Congenital corneal opacities - a surgical approach to nomenclature and classification

The classification system of congenital corneal opacification (CCO) may be better considered from a perspective of pathogenesis, surgical intervention, and prognosis. The author feels that CCO is best considered as being primary and secondary. Primary CCO includes corneal dystrophies and choristomas presenting at birth. Secondary CCO may be best considered as cases of kerato-irido-lenticular dysgenesis (KILD) and other secondary causes including infection, iatrogenic, developmental anomalies of the iridotrabecular system or lens or both, and developmental anomalies of the adnexal. The appropriate classification may help determine prognosis of any surgical intervention. Terminology is crucial to furthering our understanding of the formation of the anterior chamber if we are to do so by studying cases of CCO. Peters' anomaly is too imprecise a term to describe cases of CCO. This classification of primary and secondary CCO with its subclassifications cannot be made by clinical examination alone and necessitates other diagnostic assessments. It is time to only accept studies of CCO genotype/phenotype correlation for publication if there is clinical phenotype augmented by anterior segment imaging (OCT or high-frequency ultrasound) or histology or both.

Visual outcome and corneal changes in children with chronic blepharokeratoconjunctivitis

OBJECTIVE

To describe the cause, management, and effect of chronic blepharokeratoconjunctivitis (BKC) on the cornea and visual function in children.

DESIGN

Noncomparative, interventional, retrospective case series.

PARTICIPANTS

Twenty-seven children with BKC.

METHODS

Presenting age, best-corrected visual acuity (BCVA), refractive error, and any corneal or eyelid pathologic features were recorded. Treatment included modified lid hygiene, topical antibiotics, and steroids. Systemic therapy included oral antibiotics and, from 2003 onward, flaxseed oil as an alternative to long-term antibiotics. Amblyopia therapy included refractive correction, occlusion, or atropine therapy.

MAIN OUTCOME MEASURES

Corneal and eyelid status, visual acuity (VA), and refractive error at final examination.

RESULTS

Mean age at presentation was 6.9 years (range, 7 months-15.9 years), and mean follow-up was 2.3 years (range, 5 months-6.1 years). All patients had discomfort, conjunctival injection, and signs of posterior blepharitis at presentation. Photophobia was reported in 14 patients (52%), whereas anterior eyelid inflammation was noted in 6 (22%). Acne rosacea was confirmed in 3 patients (11%). Corneal involvement occurred in 44 eyes (81%), and a history of recurrent chalazia was seen in 18 patients (67%). Median monocular BCVAs in affected eyes were 0.28 logarithm of the minimum angle of resolution (logMAR) units (interquartile range [IqR], 0.02-0.40) at presentation and 0.02 logMAR units (IqR, 0.00-0.18) at last visit. Best-corrected VA improved in 70% of affected eyes and remained unchanged in 30%. Superimposed amblyopia was present and treated in 15 patients (48%). All 8 patients (20%) who failed to achieve VA of 0.2 logMAR units or better at the final examination had bilateral corneal involvement at presentation. One child experienced a systemic side effect from oral antibiotics. No child had significant side effects from topical treatment. Twelve patients (44%) received flaxseed oil as part of their tapering regimen. A 2-year lag between symptom onset and treatment resulted, on average, in a reduction of 0.06 logMAR units of VA (95% confidence interval, 0.00-0.12; P = 0.054).

CONCLUSIONS

These findings suggest that visual loss may be significant in BKC and that delayed treatment may result in decreased final BCVA. Adequate management needs both topical and systemic treatment. Flaxseed oil may be an effective antiinflammatory nutritional therapy alternative to long-term antibiotics.

Clinical and molecular phenotype of Aicardi-Goutieres syndrome

Aicardi-Goutieres syndrome (AGS) is a genetic encephalopathy whose clinical features mimic those of acquired in utero viral infection. AGS exhibits locus heterogeneity, with mutations identified in genes encoding the 3'-->5' exonuclease TREX1 and the three subunits of the RNASEH2 endonuclease complex. To define the molecular spectrum of AGS, we performed mutation screening in patients, from 127 pedigrees, with a clinical diagnosis of the disease. Biallelic mutations in TREX1, RNASEH2A, RNASEH2B, and RNASEH2C were observed in 31, 3, 47, and 18 families, respectively. In five families, we identified an RNASEH2A or RNASEH2B mutation on one allele only. In one child, the disease occurred because of a de novo heterozygous TREX1 mutation. In 22 families, no mutations were found. Null mutations were common in TREX1, although a specific missense mutation was observed frequently in patients from northern Europe. Almost all mutations in RNASEH2A, RNASEH2B, and RNASEH2C were missense. We identified an RNASEH2C founder mutation in 13 Pakistani families. We also collected clinical data from 123 mutation-positive patients. Two clinical presentations could be delineated: an early-onset neonatal form, highly reminiscent of congenital infection seen particularly with TREX1 mutations, and a later-onset presentation, sometimes occurring after several months of normal development and occasionally associated with remarkably preserved neurological function, most frequently due to RNASEH2B mutations. Mortality was correlated with genotype; 34.3% of patients with TREX1, RNASEH2A, and RNASEH2C mutations versus 8.0% RNASEH2B mutation-positive patients were known to have died (P=.001). Our analysis defines the phenotypic spectrum of AGS and suggests a coherent mutation-screening strategy in this heterogeneous disorder. Additionally, our data indicate that at least one further AGS-causing gene remains to be identified.

Pharmacologic management of glaucoma in childhood

An evidence-based review of the drugs available for the medical management of childhood glaucoma is presented; almost all of the drugs are not licensed for use in children. Despite this, most topical drugs are safe; however, there are some significant exceptions, such as brimonidine, which may cause apnea, among other life-threatening adverse events, in infants. Broad families of drugs are available including topical adrenoceptor antagonists, topical and systemic carbonic anhydrase inhibitors, prostaglandin analogs, adrenoceptor agonists, parasympathomimetics, and combination preparations. These drugs help to reduce intraocular pressure by reducing aqueous production or increasing the outflow facility. The variety of anti-ocular hypertensive medications for childhood glaucoma has increased in recent years. The vast majority of data on these medications are from adult studies but each year more experience of their use in pediatric glaucoma is gained. In general, topical treatment is well tolerated; however, the prescribing clinician and carers should be aware of potential adverse effects and how they may present.

Surgical Treatment of Periocular Hemangiomas: A Single-Center Experience

BACKGROUND

At Great Ormond Street Hospital for Children, patients with periocular hemangiomas are assessed in a multidisciplinary team setting using a protocol developed in 1999. As part of this protocol, surgery is indicated for lesions that continue to cause amblyopia despite treatment with systemic or intralesional steroids or both. Surgery is performed by one of the authors (D.D.). This experience is described.

METHODS

A retrospective notes review was undertaken of surgically excised periocular hemangiomas.

RESULTS

Eighteen consecutive cases (15 girls and three boys) were identified as having surgical treatment over a 5-year period. The mean age at the time of surgery was 22 months (range, 5 months to 3 years). All but one of the patients had amblyopia or a threat to normal visual development. The follow-up ranged from 1 month to 4 years. Three were lower lid lesions and 15 were upper lid lesions. When there was a threat to normal visual development, preoperative imaging by ultrasound, magnetic resonance imaging, or contrast computed tomography was performed. No rebound growth or deterioration in visual development occurred in this group of patients.

CONCLUSIONS

There is limited experience in the literature of excisional surgery for the treatment of periocular hemangiomas. The authors present a series of 18 patients who have been treated at Great Ormond Street Hospital for Children after either failed medical therapies or after patient request. With the appropriate indications and surgical principles, periocular hemangiomas in children can be safely and effectively excised.

Amniotic membrane transplantation in children with symblepharon and massive pannus

OBJECTIVE

To report our pediatric experience with amniotic membrane transplantation for ocular surface and forniceal reconstruction.

METHODS

Retrospective case review of children who underwent superficial keratectomy, symblepharon lysis, and forniceal reconstruction using amniotic membrane transplantation. The underlying diagnosis, visual acuity, level of discomfort at first and last visits, and surgical details were noted.

RESULTS

Four patients (5 eyes) were included. Two patients had epidermolysis bullosa (1 recessive dystrophic and 1 junctional), 1 had laryngo-onychocutaneous syndrome, and 1 had measles-related keratitis and was positive for human immunodeficiency virus. Their mean age when initially seen was 8.7 years (age range, 4-16 years), and mean follow-up was 18.25 months (range, 12-29 months). The mean visual acuity preoperatively was 1.1 logMAR (logarithm of the minimum angle of resolution) (range, 1-1.3), and postoperatively was 0.7 (range, 0.2-1.2). All patients experienced increased ocular comfort with anatomical restoration of corneal and conjunctival surfaces. Visual acuity improved in 3 eyes. Only the patient with laryngo-onychocutaneous syndrome had recurrence of granuloma, at 9 months after surgery.

CONCLUSION

Amniotic membrane transplantation with symblepharon lysis is effective for ocular surface reconstruction in the management of epidermolysis bullosa and other conditions that cause corneal scarring and symblepharon in children. In this small series, children with epidermolysis bullosa fared better and the effects of surgery lasted longer compared with patients with other causes of symblepharon and massive pannus.

Five-year experience of the 2-incision push-pull technique for anterior and posterior capsulorrhexis in pediatric cataract surgery

PURPOSE

To describe the authors' 5-year experience of the 2-incision push-pull (TIPP) technique for pediatric anterior and posterior capsulorrhexis formation.

DESIGN

Retrospective descriptive study over a 5-year period.

PARTICIPANTS

A total of 84 eyes of 63 patients who had undergone cataract surgery in 1 center.

METHODS

Retrospective review of all consecutive patients who underwent pediatric cataract extraction with planned intraocular lens implantation and TIPP rhexis between January, 1999, and August, 2004. Any lost capsulorrhexis, or capsular tears at any stage of the operation, and the relation of optic size to anterior capsulorrhexis size were noted.

MAIN OUTCOME MEASURES

Complications during TIPP rhexis formation and any late complications at last visit.

RESULTS

The mean age at operation was 70.21 months (range, 4 weeks-18 years). All eyes had anterior TIPP rhexis; 41 eyes also had posterior TIPP rhexis, and there were no anterior or posterior capsulorrhexis loss or tears while performing the technique. In no patient in whom TIPP rhexis was performed for the posterior capsule was there an inadvertent vitreous loss during rhexis formation. All eyes had anterior rhexis diameters that were smaller than the optic diameter (5.5-6.0 mm), approximately 4 to 4.5 mm in diameter. Four capsular tears were reported; 1 tear occurred during irrigation and aspiration and the others during rigid lens insertion. No late complications were noted.

CONCLUSIONS

Our 5-year experience with the TIPP rhexis in pediatric cataract surgery has shown this to be a reliable method for producing a consistent-size capsulorrhexis opening in both anterior and posterior capsulorrhexis.

A child with laryngo-onychocutaneous syndrome partially responsive to treatment with thalidomide

Laryngo-onychocutaneous syndrome (LOCS) is a condition characterized by erosive or ulcerative skin lesions associated with excessive granulation tissue, at sites of trauma such as the digits, elbows and knees. Similar lesions can occur within the conjunctival mucosa, leading to corneal scarring and blindness. The main complications, however, occur in the respiratory tract, where a similar process of erosions and subsequent formation of granulation tissue causes airway obstruction which may lead to premature death. LOCS is now believed to be a nonblistering variant of junctional epidermolysis bullosa and to date there are no efficacious treatments available. We report a 16-year-old girl with LOCS who failed to respond to methylprednisolone and cyclophosphamide, but had a partial response to oral thalidomide with marked decrease in granulation tissue and tracheal secretions. Interruption of treatment resulted in prompt resurgence of the granulation tissue which was again controlled by reintroduction of thalidomide. We propose that in the absence of effective therapies for LOCS, a trial of thalidomide in these patients should be considered.

Monitoring Visual Function in Children With Syndromic Craniosynostosis

OBJECTIVE

To compare visual acuity, optic disc appearance, and transient pattern reversal visual evoked potentials as markers of possible visual dysfunction in children with syndromic craniosynostosis.

METHODS

Serial visual acuity, optic disc appearance, and pattern reversal visual evoked potential data were recorded in 8 patients with syndromic craniosynostosis before and after cranial vault expansion. The pattern reversal visual evoked potentials were analyzed using linear regression modeling, applied to the N80 to P100 amplitude.

RESULTS

Serial optic disc appearances were available for all 8 patients and visual acuities for 7 patients. The visual acuity deteriorated in only 1 patient, improved in 4, and fluctuated in 2, before surgery. Of the 8 patients, 3 showed no papilledema in either eye at any time, 3 showed progressive bilateral swelling before surgery, and 2 exhibited only unilateral disc swelling. In all 8 patients, there was a trend for the N80 to P100 amplitude to decrease before surgery and to increase, in all but 2 patients, after surgery.

CONCLUSIONS

This study suggests that neither optic disc appearance nor visual acuity assessment alone is a reliable marker of potential visual dysfunction in children with syndromic craniosynostosis. It also suggests that the pattern reversal visual evoked potential can provide early evidence of visual dysfunction before vault expansion surgery in these children; this dysfunction may recover postoperatively.

Penetrating orbital trauma by stiletto causing complex cranial neuropathies

Penetrating orbital injuries pose a serious threat to vision, ocular motility, and in some cases, life. Long, sharp stiletto objects may penetrate deeply, causing catastrophic damage to orbital structures, despite seemingly trivial entry wounds. The authors present two cases of penetrating orbital injuries by stiletto objects, both entering via small eyelid wounds. Traumatic optic neuropathy occurred in both cases, and was treated with corticosteroids, however the globes escaped direct injury. Injuries to the IIIrd and VIth cranial nerves were also observed. Deep orbital injuries must be excluded in patients presenting with small eyelid wounds caused by sharp penetrating objects.

Expression of FGFR-2 and FGFR-3 in the normal human fetal orbit

AIMS

To demonstrate the expression patterns of two fibroblast growth factor receptors (FGFR-2 and FGFR-3) in the normal human fetal orbit.

METHODS

6 microm orbital slide sections were prepared from 12 week old human fetal material obtained within established ethical guidelines. Radioactive in situ hybridisation techniques were used to demonstrate the expression patterns of FGFR-2 and FGFR-3 within these sections. Only one foetus had appropriate orbital sections taken.

RESULTS

FGFR-2 was expressed within the extraocular muscles (EOMs) and the optic nerve sheath and to a lesser degree within the orbital periosteal margins and the cranial sutures. FGFR-3 was expressed a lot within the periosteal margins and cranial sutures but not within either the EOMs or the optic nerve sheath.

CONCLUSIONS

FGFR-2 and FGFR-3 are differentially expressed within different orbital components. FGFR-2 gene mutations may be responsible for craniosynostotic syndromes such as Crouzon, Pfeiffer, and Apert, while those in the FGFR-3 gene may cause isolated unicoronal synostosis. EOMs may be histologically abnormal in cases of Apert, Pfeiffer, and Crouzon syndromes but not isolated unicoronal synostosis. The pattern of expression of FGFR-2 in the normal human fetal orbit may explain some of the EOM histological findings seen in some cases of Apert, Pfeiffer, and Crouzon syndromes.

The achiasmia spectrum: congenitally reduced chiasmal decussation

AIM

To describe the clinical spectrum of achiasmia, a congenital disorder of reduced relative decussation at the optic chiasm.

METHODS

A retrospective case note and patient review of nine children (four boys). Achiasmia was defined by the combination of a characteristic asymmetry of the monocular visual evoked potential (VEP) response to flash and neuroimaging showing reduced chiasmal size.

RESULTS

Three of the children had an associated skull base encephalocele with agenesis of the corpus callosum. In two patients achiasmia was associated with septo-optic dysplasia. Three patients had no neuroimaging abnormalities other than reduced chiasmal size and have no known pituitary dysfunction. One child had multiple physical deformities but the only brain imaging abnormality was reduced chiasmal size.

CONCLUSIONS

Some children with disorders of midline central nervous system development, including septo-optic dysplasia and skull base encephaloceles, have congenitally reduced chiasmal decussation. Reduced relative decussation may co-exist with overall chiasmal hypoplasia. Children with an apparently isolated chiasmal decussation deficit may have other subtle neurological findings, but our clinical impression is that most of these children function well.

Lamellar macular hole as the presenting feature in a child with Coats' disease

We report a case of Coats' disease and lamellar macular hole in a 10-year-old boy who presented with blurring of vision in his left eye. This is the first reported case of Coats' disease presenting with a lamellar macular hole in a child.

Preoperative assessment of secondary intraocular lens implantation for aphakia: a comparison of 2 techniques

PURPOSE

To compare the preoperative evaluation of secondary intraocular lens (IOL) implantation in aphakic adults following cataract extraction in childhood using slitlamp examination and high-frequency ultrasound (HFU).

METHODS

In a prospective case series, patients who had had lensectomies for congenital cataracts without primary implantation IOL were evaluated for secondary IOL insertion. Slitlamp examination and HFU were performed to study the degree of ciliary sulcus support and iridocapsular adhesions. The choice of IOL (posterior sulcus supported or anterior chamber) was compared using the 2 techniques.

RESULTS

Nine eyes of 5 patients (3 men and 2 women aged 15 to 40 years) were assessed for secondary IOL insertion. Clinical slitlamp examination suggested that 3 of 9 eyes had inadequate sulcociliary support, but HFU of these eyes revealed more than adequate capsular remnants. In all 9 eyes, sulcus-supported posterior chamber IOLs were implanted. No postoperative complications were observed, and no patients required surgery for dislocated IOL.

CONCLUSIONS

High-frequency ultrasound is a useful adjunct for the preoperative assessment of secondary ciliary sulcus-supported IOL implantation in aphakic patients who had congenital cataract extraction without IOL implantation. In patients in whom inadequate dilation precludes the detection of capsular support, posterior ciliary sulcus-supported secondary IOL implantation should be considered preoperatively. Although the technique enhances surgical planning and informed patient consent, the final decision occurs at the time of surgery with direct visualization of the ciliary sulcus support.

The value of visual evoked potentials in the evaluation of periorbital hemangiomas

PURPOSE

To present a case of a child with an extensive facial hemangioma in whom the suspicion of intracranial involvement was raised by visual evoked potential (VEP) evaluation.

DESIGN

Observational case report.

METHODS

VEP analysis was performed using flash and pattern stimuli to determine whether treatment intervention other than occlusion therapy was needed.

RESULTS

VEP analysis indicated a marked transoccipital asymmetry in the flash and pattern VEP suggestive of right hemispheric dysfunction. Neuroimaging showed intracranial extension of the hemangioma.

CONCLUSION

The VEP evaluation is a noninvasive technique performed in the awake child. This case highlights the usefulness of VEP analysis in the management of extensive periocular capillary hemangiomas and its use as a modality to identify potential intracranial involvement. Large plaquelike facial capillary hemangiomas may have possible underlying dural involvement suggestive of PHACES syndrome.

Adenoid-tonsillectomy to treat visual dysfunction in a child with craniosynostosis

We report a child with isolated saggital synostosis where a gradual deterioration of the P100 component of the pattern reversal visual evoked potential recorded during the day was associated with episodes of upper airway obstruction during sleep that correlated with periods of ICP spiking. Adenoid-tonsillectomy reversed this deterioration with coincident increase in SaO2 and decreased sleep apnoea.

Management of intracorneal bleb after trabeculectomy for congenital glaucoma

PURPOSE

Congenital glaucoma is a well-recognized entity that can occur in the presence of anterior segment dysgenesis. Trabeculectomy is an accepted intervention in the management of congenital glaucoma. The surgical technique as well as complications is well described.

METHODS

This is a case report of a 3-month-old girl with anterior segment dysgenesis and glaucoma. She was referred post-trabeculectomy with persistent corneal opacity to be considered for penetrating keratoplasty and was found to have intrastromal corneal bleb.

RESULTS

Ultrasound biomicroscopy confirmed communication of the corneal bleb with the anterior chamber, and the bleb was treated by autologous blood injection at the trabeculectomy site, under acetazolamide cover.

CONCLUSIONS

We present evidence suggesting that abnormal structure was the etiologic basis for corneal bleb formation and describe our management of this previously unreported complication of trabeculectomy.

An unusual ectodermal dysplasia with unique eye defects

We report a 12-year-old boy with dental, auricular, nasolacrimal duct and unique eyelid anomalies as well as cribriform scrotal atrophy. We believe this is the first description of such a case, although many of the features fit within the spectrum of the ankyloblepharon/ectodermal dysplasia/clefting (AEC) syndrome.

Unilateral keratoconus in a child with chronic and persistent eye rubbing

PURPOSE

To report a case of unilateral keratoconus in a 7- year-old female, secondary to chronic persistent eye-rubbing in the absence of any systemic condition.

DESIGN

Observational case report.

METHODS

In the case of this child, no organic cause was found to explain the onset of keratoconus other than persistent eye-rubbing in the affected eye.

RESULTS

Nocturnal eye padding was instigated and the condition stabilized. She was reviewed over a 2-year period of follow-up.

CONCLUSIONS

Eye-rubbing has been implicated in the pathogenesis of keratoconus. Eye-rubbing is also often a feature of a number of conditions linked to keratoconus such as Down syndrome, atopic keratoconjunctivitis, mental retardation, and Lebers' congenital amaurosis. There are a number of reports linking eye-rubbing and keratoconus in children, typically in relation to these conditions. However, in this case the keratoconus was secondary to chronic and persistent eye-rubbing in a healthy child.

Fourth and sixth cranial nerve injury after halo traction in children: a report of two cases

BACKGROUND

Spinal traction is the application of a longitudinal force to the spinal column as a means of stabilizing a damaged or abnormal spine. Although not well documented in the ophthalmic literature, complications include cranial nerve palsies, with the sixth nerve being most commonly affected. Fourth nerve palsies have not previously been reported to our knowledge. We present 2 cases of combined fourth and sixth palsies after cervical traction.

METHODS

Retrospectively, we reviewed the ophthalmic findings in 2 children with diplopia after spinal traction.

RESULTS

Case 1 suffered a traumatic rotatory atlantoaxial subluxation and underwent halo traction. Case 2 required traction to correct a scoliosis secondary to osteogenesis imperfecta. In both cases, sixth nerve palsies were apparent soon after traction. Careful orthoptic examination revealed additional fourth nerve involvement. After 3 months, both cases showed partial resolution of the cranial nerve injuries.

CONCLUSIONS

Cranial nerve injury may occur with spinal traction. Fourth nerve palsy may be underreported because of masking by a coinciding sixth nerve palsy.

An ultrasound based classification of periocular haemangiomas

AIMS

To propose a classification system for periocular haemangiomas based on ultrasound evaluation.

METHODS

Retrospective review of ultrasound images from children seen in the authors' unit with periocular haemangiomas. Static ultrasound images from 50 patients with periocular haemangiomas were reviewed as identified from a computerised database. Each haemangioma ultrasound image was classified into three categories: (1) preseptal only; (2) preseptal + extraconal; (3) preseptal + extraconal + intraconal. These were compared with the categories given to each patient at first presentation after dynamic scanning.

RESULTS

Classification was possible from the static images in 44 (88%) cases. Of those classified 20 (45%) were preseptal only; 17 (39%) were preseptal + extraconal, and seven (16%) had an additional intraconal component. The classification in all 44 cases was the same as that given at the time of presentation. In the small number of cases which went to surgery or had neuroimaging, the ultrasound classification was confirmed.

CONCLUSIONS

Ultrasound classification was not difficult to perform and no child needed sedation or general anaesthesia for this exam. Ultrasound anatomical classification is an important first step in determining appropriate treatment of periocular haemangiomas. The authors present what they believe to be the first such classification.

Phenotypic diversity and mutation spectrum in hypotrichosis with juvenile macular dystrophy

Hypotrichosis with juvenile macular dystrophy is a rare autosomal recessive disorder characterized by abnormal growth of scalp hair during infancy, and by the later occurrence of macular degeneration leading to blindness during the first to third decade of life. Hypotrichosis with juvenile macular dystrophy was recently shown to result from mutations in CDH3 encoding P-cadherin. In this study, we assessed 27 individuals, including nine patients, belonging to five families in an attempt to characterize further the CDH3 mutation spectrum and delineate possible phenotype-genotype correlations. Deleterious biallelic mutations, predicted to lead to the translation of a dysfunctional protein, were found in all affected individuals. Four of these mutations are novel. Affected individuals of two large separate apparently unrelated families of Arab Israeli origin were found to carry the same homozygous mis-sense mutation (R503H) in exon 11 of the CDH3 gene. This mutation, which alters a Ca2+-binding site in the fourth extracellular domain of P-cadherin, was previously described in a third unrelated Arab Israeli family. Using haplotype analysis for a series of polymorphic markers encompassing the CDH3 gene, we obtained evidence suggesting a founder effect for R503H in the Arab Israeli population. We also compared the dermatologic and ophthalmologic features of 22 hypotrichosis with juvenile macular dystrophy patients with known recessive mutations in CDH3. Whereas hair paucity and macular degeneration were found in all patients, we noticed significant interfamilial and intrafamilial differences in hair morphology, associated skin findings as well as severity and age of onset of visual disability. Altogether, our results obtained in a series of families of various ethnic origins firmly establish mutations in CDH3 as the proximal cause of hypotrichosis with juvenile macular dystrophy and demonstrate genetic homogeneity as well as phenotypic heterogeneity in this disorder.

Ocular and systemic side effects of brimonidine 0.2% eye drops (Alphagan®) in children

INTRODUCTION

Brimonidine 0.2% (Alphagan) is a topical alpha-2 agonist widely used as an antihypertensive. There have been occasional reports of systemic adverse effects in children including apparent central nervous system depression. There are few data available on the overall safety of brimonidine 0.2% in children.

METHODS

Computerised pharmacy records were used to identify all children who had been prescribed brimonidine 0.2% in our eye department between August 1999 and June 2001, and their notes were reviewed.

RESULTS

In all, 23 patients were identified from pharmacy records and 22 sets of notes were recovered and reviewed. The mean age at commencement of treatment was 8 years (range 0-14 years). In all, 10 (46%) were treated in one eye and 12 (54%) in both. Brimonidine 0.2% was taken for a mean 14 months (range 1 day-75 months). A total of 14 (64%) patients were already taking a topical beta-blocker when brimonidine 0.2% was commenced and a further four (18%) were being treated with another topical hypotensive agent. Of the 22 patients, six (27%) had to stop brimonidine 0.2% because of adverse side effects (two because of local irritation/allergy, two because of tiredness, and two because of fainting attacks).

DISCUSSION

Many topical hypotensive agents are not licensed for use in children and few safety data are available. In this study, 18% of children had systemic adverse effects sufficient to necessitate stopping the drug. It is possible that educational impairment may have passed unnoticed in others. Larger studies are required to investigate this further.

Latanoprost in port wine stain related paediatric glaucoma

AIM

To evaluate the efficacy of latanoprost (Xalatan) as adjunctive therapy in port wine stain related paediatric glaucoma.

METHODS

A retrospective non-randomised study. Patients with previous surgical intervention and medical treatment were included. Measurements were recorded from clinic and/or examination under anaesthetic (EUA) visits. A successful outcome was considered to be patients who required no further intervention following initiation of latanoprost, with stable glaucoma factors as well as drop in intraocular pressure.

RESULTS

14 patients and 17 eyes were reviewed in total. The mean age of glaucoma diagnosis was 2.59 years (0.1-5.25 years) and of commencing latanoprost was 6.8 years (1.40-12.90 years). Percentage success at 1 month, 3 months, 6 months, and 1 year was 70.6%, 64.7%, 58.9%, and 47.1%, respectively, of eyes treated which translated to 71.4%, 64.2%, 57.1%, and 50% respectively of patients treated.

CONCLUSIONS

A trial of latanoprost as adjunctive therapy in patients with port wine stain related glaucoma may temporise the need for surgery; with 50% of patients being controlled at 1 year follow up. Lack of efficacy was detected as early as 1 month following commencement of treatment.

Visual outcomes and amblyogenic risk factors in craniosynostotic syndromes: a review of 141 cases

AIMS

To determine the visual outcome and prevalence of amblyogenic risk factors in children with craniosynostotic syndromes.

METHODS

The case notes of 141 children seen within the craniofacial unit were reviewed and information retrieved on date of birth, age at first and last examination, cycloplegic refraction at last visit, best corrected visual acuity at last visit, horizontal ocular deviation in primary position at first visit, and alphabet pattern if any. The presence of astigmatism, its magnitude, and orientation of axis were determined.

RESULTS

40.3% of patients had 1 dioptre (D) of astigmatism or greater and, of these, 64% had oblique astigmatism in at least one eye. Anisometropia of 1D or more was found in 18% of patients (age matched normals 3.5%). Horizontal strabismus was found in 70% (38% exotropia, 32% esotropia). Visual outcome results showed 39.8% of patients (45 of 113) had visual acuity of 6/12 or worse in their better eye.

CONCLUSION

In the largest study to date a poor visual outcome was shown in children with Crouzon's, Pfeiffer's, Apert's, and Saethre-Chotzen syndromes (39.8% with 6/12 or worse in the better eye) together with significant prevalence of amblyogenic risk factors.

Foster-type modification of the Knapp procedure for anomalous superior rectus muscles in syndromic craniosynostoses

PURPOSE

To describe the surgical management of anomalous superior rectus muscles in patients with syndromic craniosynostoses.

METHODS

Retrospectively reviewed were case notes of 3 patients with vertical deviations that were thought to have anomalous superior rectus muscles.

RESULTS

All 3 patients had hypotropia preoperatively, and 2 had coexisting exotropia. Two patients exhibited massive subconjunctival fibrosis intraoperatively, but none had undergone previous strabismus surgery, although they had undergone craniofacial procedures. Orbital imaging (either computed tomographic or magnetic resonance imaging scans) confirmed an absent or thinned superior rectus muscle in all 3 patients. All 3 underwent a Knapp procedure with appropriate recession and resection of the transposed horizontal rectus muscles if indicated. A nonabsorbable suture was placed in the sclera at the upper border of each horizontal rectus muscle to draw this border closer to the vertical midline, approximately 16 to 18 mm from the limbus (Foster-type modification). In each case, the hypotropia and upgaze were improved but not completely normalized.

CONCLUSIONS

A Foster-type modification of the Knapp procedure satisfactorily corrected the hypotropia in these patients. Orbital imaging can confirm the presence of an anomalous superior rectus muscle. The massive subconjunctival fibrosis may be explained by the type of previous craniofacial surgery the patients had undergone.

Sustained raised intracranial pressure implicated only by pattern reversal visual evoked potentials after cranial vault expansion surgery

Craniosynostosis, the premature fusion of cranial sutures, may be associated with raised intracranial pressure (ICP) with or without a reduced intracranial volume. Regardless of the aetiology, raised ICP may result in optic neuropathy, the timely detection of which can prevent further visual deterioration. Raised ICP is usually treated with craniofacial surgery such as cranial vault expansion. In this case study, we recorded serial pattern reversal visual evoked potentials (pVEPs) and obtained digital optic disc images before and after cranial vault expansion surgery. The amplitude of the pVEPs continued to decrease after cranial vault expansion surgery, prompting further neuroimaging that implicated a blocked ventriculo-peritoneal shunt. Only after shunt revision did the pVEP amplitude increase. Throughout the monitoring period, there was no change in the appearance of either the right or left optic disk, nor a consistent change in visual acuity.

Informing parents of visually impaired children: who should do it and when?

BACKGROUND

Parents of sick or disabled children are likely to be more stressed than parents of non-disabled children and may benefit from being given information about their child's condition and its implications, but the stage at which parents should receive such information and who should provide it has not been fully investigated. The impact of written information on stress levels of parents of visually impaired children, seen in the ophthalmology clinic of a children's hospital, was explored in this study and the question of who parents thought should provide information, and at what stage, was also investigated.

METHODS

A longitudinal, experimental intervention study was conducted to compare the effect on perceived stress levels of providing information about the implications of visual impairment to parents. Effects were compared according to the child's age and explored in relation to baseline stress levels. The study included a frequency analysis about parents' knowledge of visual impairment and how it relates to education, and their response to being given written information.

RESULTS

The results did not show an effect on levels of parental stress but did find that parents of school age children were more stressed than those of preschool age. Over 80% of participants considered that information was given too late and suggested it should be given soon after diagnosis. Of the controls, 32.6% thought the general practitioner should provide information on education although participants were more likely to expect the hospital to provide it.

CONCLUSIONS

The majority of parents would prefer to receive information soon after diagnosis of their child's visual impairment. Most parents do not know who to approach for information on education. Giving them access to patient liaison teams who could advise about the repercussions of visual impairment in children would be beneficial.

The morphology and natural history of childhood cataracts

The morphology of congenital cataract reflects a combination of the timing and nature of the cause, the anatomy of the lens including its capsule, its development, and changes that take place with time. Morphology may variably affect prognosis, give a clue to the etiology and the age of onset and, in an isolated case, sometimes suggest heritability. The spectrum of morphological variations is enormous and can be complex. A comprehensive approach is to classify the variations according to the area of the lens involved, and sub-dividing them by a detailed description of the shape and appearance. Each specific morphological type is then analyzed determining the etiology, visual prognosis, and management. The use of gene markers has allowed many of these variations to be identified and categorized. Cataracts in childhood can involve the whole lens, in which case they are called total, Morgagnian, or disk-like. They can affect only the center of the lens: lamellar, nuclear, oil droplet, cortical, or coronary. They can be anterior: anterior polar, anterior subcapsular, or anterior lenticonus. The posterior aspect of the lens can also be affected in different fashions: Mittendorf's dot, posterior lenticonus, posterior cortical cataracts, or posterior subcapsular. There are five more forms that must be described separately: punctuate lens opacities, sutural cataracts, coralliform or crystalline, wedge-shaped, and persistent hyperplastic primary vitreous.

Hypotension and bradycardia in infants after the use of topical brimonidine and beta-blockers

Brimonidine is a selective alpha-2 adrenergic agonist used to treat glaucoma. There have been several reports of central nervous system depression after its use in infants. We observed rapid-onset bradycardia and decreased blood pressure in addition to central nervous system depression in 2 infants who received concomitant topical brimonidine and beta-blockers.

Two-incision push-pull capsulorhexis for pediatric cataract surgery

Pediatric capsulorhexis is a challenging surgical technique because of the elasticity of the pediatric anterior capsule. This technique of manual capsulorhexis allows reliable and reproducible results for the size and centration of anterior and posterior capsulorhexes in pediatric cases. The technique is a modification of a previously reported method.

Clinicopathological correlation of congenital corneal opacification using ultrasound biomicroscopy

AIM

To investigate the correlation between clinical, high frequency ultrasound biomicroscopy (UBM) and, where possible, histological findings in cases of congenital corneal opacification presenting to the departments of ophthalmology, Great Ormond Street Hospital for Children, London, and the Hospital for Sick Children, Toronto, Canada.

METHOD

22 eyes of 13 children (age range 3-225 days) with congenitally opaque corneas were examined. UBM was performed using the ultrasound biomicroscope (Allergan-Humphrey). All eyes underwent penetrating keratoplasties (PKP) except five. The host corneas were all sent for histological examination.

RESULTS

The final diagnosis in our series was Peters' anomaly in nine cases (70%), corneal dystrophy in two cases (15%), and sclerocornea in two cases (15%). The UBM findings changed the clinical diagnosis in five cases (38%). In these five cases histology was available in four and confirmed the UBM diagnosis in each case. In no case of the 13 where histology was available did it contradict the UBM findings. In two cases a hypoechoic region in the anterior stroma was seen on UBM which correlated histologically with absent Bowman's layer and oedema. In two cases UBM revealed aniridia and in one, congenital aphakia, which was not apparent clinically.

CONCLUSION

UBM examination is not only very useful in evaluating the clinical diagnosis in congenital corneal opacification, it also acts as a preoperative guide in cases undergoing PKP by detecting keratolenticular and iridocorneal adhesions and other ocular abnormalities such as aniridia and congenital aphakia. In all cases where PKP was performed the UBM diagnosis was confirmed histologically. The clinical diagnosis was incorrect in five cases. This has important implications in studies of phenotype/genotype correlation of congenital corneal opacification.

Values of electroretinogram responses according to axial length

Accurate interpretation of electroretinograms (ERGs) requires knowledge of effects of axial myopia on ERG responses. Our purpose was to derive expected changes of ERG responses according to axial length, to stimulus conditions that conform to the International Society for Clinical Electrophysiology of Vision (ISCEV) Standard for Electroretinography. ERGs from 60 subjects were recorded. The subjects were assigned to one of three groups according to the level of myopia. Thirty-three subjects had high myopia (-6.00 D to -14.50 D; mean age, 31 years), eight had mild myopia (-3.00 D to -5.00; mean age, 28 years), and 19 had a small refractive error (+0.75 D to -2.75 D; mean age, 27 years). No subjects had myopic retinopathy. Stimulus-response curves were fitted to dark-adapted b-wave amplitudes and maximum amplitude and semi-saturation constants derived. Axial lengths, measured with A scan ultrasound, ranged from 22.2 mm to 30.0 mm. Analysis of variance and post hoc t-tests revealed significant difference between subjects with high myopia and subjects with small refractive error for ERG amplitude data. There were no significant differences between the three groups for implicit times, the ratio of b- to a-wave and semi-saturation constant. There is linear reduction in the logarithmic transform of ERG amplitude with increasing axial length, related more to axial length than refractive error. We provide relative slope and intercept values, allowing labs to derive expected ERG amplitudes according to axial length. These derivations are valid for persons with no retinopathy.

Ultrasound biomicroscopy of the eye in cystinosis

OBJECTIVE

To describe the ocular ultrasound biomicroscopy (UBM) findings in patients with cystinosis.

METHODS

Six patients with infantile nephropathic cystinosis, aged 16 to 25 years, and 6 controls (matched for age and spherical refractive error) were examined clinically and with UBM. Scleral reflectivity, corneal and iris thickness, central anterior chamber depth, angle width, trabecular meshwork to ciliary process distance, and ciliary sulcus width were measured.

RESULTS

No patient had glaucoma or posterior synechiae, but all had crystals in the trabecular meshwork apparent with gonioscopy. Using UBM, the cornea and iris appeared similar in both groups, but the scleral reflectivity was increased in patients (P =.003). The angle was narrower in patients (mean +/- SD, 20 degrees +/- 7 degrees ) than controls (31 degrees +/- 5 degrees, P<. 001). The anterior chamber was shallower in patients (2556 +/- 197 microm) than controls (2968 +/- 284 microm, P<.001). The ciliary sulcus was closed or narrow in all patients (83 +/- 112 microm) compared with controls (339 +/- 135 microm, P<.001), with a reduction in the trabecular meshwork to ciliary process distance.

CONCLUSIONS

This report of ocular UBM findings in cystinosis demonstrated narrowing of the angle and a ciliary body configuration similar to that reported for plateau iris syndrome. Gonioscopy demonstrated crystals in the trabecular meshwork. These findings may explain the predisposition of these patients to glaucoma.

High-frequency ultrasonography findings in persistent hyperplastic primary vitreous

PURPOSE

To identify anatomic correlates in eyes with persistent hyperplastic primary vitreous (PHPV) by using high-frequency ultrasonography.

METHOD

Three main groups of patients were studied by means of high-frequency ultrasonography over a 19-month period. Group I included 9 eyes of 9 patients with newly diagnosed unilateral PHPV. Group II included 4 eyes of 4 patients with unilateral PHPV that had been previously surgically treated. Group III included 22 eyes and was a control group of patients without PHPV. This group consisted of the 5 contralateral normal eyes of 5 patients with unilateral PHPV in the fellow eye, both eyes of one patient with uncomplicated unilateral cataracts, the affected eye of one patient with unilateral uncomplicated cataract, the affected eye of one patient with isolated retinal coloboma, and 13 normal eyes of 7 young adults. Group I and II patients also had B-scan ultrasonography performed and had any intraoperative findings noted.

RESULTS

Characteristic features of PHPV, such as centrally dragged ciliary processes and swollen anteriorly displaced lens, were observed only in those eyes with PHPV. A new echographic finding of a double linear echo was observed in the region of the pars plana or plicata only in eyes with PHPV. This finding was confirmed intraoperatively to be consistent with a thickened adherent anterior hyaloid face and not to be an anteriorly inserted peripheral retina.

CONCLUSION

High-frequency ultrasound can be reliably used to distinguish characteristic features of PHPV. To our knowledge this is the first such description of the use of high-frequency ultrasonography in PHPV eyes. Furthermore, the presence of a thickened adherent anterior hyaloid face may help explain the well-recognized complications of peripheral retinal tears and retinal detachments during and after surgical intervention.

Ocular abnormalities in Alagille syndrome

OBJECTIVE

To assess the type and frequency of ocular abnormalities occurring in Alagille syndrome (AS) in a large group of affected patients and their parents and the potential pathogenetic role of fat-soluble vitamin deficiency.

DESIGN

Observational case series.

PARTICIPANTS

Twenty-two children with AS and 23 of their parents participated.

MAIN OUTCOME MEASURES

Participants underwent full ophthalmic examination, including refraction, orthoptic examination, keratometry, slit-lamp examination, and funduscopy. Corneal diameter measurement was performed in a subset of nine and fluorescein angiography in a subset of six. Serum levels of vitamins A and E and cholesterol were measured.

RESULTS

The most common ocular abnormalities in patients with AS were posterior embryotoxon (95%), iris abnormalities (45%), diffuse fundus hypopigmentation (57%, a previously unreported finding), speckling of the retinal pigment epithelium (33%), and optic disc anomalies (76%). Microcornea was not associated with large refractive errors, and visual acuity was not significantly affected by these ocular changes. Vitamin levels were normal. Ocular abnormalities including posterior embryotoxon, iris abnormalities, and optic disc or fundus pigmentary changes were detected in one parent in 36% of cases.

CONCLUSIONS

Alagille syndrome is associated with a characteristic group of ocular findings without apparent serious functional significance and probably unrelated to fat-soluble vitamin deficiency. Simple ophthalmic examination of children with neonatal cholestatic jaundice and their parents should allow early diagnosis of AS, eliminating the need for extensive and invasive investigations.

Ectopia lentis et pupillae. A hypothesis revisited

BACKGROUND

Ectopia lentis et pupillae (ELeP) is a rare congenital inherited disorder characterized by lenticular and pupillary ectopia. Recent speculation on its pathogenesis is based on clinical observation and includes a neuroectodermal defect or persistence of fetal vasculature. None of these reports included histopathology or imaging studies.

STUDY DESIGN

Case report and literature review.

INTERVENTION

The authors examined a 55-year-old woman with ELeP using 10-MHz and 50-MHz ultrasonography to demonstrate the structural abnormalities present. Five patients (eight eyes) who had undergone cataract extraction without lens implantation were also examined.

RESULTS

In the patient with ELeP, the right pupil was displaced inferiorly and the left temporally. An ultrasound scan at 10 MHz showed both lenses lying inferiorly in the vitreous. An ultrasound scan at 50 MHz allowed detailed examination of the anterior segment, including the iris and ciliary body, and showed two main features in each eye, including a lack of definition of ciliary processes, except in that quadrant toward which the pupil was displaced, and a membrane-like structure extending forward and attaching to the proximal pupil margin. The membrane passed over the tips of the ciliary processes to a more posterior origin.

CONCLUSIONS

The only histologic reports of this condition are from the beginning of this century in the German literature. Ultrasonography at 50 MHz allows high-resolution in vivo imaging of anterior structures that are not clinically visible. The authors' findings in this case of ELeP are sufficiently different from those of non-ELeP-related aphakia to suggest that they are not solely due to aphakia. Furthermore, the authors' findings are very similar to the only histologic reports suggesting that the pupillary and lenticular ectopia results from mechanical tethering of the pupil with zonular disruption. This hypothesis has not been discussed in the recent literature.

Ocular ultrasound in Alagille syndrome: a new sign

BACKGROUND

Alagille syndrome (AS) is one of six forms of familial intrahepatic cholestasis, all of which present with neonatal jaundice and paucity of intrahepatic bile ducts. Differentiation of these individual syndromes is crucial as their treatments and prognoses vary. It is the ophthalmic features, posterior embryotoxon on particular, that distinguish AS.

METHODS

The authors performed full ocular examination, including A- and B-scan ultrasound, refraction, and, where possible, fluorescein angiography in 20 unrelated children with AS and 8 with non-AS-related cholestasis.

RESULTS

There was ultrasound evidence of optic disc drusen in at least one eye in 95% and bilateral disc drusen in 80% of patients with AS but in none of the patients who were non-AS at the time of examination. Independent review of hard-copy scans suggested drusen in at least one eye in 90% of the cases and bilateral drusen in 50%, although this latter figure rose to 65% on review of the angiograms. This is markedly higher than the incidence in the normal population (0.3%-2%). Axial lengths were shorter than expected for the older age group (older than 10 years of age), but this was not associated with gross ametropia.

CONCLUSION

This strong association of AS and optic disc drusen has not been reported previously and represents not only the first significant association between a systemic condition and disc drusen but also a possibly useful tool in the diagnosis of AS, especially in young children.

Effect of applanation tonometry on mean corneal curvature

PURPOSE

To evaluate whether applanation tonometry affects corneal curvature and if so, the implications for intraocular lens power calculation.

SETTING

Birmingham and Midland Eye Hospital, Birmingham, England.

METHODS

Twenty-two patients attending the preoperative assessment clinic were enrolled in the study. Keratometry was performed immediately before, 1 minute after, and 10 minutes after standard Goldmann tonometry. Main outcome measures were mean corneal refractive power and its reproducibility (coefficient of repeatability).

RESULTS

No clinically significant difference was noted between preapplanation and postapplanation readings (P = .6), and reproducibility was not significantly affected.

CONCLUSION

The results indicate that corneal applanation before keratometry does not compromise the prediction of postoperative refraction.