a rapidly growing warty nodule on his right thigh within six months. It is not painful nor itchy. There is no bleeding. He did not remember any history of injury on that area. Physical examination revealed a solitary warty nodule around 2cm in diameter on his right thigh.

Rapid Growth Of A Warty Nodule

Complete Dermatology case, 0.5 CME POINT will be awarded for at least 3 correct answers in total

1. What may be the possible diagnosis of this gentleman’s skin lesion?a) Common wart d) Cutaneous hornb) Verrucous carcinoma e) All of the abovec) Keratoacanthoma

2. What investigation do you want to order?a) Skin scraping for fungal smear and cultureb) Skin scraping for cytologyc) Skin scraping for HPV DNAd) Skin biopsy for histologye) No need to have any investigation

3. This lesion is due to infection. (True or False)?

4. What is (are) the treatment for this gentleman?a) Surgical excision c) Cryotherapyb) Curettage and d) Radiation therapy cauterization e) All of the above

5. The lesion may recur. (True or False)

January Answers

Dermatology Series for January 2021 is provided by:Dr. LEUNG Wai Yiu, Dr. TANG Yuk Ming, William,

Dr. CHAN Hau Ngai, Kingsley, Dr. KWAN Chi Keung and Dr. NG Shun ChinSpecialists in Dermatology & Venereology

一月皮膚科個案研究之內容承蒙梁偉耀醫生、鄧旭明醫生、陳厚毅醫生、關志強醫生及吳順展醫生提供。

1. BThis is a localized form of asteatotic eczema (or eczema craquelé). The pathogenesis is a decreased lipid amount in the skin layer which leads to increased water loss. It is also associated with environmental factors such as low humidity or cold weather, frequent use of soap and bathing.

2. IIAsteatotic eczema occurs frequently in the elderly as aging is the most common cause of xerosis. Moreover, men are more commonly affected than women.

3. TThe incidence of asteatotic eczema is the highest in cold climate and winter as it is often exacerbated by low humidity, xerosis and prolonged hot showers/baths.

4. CEducate patients of some general measures such as liberal use of moisturizers, avoiding excessive use of soap or prolonged hot baths is usually sufficient to control asteatotic eczema. Low potency topical steroids may be required for those who do not respond to these measures. Systemic antibiotics is not usually indicated unless there is infection.

ANSWER SHEET

Answer Sheet

February 2020

Name Signature:

HKMA Membership No.

Contact Tel No.:

HKID No. - xxx(x)

Please return thecompleted answer sheetto the HKMA Secretariat(Fax: 2865 0943) on orbefore 15 March 2021for documentation.If you completethe exercise online,you are NOT required toreturn the answer sheet by fax.

Please answer ALL questions and write the answers in the space provided.

A maximum of 20 points can be awarded for se l f -study per year and no upper limit of CME points for attending CME lectures

DermatologyCardiologyComplete Dermatology, 0.5 CME point will be awarded for at least three correct answers

Complete Cardiology, 0.5 CME point will be awarded for at least two correct answers

1 2 3 4 5

(revised in August 2019)

CME Physical Lecture Policy and ProcedureRegistration1. Please complete the reply slip and return to HKMA Secretariat in person

or by fax/mail/email.2. Enrollment priorities will be given to doctors who have purchased

packages. For Community Network Lectures, priorities will be given to doctors from that Community Network with Packages, then doctors from that Community Network.

3. No walk in or on-site payment will be accepted. Attendance without registration will not be recognized and CME point will not be accredited.

4. Please ensure that your registration is confirmed before attending lecture. Only successfully registered doctors who paid could attend the lecture.

5. The HKMA Secretariat will notify doctors who have successfully enrolled to arrange for payment. If doctors have not arranged for payment within a specified period after the notification, the seat will be released to doctors on waiting list without further notice.

Payment1. All HKMA CME lectures that involve registration and enrollment through

the HKMA would require the collection of lecture fee (unless otherwise specified).

2. The lecture fee is $50 for HKMA members and $100 for non-members per lecture.

3. Online payment is available to doctors who have registered the HKMA website online system. One transaction is for one lecture only.

4. Packages could be purchased through cash or cheque only.5. Cash payments have to be paid in person at HKMA Secretariat and

cheque payments have to be mailed or paid in person at HKMA Secretariat.

6. Fee can be paid together in one cheque for lecture within the same month. Only combined cheque payment for not more than 2 packages will be accepted.

7. No refund or transfer will be allowed after payment is made. Payment cannot be transferred to other lectures or for other specified doctors.

CME Online Payment & CME Self-Studies SeriesCME Online PaymentThe HKMA is excited to introduce online payment for CME Lectures:1. Login to CME Portal to apply for a lecture2. Receive SMS notification3. Pay online!

Online payment available ONLY for attending a single lesson, payment for package is unavailable currently.CME Self-Studies SeriesYou can register the CME Lectures and finish the CME Self-Studies Series within the webpage (www.hkma.org).Don’t wait! Please register and create your own account through https://www.thkma.org/members/register.php (1st time register account is limited on desktop ONLY) to experience our new Members Portal.Information for ParticipantsSpecial weather arrangementWhen Tropical Storm Warning Signal No. 8 (or above) or a Black Rainstorm Warning Signal is in force within 3 hours of the commencement time, the relevant CME function will be cancelled. (i.e. CME starting at 2:00 pm will be cancelled if the warning signal is hoisted or in force any time between 11:00 am and 2:00 pm).The function will proceed as scheduled if the signal is lowered three hours before the commencement time. (i.e. CME starting at 2:00 pm will proceed if the warning signal is lowered at 11:00 am, but will be cancelled even if it is lowered at 11:01 am).When Typhoon No. 8 Signal or a Black Rainstorm signal is in force after CME commencement, announcement will be made depending on the conditions as to whether the CME will be terminated earlier or be conducted until the end of the session.The above are general guidelines only. Individuals should decide on their CME attendance according to their own transportation and work/home location considerations to ensure personal safety.General lecture policy1. Doctor should sign for own CME.2. Registration will cease when Q & A Session starts.3. No recording unless permission is granted by the HKMA.4. If doctor has attended CME Lecture and CME Live at the same point of

time, only CME Points for the Lecture would be counted.5. The HKMA will investigate when non-compliance at CME Session is

reported, further action will be considered to ensure all CME activities are properly held.

6. For enquiries, please contact the CME Department of the HKMA Secretariat at 2527-8452.

SPOTlightComplete Spotlight, 1 CME point will be awarded for at least 5 correct answers

1 2 3 4 5 6 7 8 9 10

1 2 3 4

16 HKMA CME Bulletin 持續醫學進修專訊 February 2021 www.hkma.org

CME LiveCME notifications

Date Organizer and Topic SpeakerCME

Points

CME Accreditation from Colleges (Pending) #

1. 22 February (Mon)

HKMA Yau Tsim Mong Community NetworkLecture Series on Surgery (Session 2) - Non-Surgical Treatment of Benign Thyroid Nodule

Dr. KAN Mei Yee, DaisyConsultant, Department of Surgery, Kwong Wah Hospital

1 Yes

2. 23 February (Tue)

The Hong Kong Medical Association & the Gleneagles Hong Kong HospitalCA lung/Lung Nodules and Ground Glass Opacities: how should we manage them?Sponsor: Gleneagles Hong Kong Hospital

Dr. WAN Chi KinSpecialist in Respiratory Medicine

Dr. SIHOE Dart Loon, AlanSpecialist in Cardio-thoracic Surgery

1 Yes

3. 25 February (Thu)

HKMA Hong Kong East Community NetworkHemorrhoids... A Common Disease and Effective Treatment OptionsSponsor: Servier Hong Kong Ltd

Dr. NG Ka KinSpecialist in General Surgery

1 Yes

The HKMA CME Live Lecture in February 2021

All lectures start at 2:00-3:00 p.m.

本診所將於至休息，

並於年初開診。

This clinic will be closed from

to for Lunar New Year.

如有緊急查詢，請致電In an emergency, please contact

17HKMA CME Bulletin 持續醫學進修專訊 February 2021www.hkma.org

CME Live CME notifications

Date Organizer and Topic SpeakerCME

Points

CME Accreditation from Colleges (Pending) #

1. 3 March (Wed)

The Hong Kong Medical AssociationThe Evolving Landscape Of Anticoagulation Management In Atrial FibrillationSponsor: Pfizer Corporation Hong Kong Ltd

Dr. JIM Man HongSpecialist in Cardiology

1 Yes

2. 4 March (Thu)

The Hong Kong Medical AssociationCan Antioxidant Help Your Patients With Atopic Dermatitis?Sponsor: A. Menarini Hong Kong Limited

Dr. LOO King Fan, StevenSpecialist in Dermatology & Venereology

1 Yes

3. 5 March(Fri)

The Hong Kong Medical AssociationA New Horizon In Psoriasis ManagementSponsor: AbbVie Ltd.

Dr. CHAN Yung, DavisSpecialist in Dermatology & Venereology

1 Yes

4. 9 March (Tue)

The Hong Kong Medical Association Treatment approach on the management of H. Pylori infectionSponsor: Abbott Laboratories Limited

Dr. LEE Ming Kai, DerekSpecialist in Gastroenterology & Hepatology

1 Yes

5. 10 March (Wed)

HKMA Central, Western & Southern Community NetworkMultidisciplinary Management of LUTS PatientsSponsor: Astellas Pharma Hong Kong Co, Ltd.

Dr. CHAN Fei, CharlesSpecialist in Geriatric Medicine

1 Yes

6. 11 March (Thu)

HKMA Kowloon East Community NetworkEarly Rhythm-Control Therapy in Patients with Atrial FibrillationSponsor: Sanofi Hong Kong Limited

Dr. HUNG Yu Tak Specialist in Cardiology

1 Yes

7. 16 March (Tue)

HKMA Yau Tsim Mong Community NetworkRight Treament at the Right time for the Men with BPH/LUTSSponsor: GlaxoSmithKline Limited

Dr. LEUNG Yiu LamSpecialist in Urology

1 Yes

8. 18 March (Thu)

HKMA New Territories West Community NetworkThe Threat of a ‘Twindemic’Sponsor: Roche Hong Kong Limited

Dr. CHOI Kin WingSpecialist in Infectious Disease

1 Yes

9. 24 March (Wed)

The Hong Kong Medical AssociationChoosing Right Beta-Blocker For CHF And HTNSponsor: A. Menarini Hong Kong Limited

Dr. CHOW Hoi Fan, DannySpecialist in Cardiology

1 Yes

10. 25 March (Thu)

HKMA Hong Kong East Community NetworkEvolution of Thyroidectomy in the Era of TechnologySponsor: Medtronic Hong Kong Medical Limited

Dr. WONG Kai PunSpecialist in General Surgery

1 Yes

11. 26 March (Fri)

HKMA Kowloon City Community Network Importance of Controlling Allergic Rhinitis in Children During Pandemic Sponsor: GlaxoSmithKline Limited

Dr. TSANG Wing YanSpecialist in Paediatrics

1 Yes

Please register through https://forms.gle/uugzuqW2faqmRjYg6 or scan the QR code underneath if you are interested to attend. For enquiry, please contact the Secretariat at 2527 8285.

# Accreditation from various colleges pending, for specialists, please completed the quiz online within two hours after the lecture with at least 50% correct for CME/ CPD points. For lecture without “Yes”, CME Accreditation is for Non-Specialists Only. Non-Specialists doctors must complete lecture quiz (10 Q&A) and answer questions within two hours after the lecture with at least 50% correct.

The HKMA CME Live Lecture in March 2021

All lectures start at 2:00-3:00 p.m.


CME LiveCME notifications

Date Topic Speaker

02 March 2021 (Tue) The Application & Effectiveness Of Allergen Immunotherapy In Co-Morbid Allergic Diseases

Dr. CHAN Wai Ming, AlsonSpecialist in Paediatric Immunology, Allergy and Infectious Diseases

13 April 2021 (Tue) 10 Things That You Need Know About Prostate Cancer Dr. POON Ming Chun, DarrenSpecialist in Clinical Oncology

04 May 2021 (Tue) Recent Advance In GORD Dr. KWONG Wing HangSpecialist in General Surgery

01 June 2021 (Tue) Common Upper Limb Fractures And Options Of Treatment

Dr. KOU Sio KeiSpecialist in Orthopaedics & Traumatology

06 July 2021 (Tue) Surgical Management Of Lymphoedema Dr. CHOI Wing KeeSpecialist in Plastic Surgery

03 August 2021 (Tue) Glaucoma-Beyond Intraocular Pressure, The Updates We Should Know

Dr. BAIG, Nafees BegumSpecialist in Ophthalmology

HKMA-HKSH CME Programme 2021All lectures start at 2:00-3:00 p.m.

HKMA-GHK CME Programme 2021All lectures start at 2:00-3:00 p.m.

Date Topic Speaker

12 March 2021 (Fri) Update On Minimally Invasive Spine Surgery Dr. LAM Cheung Hing, EricSpecialist in Orthopaedics & Traumatology

20 April 2021 (Tue) Update On Management Of Peritoneal Malignancy Dr. Jeremy YIPSpecialist in General Surgery

25 May 2021 (Tue) Update On Renal Stone Management Dr. CHUNG Yeung, VeraSpecialist in Urology

22 June 2021 (Tue) Management On Musculoskeletal Tumor Dr. SO Yat Cheong, TimothySpecialist in Orthopaedics & Traumatology

CME Accreditation: 1 CME point per day #Registration: Please scan the QR code or register through https://forms.gle/tpiC2geoxY3D6Kxf7Registration Deadline: Monday, 8 March 2021Enquiry: CME Department, Tel: 2527 8285 / [email protected]

# Accreditation from various colleges pending. For Specialists, please completed the quiz online within two hours after the lecture with at least 50% correct for CME/CPD point(s). For Non-Specialists Doctors, please completed the quiz online within two hours after the lecture with at least 50% correct for CME point(s).


CME Live CME notifications

Session Date (All Thursdays) Topic & Speaker Learning mode 1. 18 March 2021 Update on COVID-19 Vaccine

Dr. Kitty FUNGInfection Control Officer,Consultant, Department of Pathology, UCH

Online Lecture (lectures will be conducted via Zoom. Participants are required to attend the sessions through Zoom)

2. 13 May 2021 Management of GERD in Primary Care SettingDr. FONG Ka LeukAssociate Consultant, Department of Medicine & Geriatrics, UCH

3 8 July 2021 Management on Fungal InfectionsDr. David LUKConsultant, Department of Paediatrics & Adolescent Medicine,UCH / Hong Kong Children’s Hospital

4. 29 July 2021 Update on Management of ParkinsonismDr. CHEUNG Ka YinAssociate Consultant, Department of Medicine & Geriatrics, UCH

5. 9 September 2021 Update on Management of Prostate Cancer1. Dr. LAM Ho ChingAssociate Consultant, Department of Oncology, UCH2. Dr. CHAN Hoi ChakAssociate Consultant, Department of Surgery, UCH

6. 4 November 2021 Prolapse and Incontinence SymptomsDr. YU Chung Hung, MandyDeputy Service Director (Quality & Safety), Kowloon East Cluster,Associate Consultant, Department of Obstetric & Gynaecology , UCH

7. 25 November 2021 Dementia ManagementDr. MA Chung Yee, ArinsinaAssociate Consultant, Department of Medicine & Geriatrics, UCH

Time : 2:00 – 3:00 p.m. (Lecture)Capacity/Remarks : 48. Participants need to finish a multiple choice question exercise after each lecture Certification : Certificates will be issued to participants who have completed 4 sessions or moreCME Accreditation : Pending

Certificate Course for GPs 2021Co-organized by

Registration Form

Please return the completed form to Ms. Polly TAI / Ms. Cordy WONG (UCH) by FAX at 2660 7720. For enquiry,please contact: Ms. HAW at 3949 3079, Ms. TAI at 3949 3430 OR Ms. WONG at 3949 3087.

I would like to register for the following lecture(s): (please “√”as appropriate)

Certificate Course for GPs 2021 FAX: 2660 7720Name: Tel: Fax:

Address:

Email Address:

I agree that the lecture will be videotaped by the organizers.

My clinic is located

At Kowloon East (Please specify*: )

Outside Kowloon East Region ( )

* Null entry will be treated as non-Kowloon East member registration.

Signature: Date:

Data collected will be used and processed for the purposes related to these events only.

Hong Kong College of Family Physicians

The HKMA Central, Western and Southern Community Network (CW&SCN) ~ Dr. YIK Ping Yin

Dr. CHAU Chi Hong presenting a CME Live Lecture on 13 Januar y 2021

Dr. CHOW Siu Wah, Jennif er presenting a CME Live Lecture on 8 Januar y 2021

Dr. Martin WONG presenting a CME Live Lecture on 27 Januar y 2021

Dr. CHAN Pak To presenting a CME Live Lecture on 29 Januar y 2021

The Hong Kong Medical Association

Dr. PAN Pey Chyou presenting a CME Live Lecture on 5 Januar y 2021

Dr. YEUNG Chun Yip giving a CME Live Lecture on 15 Januar y 2021

The HKMA Kowloon City Community Network (KCCN) ~ Dr. CHIN Chu Wah and Dr. CHAN Man Chung, JP

Mr. Gabriel CHU (left, Speaker), Dr. Christian FANG (middle, Moderator) and Dr. Damian MAK (right, Moderator) with several speakers in Zoom platform presenting a CME Live Half-Day Symposium on 30 Januar y 2021


Meeting Highlights

The HKMA Kowloon East Community Network (KECN) ~ Dr. AU Ka Kui, Gary

Dr. Stanley LO presenting a CME Live Lecture on 7 Januar y 2021

The HKMA Kowloon West Community Network (KWCN) ~ Dr. TONG Kai Sing

Dr. HO Kwan Lun presenting a CME Live Lecture on12 Januar y 2021

Dr. Kelvin CHAN giving a CME Live Lecture on 28 Januar y 2021

The HKMA Hong Kong East Community Network (HKECN) ~ Dr. CHAN Nim Tak, Douglas

The HKMA New Territories West Community Network (NTWCN) ~ Dr. CHEUNG Kwok Wai, Alvin


Meeting Highlights

Group picture of the Q&A session on 16 Januar y 2021 Dr. CHAN Fei giving a session on Symposium on End of Lif e Care on 16 Januar y 2021

HKMA CME BulletinMonthly Self-Study Series Call for Articles

Since its publication, the HKMA CME Bulletin has become one of the most popular CME readings for doctors. This monthly publication has been serving more than 10,000 readers each month through practical case studies and picture quizzes. To enrich its content, we are inviting articles from experts of different specialties. Interested contributors may refer to the General Guidance below. Other formats are also welcome.For further information, please contact CME Dept. at 2527 8452 or by email at [email protected] Guidance for AuthorsIntended Readers : General PractitionersLength of Article : Approximately 8-10 A-4 pages in 12-pt fonts in single line spacing, or around 1,500-2,000 words

(excluding references).Review Questions : Include 10 self-assessment questions in true-or-false format. (It is recommended that analysis and answers to most questions be covered in the article.)Language : EnglishHighlights : It is preferable that key messages in each paragraph/section be highlighted in bold types.Key Lessons : Recommended to include, if possible, a key message in point-from at the end of the article.Others : List of full name(s) of author(s), with qualifications and current appointment quoted, plus a digital

photograph of each author.Deadline : All manuscripts for publication of the month should reach the Editor before the 1st of the previous

month.All articles submitted for publication are subject to review and editing by the Editorial Board.We welcome submissions for consideration which are original and not under consideration for any other publication at the same time. Articles submitted will be checked using originality detection software. For details please contact CME Bulletin Editorial Office of the HKMA.

Receiving Electronic Copy Of CME Bulletin

The CME Bulletin has been mailed to members on the 15th of each month since year 2000. As an initiative to protect the environment and smart costing, HKMA encourages members to receive these documents via email or read them online at the HKMA website (http://www.hkma.org/), rather than receiving hard copies by post.

If you would like to receive the CME Bulletin by email, or to complete the self-assessment questions on the HKMA website, please indicate your preference by filling in the reply slip below.

REPLY SLIP

I would like to receive the HKMA CME Bulletin

By email (Please provide your valid email address):

By downloading from the HKMA website (http://www.hkma.org/)

Name: HKMA Membership No:

Signature: Date:

Please return the completed form to us by fax (2865 0943) or email ([email protected]).

香港醫生網The Hong Kong Doctors Homepage

www.hkdoctors.org

This web site is developed and maintained by the Hong Kong Medical Association for all registered Hong Kong doctors to house their Internet practice homepage. The format complies with the Internet Guidelines which was proposed by the Hong Kong Medical Association and adopted by the Medical Council of Hong Kong.

We consider a practice homepage as a signboard or an entry in the telephone directory. It contains essential information about the doctor including his specialty and how to get to him. This facilitates members of the public to communicate with their doctors.

This website is open to all registered doctors in Hong Kong. For practice page design and upload, please contact the Hong Kong Medical Association Secretariat.

由香港醫學會成立並管理的《香港醫生網》，是一個收錄本港註冊西醫執業網頁的網站。內容是根據由香港醫學會擬訂並獲香港醫務委員會批准使用的互聯網指引內的規定格式刊載。

醫生的「執業網頁」性質與電話索引內刊載的資料相近。目的是提供與醫生執業有關的基本資料，例如註冊專科及聯絡方法等，方便市民接觸個別醫生。

任何香港註冊西醫都可以參加《香港醫生網》。關於網頁版面安排及上載之詳情，請與香港醫學會秘書處聯絡為荷。

CME Calendar

23HKMA CME Bulletin 持續醫學進修專訊 February 2021www.hkma.org

February 2021

18 February(Thu)2:00-3:00 p.m.

HKMA New Territories West Community NetworkLeading the Shift in Paradigm in T2D Treatments: Cardio-Protection with Glucose-Lowering DrugHKMA Facebook CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

19 February(Fri)2:00-3:00 p.m.

The Hong Kong Medical AssociationLecture Series on Surgery (Session 2)-Non-Surgical Treatment of Benign Thyroid NoduleHKMA Facebook CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

22 February(Mon)2:00 – 3:00 p.m.

HKMA Yau Tsim Mong Community NetworkLecture Series on Surgery (Session 2) – Non-Surgical Treatment of Benign Thyroid NoduleHKMA Facebook CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

23 February(Tue)2:00-3:00 p.m.

The Hong Kong Medical Association & the Gleneagles Hong Kong HospitalCA lung/Lung Nodules and Ground Glass Opacities: how should we manage them?HKMA Facebook & Zoom CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

25 February(Thu)2:00-3:00 p.m.

HKMA Hong Kong East Community NetworkHemorrhoids... A Common Disease and Effective Treatment OptionsHKMA Facebook CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

March 2021

2 March (Tue)2:00-3:00 p.m.

The Hong Kong Medical Association & the Hong Kong Sanatorium & HospitalThe Application & Effectiveness Of Allergen Immunotherapy In Co-Morbid Allergic DiseasesHKMA Facebook & Zoom CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

3 March(Wed)2:00-3:00 p.m.

The Hong Kong Medical AssociationThe Evolving Landscape Of Anticoagulation Management In Atrial FibrillationHKMA Facebook CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

4 March(Thu)2:00-3:00 p.m.

The Hong Kong Medical AssociationCan Antioxidant Help Your Patients With Atopic Dermatitis?HKMA Facebook CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

5 March(Fri)2:00 – 3:00 p.m.

The Hong Kong Medical AssociationA New Horizon In Psoriasis ManagementHKMA Facebook CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

9 March (Tue) 2:00 - 3:00 p.m.

The Hong Kong Medical AssociationH. Pylori Treatment approach on the management of infectionHKMA Facebook CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

10 March(Wed)2:00-3:00 p.m.

HKMA Central, Western & Southern Community NetworkMultidisciplinary Management of LUTS PatientsHKMA Facebook CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

11 March(Thu)2:00-3:00 p.m.

HKMA Kowloon East Community NetworkEarly Rhythm-Control Therapy in Patients with Atrial FibrillationHKMA Facebook CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

12 March(Fri)2:00-3:00 p.m.

The Hong Kong Medical Association and the Gleneagles Hong Kong HospitalUpdate On Minimally Invasive Spine SurgeryHKMA Facebook & Zoom CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

16 March(Tue)2:00-3:00 p.m.

HKMA Yau Tsim Mong Community NetworkRight Treament at the Right time for the Men with BPH/LUTSHKMA Facebook CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

18 March(Thu)2:00-3:00 p.m.

HKMA New Territories West Community NetworkThe Threat of a ‘Twindemic’HKMA Facebook CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

24 March(Wed)2:00-3:00 p.m.

The Hong Kong Medical AssociationChoosing Right Beta-Blocker For CHF And HTNHKMA Facebook CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

25 March(Thu)2:00-3:00 p.m.

HKMA Hong Kong East Community NetworkEvolution of Thyroidectomy in the Era of TechnologyHKMA Facebook CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

26 March(Fri)2:00-3:00 p.m.

HKMA Kowloon City Community NetworkImportance of Controlling Allergic Rhinitis in Children During PandemicHKMA Facebook CME Live LectureHKMA CME Dept. – Tel: 2527 8452

1

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