[Corneal tumor secondary to trichiasis]

A rare lesion of secondary amyloidosis of the cornea caused by trichiasis is reported. A 33-year-old Asian woman presented with progressive decrease of visual acuity of the right eye evolving over several years, combined with the growth of a lower budding, gelatinous, pink corneal mass located next to an inferior lid trichiasis. The treatment consisted of eyelid surgery for trichiasis, followed by ablation of the corneal lesion by anterior keratectomy. After 14 months of follow-up, no recurrence was observed. Visual acuity is 9/10 P3 without correction. Pathological examination of the mass revealed secondary corneal amyloidosis, AL type (light chains), rarely reported in the literature (18 cases). No other organ involvement by amyloidosis was identified. Corneal amyloidosis is a rare complication of trichiasis. To avoid recurrence, this anomaly should be recognized as the cause and should be treated prior to removal of the corneal lesion.

[Infantile cataract and surgical management]

The cataract or opacification of the lens raises, in the child, two problems: of clinical diagnosis but especially of action to be taken therapeutic in particular surgical in front of a juvenille lens. This leads to a step and a therapeutic strategy, which must, individually, weigh the advantages and the disadvantages of the surgery. It is a frequent cause of visual handicap in the child. In the event of unilaterality, the major risks are the amblyopia and the aniseiconia. The elements to be analyzed are linked or the bilaterality, the type and the importance of opacity, local or general associated malformations, precocity diagnoses, and with regard to the treatment, the potential surgical complications, the quality of the optical correction, the postoperative assumption of responsibility and the cooperation of the parents. In all the cases, it will always be necessary to treat the functional part of the amblyopia.

Free exploration of painting uncovers particularly loose yoking of saccades in dyslexics

Binocular yoking of saccades is essential for single vision of words during reading. This study examines the quality of binocular coordination in individuals with dyslexia, independent of the process of reading. Fifteen dyslexia children (11.2+/-1.4 years) and 15 non-dyslexia individuals (8 children, aged 11.1+/-1.3 years, and 7 adults, 24+/-3 years) were studied. Eye movements were recorded in two conditions. In the control condition, participants made saccades to a single target where the saccade direction and magnitude were controlled. In the experimental condition saccades were allowed to move freely while viewing paintings. The results indicated that, compared with the non-dyslexia group, the dyslexia group showed a larger saccade amplitude difference between the two eyes, as well as a larger conjugate post-saccadic drift, during painting exploration than that for saccades to a single target. While both groups showed a larger disconjugate post-saccadic drift during painting exploration relative to the control condition, this showed a negative correlation with saccade disconjugacy (i.e. disconjugate drift reduced the disparity) only for the non-dyslexia group. These results indicate that individuals with dyslexia have problems of binocular coordination, both during the saccade and fixations, which are independent of the reading process. It is suggested that this reflects an immaturity of the normal oculomotor learning mechanisms.

Speed and accuracy of saccades, vergence and combined eye movements in subjects with strabismus before and after eye surgery

The purpose of the study was to examine spatio-temporal characteristics of horizontal eye movements in the natural space (saccade, vergence and combined movements) in young subjects with early onset convergent or divergent strabismus. Nine young subjects (8-20 years old) were tested: three with divergent strabismus, six with convergent strabismus. A standard paradigm was used to elicit pure horizontal saccades at far and at close viewing distance, pure vergence along the median plane (convergence and divergence) and saccades combined with vergence movements. Horizontal eye movements from both eyes were recorded by a photoelectric device. Eye movements were recorded before surgery, and, for the majority of the subjects, two times after surgery. Before surgery the accuracy of convergence and divergence movements in their pure or combined form was poor with respect to normal values. The mean velocity of convergence was also abnormally slow. Strabismus surgery improved significantly the accuracy of these types of eye movements. The speed of pure convergence and of divergence combined movements increased significantly after surgery. We concluded that poor vergence eye movement's performance, particularly those found for convergence in strabismic subjects could be due to impairment in the central structures related to sensory disparity inputs. Adaptive mechanisms promoted by the realignment of the eyes could be at the origin of the improvement in the vergence performances observed in our subjects after strabismus eye surgery.

Dépistage des troubles visuels entre 3 et 5 ans : expérience du service départemental de la Protection Maternelle et Infantile dans les Hauts-de-Seine

INTRODUCTION

Prevalence of visual impairment is estimated at 15% at the age of 5 years. Early visual screening is essential to prevent the risk of amblyopia and treat strabismus. The Maternal and Infant Welfare department of the Hauts-de-Seine district (France) organized a systematic visual screening during a routine health check-up in 3- to 4-year-old preschool children. In this population, 4% of children were wearing corrected lenses before check-up and 12% of children were referred to an ophthalmic consultant. The aim of this study was to document the performance and limitations of two visual acuity measurement tests: the Stycar test (separated presentation of letters) and Cadet letters test (grouped presentation).

PATIENTS AND METHODS

Twelve physicians conducting check-ups in 56 of the department's preschools constituted two random samples of representative children. The first sample of 201 children included 3- to 4-year-olds with a positive visual screening on the Cadet or Stycar test and the results and recommendations were collected. The second sample included 238 children who had a first negative visual screening at 3-4 years old with the Stycar test. We then conducted a second visual screening at 4-5 years-old with the Cadet letters test and collected results.

RESULTS

In the first sample of 201 children, 73 were lost to follow-up, 40 had a normal documented ophthalmic examination, 63 needed glasses and 25 needed follow-up. The positive predictive value (PPV) of the Stycar test was much higher than the PPV of the Cadet test (79% versus 48%, p<10-4). After this first screening, prevalence of visual impairment at 3-4 years old was estimated at 8%. In the second sample of 238 children, four children were recently lens adapted and 36 were referred to an ophthalmic consultant. Of these 36 children, 11 were lost to follow-up (of these children, two had a very low visual acuity (2/10 and 3/10), four had a normal ophthalmic examination, 13 needed glasses, and eight needed a follow-up. Of the total sample, 10.5% of the children had a documented visual insufficiency on the primary Stycar test screening. The PPV of the Cadet letters test was 84% (IC95%[70%; 98%]). Results of the Cadet letters test was independent of the delay between the two tests.

CONCLUSION

Although one-third of the children did not follow the recommendations for follow-up consultation, we demonstrate that visual acuity evaluation was insufficient at 3-4 years of age, and the problems were caught at 4-5 years of age with the Cadet test. Physicians must be aware of the difficulty of the Cadet test at 3-4 years of age but also that screening is inadequate when the Stycar test is normal. A second visual screening, taking into account separating problems on the Cadet test is justified at 4-5 years of age The Stycar test must be discontinued after 4-5 years of age when compliance and the predictive value of the Cadet letters test become excellent.

Le glaucome dans l’aniridie

Aniridia consists in a congenital absence of the iris, with incidence varying from 1/64,000 to 1/96,000. This complex embryologic malformation involves the iris, trabecula, and cornea with limbal stem cell deficiency. Aniridia is a genetic haplo-insufficiency expression of the PAX6 gene located on chromosome 11p13. The associated clinical ocular signs could be congenital cataract, congenital glaucoma (the most common complication), keratopathy, ptosis, nystagmus, foveal aplasia, or microphthalmia. More than half of aniridic patients will develop glaucoma, so a regular complete tensional check-up is recommended. Central pachymetry is thicker than in the general population and overestimates ocular pressure if a corrective coefficient is not used. When glaucoma is diagnosed, medical or surgical treatment should be adapted to the child's age. In younger children, trabeculotomy is preferable to trabeculectomy in the first step if the cornea is clear enough. In older children or teenagers, a classical medical treatment must be initiated first, but surgical treatment will often be needed later. Trabeculectomy is the surgical procedure to choose for these older patients or can be combined with cataract surgery in adults. In severe glaucoma, after failure of trabeculectomy with or without mitomycin C, glaucoma surgery with drainage placement could be necessary to control ocular pressure and preserve vision. The outcome of glaucoma in aniridia is always severe and requires medical and surgical treatment adapted from infancy to adulthood.

Evidence for frequent divergence impairment in French dyslexic children: deficit of convergence relaxation or of divergence per se?

AIM

There is a controversy as to whether dyslexic children present visuo-motor disabilities such as vergence and accommodative problems assessed with orthoptic tests. The purpose of this study is to re-examine this issue in a large population of children.

METHODS

Extensive orthoptic evaluation was made in 57 dyslexic and 46 non-dyslexic ("normal") age-matched children. Convergence and divergence capacities were evaluated at two distances (30 cm and 400 cm).

RESULTS

Binocular vision measured with stereo-acuity tests was normal in dyslexics. In contrast, the near point of convergence was significantly more remote in dyslexics; most importantly, divergence at both far and near distance was significantly more reduced in dyslexics (median value 4 pD and 10 pD, respectively, at far and near) than in "normals" (median value 6 pD and 12 pD, at far and near).

CONCLUSION

The existence of the divergence deficit at far distance indicates the presence of deficit of divergence per se, independently from convergence and accommodation relaxation. This result is novel and corroborated by physiological studies indicating distinct control of convergence and divergence, both at the cortical and subcortical premotor level. We conclude that vergence deficits are frequently present in dyslexics, and that dyslexics should be re-educated; training should address distinctively convergence and divergence subsystems.

High proportion of pituitary abnormalities and other congenital defects in children with congenital nasal pyriform aperture stenosis

We aimed to determine the occurrence of pituitary dysfunction and additional malformations in patients with congenital nasal pyriform aperture stenosis (CNPAS) and to predict which patients are at risk of pituitary dysfunction. Among the 40 studied patients, hypothalamo-pituitary (HP) axis abnormalities were found in 16 patients (40%), with endocrine dysfunction (n = 9) and/or abnormal HP MRI findings (n = 15). A normal HP axis on MRI was highly predictive of normal endocrine function. Of the 40 patients, 31 had additional abnormalities in the cranio-facial area (n = 26), the brain (n = 12), the vertebrae (n = 5), the limbs (n = 4), the heart (n = 7) and the kidney (n = 3). Six patients had syndromic associations: VACTERL (n = 4), CHARGE (n = 1) and RHYNS (n = 1) syndromes. Craniofacial and brain malformations were more common in patients with HP axis abnormalities than in patients with normal HP axis. Familial history of midline defects and/or consanguinity were found in 30% of patients. In conclusion, HP axis abnormalities are frequent in patients with CNPAS and justify MRI of the brain early in life and clinical evaluation to screen for patients with pituitary insufficiency. CNPAS may be a genetically heterogeneous condition with a large phenotypic variability that shares common etiological mechanisms with the various forms of the holoprosencephaly phenotype.

Le test de provocation conjonctival : recommandations pratiques pour le diagnostic des conjonctivites allergiques

The diagnosis of ocular allergy, which has become a real public health problem occurring in 25% of the general population and continues to rise, requires allergic testing. Skin and blood tests combined with interviewing the patient demonstrate sensitivity to one or more antigens. However, while allergic testing and interviews generally reveal the cause of the symptoms, only the conjunctival provocation test (CPT) provides clear evidence of a functional relation between the conjunctival pathology and exposure to the antigen. Since there is still no validated consensus regarding the criteria for positivity of the CPT in routine practice, the working group attempted to establish the major guidelines for conducting the test, to standardize approaches and pinpoint areas of uncertainty. The group established a consensus regarding the conditions for using the test (patient selection, allergens to be tested, usable concentrations, the test protocol, the signs and symptoms to be assessed, interpretation of results, follow-up) and identified two distinct patient groups (outpatients and hospitalized patients) in whom test-taking conditions are different. The outpatient group includes patients suffering from benign forms of conjunctivitis (acute, seasonal, or chronic) and those sensitive to the usual allergens (mainly domestic and airborne). In these cases, the test is given in a medical setting with an allergologist or an ophthalmologist who instills the drops relatively rapidly. The criterion for positivity is the extent of the pruritus. On the other hand, in the hospital population, which is composed of patients suffering from vernal conjunctivitis, the attempt to establish the triggering factor requires a more elaborate protocol carried out in an ophthalmologic setting and based on the association of a range of clinical and biological factors. The deliberations of the working group should lead to the standardization of the CPT procedure for diagnostic purposes.

[Clinical study of Supranettes pads in the treatment of seasonal or perennial allergic conjunctivitis in children]

PURPOSE

Ocular allergy is a common disease that is on the rise. Seasonal and perennial conjunctivitis are the most common forms of ocular allergy. Itching, hyperemia, foreign body sensation, irritation, blurred vision or ocular dryness sensations, tearing, and photophobia are the clinical signs observed in patients. A topical antiallergic treatment is prescribed associated with ocular cleaning to contribute to an antigen washing of the ocular surface. Our study aimed to evaluate the use of Supranettes pads as supplementation treatment in children for seasonal or perennial conjunctivitis.

MATERIAL AND METHODS

Our prospective study was done in children with a diagnosis of seasonal or perennial clinical ocular allergy. Every symptom was rated from 0 to 4 according to the intensity described by the children and their parents. Twenty children (range, 4-10 years) presenting an ocular allergy were included in the study. A topical antiallergic treatment membrane stabilizer or antihistamine and Supranettes pads were prescribed for ocular cleaning of one randomized selected eye four times a day. Patients were seen in consultation 1 month later to evaluate the treatment. The ocular comfort of each eye, one treated with Supranettes pads and the other not treated by Supranettes pads, was evaluated by the child helped by parents on a graduated self-evaluation scale (range, 0-10). The Mann-Whitney statistical test was used to differentiate the two groups.

RESULTS

Of the 20 patients, eleven presented seasonal conjunctivitis and nine perennial conjunctivitis. Six of them presented conjunctivitis with a slight to moderate superficial punctuate keratitis. At the consultation on day 28+/-3, patients who were first treated showed clear improvement of clinical signs with the prescribed treatment. The statistical comparison of the two groups confirmed a significant difference (p<0.05) to the advantage of the group using the Supranettes pads.

DISCUSSION

Ocular washing is essential in the treatment of allergic conjunctivitis. The new galenic form of ocular cleaning by physiological serum-impregnated pads is simple to use for children. An objective significant difference is difficult to observe in 1 month.

CONCLUSION

This study underlines the importance of the comfort of Supranettes pads evaluated in the treatment of children's conjunctivitis. It confirms the advantage of developing evaluation studies including patient satisfaction and quality of life in ophthalmology.

Binocular coordination of saccades in children with vertigo: dependency on the vergence state

The present study examines the quality of binocular coordination of saccades at far and near distance in 15 children with symptoms of vertigo headache and equilibrium disorders; these children show normal vestibular function but abnormal convergence eye movements (e.g., long time preparation, slow execution and poor accuracy, see ). The results show normal binocular saccade coordination at far distance, but large abnormal disconjugacy for saccades at near distance. During combined saccade-vergence movements (studied in six of these children), convergence remains abnormally slow. This supports the interpretation according to which poor binocular yoking of the saccades is linked to the reduced ability to produce fast convergence during the saccade; a learning mechanism based on rapid vergence would help to reduce the abducting-adducting asymmetry of the saccades. An alternative interpretation would be reduced learning ability for monocular adjustment of the saccade signals.

Latency of saccades, vergence, and combined movements in children with early onset convergent or divergent strabismus

The goal of this study was to examine latency of horizontal eye movements in the natural space (saccades, vergence, and combined saccade-vergence movements) in children with early onset convergent or divergent strabismus. Ten children were tested (8-11 years old): three with divergent strabismus, seven with convergent strabismus. A paradigm was used to elicit pure lateral saccades at far and near distance, pure vergence (convergence and divergence) and saccades combined with vergence movements. Horizontal eye movements from both eyes were recorded simultaneously by a photoelectric device (Oculometer, Dr. Bouis). The latency of saccades (at far and near distance), of vergence (convergence and divergence), and of combined movements greatly varies among subjects and has tendency to be longer than that observed in normal children of matched age, however, these differences reach significance in only a few cases. Children with divergent strabismus and residual gross binocular vision show abnormally longer vergence latencies than children with convergent strabismus without binocular vision. The initiation of combined movements does not show a dominant pattern, such as preceding vergence, as is found in normal children. Finally, strabismus surgery has no major effect on latencies. We conclude that there is no overall deficiency in latencies of eye movements in 3D space in children with early onset strabismus. Most likely, monocular visual input can be efficient as normal binocular vision for vergence movements. In a few subjects with divergent strabismus and fragile, intermittent binocular vision, latencies can be abnormally long, just because of the fragile binocular input and/or attention effort needs to use it. The absence of a pattern of initiation similar to normal children could be due to attention and fixation capabilities.

Three patients with hallucal polydactyly and WAGR syndrome, including discordant expression of Wilms tumor in MZ twins

The WAGR contiguous gene deletion syndrome is a combination of Wilms tumor, Aniridia, Genito-urinary abnormalities, and growth and mental retardation which is invariably associated with an 11p13 deletion. We report two monozygotic twins and a third, unrelated patient with WAGR syndrome and additional clinical features not usually associated with WAGR. Both twins had developmental delay, growth deficiency, severe ocular involvement (nystagmus, aniridia, cataracts), atrial septal defect and two uncommon findings: agenesis of the corpus callosum and duplication of the halluces. One twin developed Wilms tumors aged 19 months while her sister remained tumor free by the age of 6.5 years. The singleton patient showed typical WAGR syndrome and preaxial hallucal polydactyly. Molecular cytogenetic studies refined the identification of the extent of the deleted segments, which were not identical in the two families. The two deletions included the PAX6 and WT1 genes as previously reported in typical WAGR patients. The unusual anomalies described in this report, may represent the expression of low penetrant traits associated with haploinsufficency of one or more of the genes present in the deletion (PAX6 is expressed in CNS) or may indicate epistatic influences of modifier genes on the expression of gene(s) present in the WAGR region.

Combination of WAGR and Potocki–Shaffer contiguous deletion syndromes in a patient with an 11p11.2–p14 deletion

Aniridia, Wilms tumor, genitourinary abnormalities, growth and mental retardation are the cardinal features of the WAGR 11p13 deletion syndrome. The Potocki-Schaffer syndrome or proximal 11p deletion syndrome (previously DEFECT11 syndrome) is a contiguous gene syndrome associated with deletions in 11p11.2, principal features of which are multiple exostoses and enlarged parietal foramina. Mental handicap, facial dysmorphism and craniosynostosis may also be associated. We report a patient with combined WAGR and Potocki-Shaffer syndromes, and obesity. She presented with aniridia, cataract, nystagmus, corneal ulcers and bilateral congenital ptosis. A left nephroblastoma was detected at 15 months. Other features included moderate developmental delay, growth deficiency, facial dysmorphism, multiple exostoses and cranial lacunae. High-resolution and molecular cytogenetics confirmed a del(11)(p11.2p14.1) deletion with a proximal breakpoint between the cosmid DO8153 and the BAC RP11-104M24 to a distal breakpoint between cosmids CO8160 (D11S151) and F1238 (D11S1446). The deletion therefore includes EXT2, ALX4, WT1 and PAX6. This case appears to be the second patient reported with this combined deletion syndrome and confirms the association of obesity in the WAGR spectrum, a feature previously reported in four cases, and for which the acronym WAGRO has been suggested. Molecular and follow-up data on the original WAGRO case are briefly presented.

Speed-accuracy of saccades, vergence and combined eye movements in children with vertigo

Vergence abnormalities could lead to inappropriate vestibulo-ocular reflex (VOR), causing vertigo and imbalance (Brandt 1999). Indeed, a recent study by Anoh-Tanon et al. (2000) reported the existence of a population of children with symptoms of vertigo in the absence of vestibular dysfunction but with abnormal vergence findings in orthoptic tests. The purpose of this study was to examine in such children the accuracy, duration and mean velocity of vergence and saccades; additionally, for a few subjects, the effect of orthoptic vergence training on these parameters was also investigated. LEDs were used to stimulate saccades, pure vergence along the median plane and combined saccade-vergence movements. Movements from both eyes were recorded with a photoelectric device (Bouis). The results show that children with vertigo perform saccades as normal subjects of comparable age. In contrast, vergence, particularly convergence, shows abnormalities: poor accuracy, long duration and low speed. During combined movements, the well known reciprocal interaction between the saccade and the vergence is present only for saccades combined with divergence; for saccades combined with convergence such interaction is abnormal: the saccade is slowed down by the convergence but the convergence is not accelerated by the saccade. Orthoptic training improves significantly the accuracy of all eye movements; such improvement was significant for all types of eye movements except for divergence (pure and combined). Furthermore, convergence remains abnormal and the lack of acceleration by the saccade persists. These specific convergence deficits could be of both subcortical and cortical origin. Orthoptic training improves the accuracy presumably via visual attentional mechanisms, but cannot completely override deficits related to subcortical deficiencies.

Abnormality of vergence latency in children with vertigo

It is well known that vergence movements are important for distance appreciation, depth vision and stereopsis. Moreover, vergence movements are very probably used by the CNS during head and body motion to adjust the gain of the vestibulo-ocular reflex (VOR) according to the viewing distance. A recent clinical study of Anoh-Tanon et al. suggested that vertigo in children with normal vestibular function could be associated with abnormal vergence clinically assessed. The purpose of this study was to test this hypothesis with objective vergence eye movement recordings. We examined the latency of vergence, saccades and combined movements in twelve children with the complaint of vertigo but without vestibular abnormality. Convergence and saccades combined with convergence or with divergence had abnormally long latencies (relative to normal children of matched age). In contrast, divergence and isolated saccades showed only mild latency increase relative to normals. Lengthening of latency could be due to impaired cortical control. Orthoptic vergence training reduced all latencies; however, even the reduced latency of vergence and of combined movements was still abnormal. The improvement after orthoptic vergence training could be due to increased visual attention, although such mechanism cannot eliminate completely the initiation deficit of vergence movements. Objective eye movement recordings are thus useful for a diagnosis and treatment of children with vertigo.

Sudden blindness caused by anterior ischemic optic neuropathy in 5 children on continuous peritoneal dialysis1 1Published partially (case 3) in abstract form in Arch Ped 7:437, 2000, and in Pediatr Nephrol 16:C4, 2001

The authors report the occurrence of sudden blindness in 5 children (mean age, 32 months; range, 11 to 60) during continuous peritoneal dialysis regimen. All children presented with loss of light perception, visual fixation and ocular pursuit, and bilateral mydriasis unreactive to bright light. Fundoscopic examination found signs of anterior ischemic optic neuropathy with disc swelling, edema, and hemorrhages. Whereas 1 patient was dehydrated, the 4 other patients appeared well and not dehydrated. Nevertheless, blood pressure was below the normal range in all of them. Therefore, hypovolemia is highly suspected to have been the cause of ischemic optic neuropathy in all cases. Treatment consisted of steroids (4 patients), anticoagulation or antiagregation drugs (3 patients), plasma or macromolecules infusions (2 patients), vasodilatators (2 patients), and transient dialysis interruption (1 patient). One child with hepatic cirrhosis died 4 days later of acute liver insufficiency owing to ischemic hepatic necrosis. The other children had only partial improvement of vision during the following months. Because the prognosis of ischemic optic neuropathy is very poor, diagnosis and treatment of chronic hypovolemia in children on continuous peritoneal dialysis is essential to prevent such a devastating complication.

Saccades, vergence and combined eye movements in a young subject with Congenital Central Hypoventilation Syndrome (CCHS)

PURPOSE

To study saccades, vergence and combined eye movements in a case of Congenital Central Hypoventilation Syndrome.

METHODS

A 16-year-old girl with congenital partial third cranial nerve palsy, with ptosis and divergent strabismus dependent on viewing distance, participated in this study. A first operation for her ptosis was done seven years ago and an operation for her strabismus was done four years ago. The day of our oculomotor test, the patient had a residual exotropia of 12 prism diopters, mild amblyopia of the left eye and no binocular vision. LEDs on a table placed at eye level were used to stimulate saccades, pure vergence along the median plane and combined saccade-vergence movements. Horizontal eye movements from both eyes were recorded simultaneously with a photoelectric device (Bouis Oculometer).

RESULTS

The binocular coordination of saccades in this subject was unstable and more variable than normal, and there was divergent post-saccadic drift, i.e., in the direction of her residual deviation. The patient had difficulty making movements in space, particularly vergence eye movements. Pure saccades and combined movements showed abnormally long latencies and marked hypometrias. The velocity of pure saccades was normal. In contrast, the velocity of saccades in the combined movements was abnormally slow.

CONCLUSION

The long latency and the low accuracy of the eye movements in natural space indicate a general deficit in the central circuitry that controls the initiation and programming of all these types of eye movements. The absence of pure vergence and the slowness of the saccades in the combined movements could be due to a brainstem deficit specific to the vergence oculomotor system.