Hand-held spectral domain optical coherence tomography finding in shaken-baby syndrome

Reproducibility of Portable OCT and Comparison with Conventional OCT

Optical coherence tomography (OCT) is an indispensable instrument in ophthalmology; however, some facilities lack permanent OCT devices. ACT100, a portable SD-OCT system, allows for medical examinations at hospitals that do not have OCT and house calls. We investigated the usefulness of ACT100 by examining the reproducibility of retinal thickness measurements in 35 healthy participants with normal eyes using ACT100 and Cirrus. Using two OCTs, the OCT imaging of both eyes of each subject was performed. Macular retinal thickness was evaluated using the average value in nine lesions of the Early Treatment Diabetic Retinopathy Study (ETDRS) circle. Both models captured images in all cases. In the right eye, mean retinal thickness was significantly lower than in the ACT100 group in all regions; however, the measured values correlated well. The intraclass correlation coefficients showed the same high reliability as the Cirrus. The coefficients of variation (CVs) of both models showed little variation and high stability; however, the CV of ACT100 was significantly higher. The left eye was almost identical. Macular retinal thickness measured using ACT100 showed slightly greater variability than that by Cirrus; the reproducibility was good and correlated well with that of Cirrus. This technique is a suitable alternative to conventional OCT.

Characteristics and associations of ocular and non-ocular manifestations of shaken baby syndrome

OBJECTIVES

Shaken baby syndrome (SBS), a subset of abusive head trauma, results from non-accidental, violent head shaking. Most survivors suffer permanent neurological sequelae. Accurate diagnosis is imperative and remains challenging. The purpose of this study is to describe ocular injuries and associated neurotrauma in suspected SBS.

METHODS

We retrospectively surveyed the National Trauma Data Bank 2008-2014 for patients ≤ 3 years old admitted for suspected SBS. Statistical analysis was performed with SPSS software. Significance was set at p < 0.05.

RESULTS

Three hundred forty-seven (13.9%) of 2495 patients who were ≤ 3 years old were admitted with abusive head trauma and ocular injuries which resulted from suspected SBS. Most were < 1 year old (87.9%) and male (54.2%). Common eye injuries were retinal hemorrhages (30.5%), eye/adnexa contusion (14.7%), and retinal edema (10.7%). Common neurotrauma were subdural (75.5%), subarachnoid (23.9%), and intracerebral hemorrhage (ICH) (10.4%). Mean (SD) Injury Severity Score was severe, 20.2 (8.2), and Glasgow Coma Score was moderate, 9.2 (12.8). The mortality rate was 16.7%. Retinal hemorrhages were not significantly associated with one type of neurotrauma over others. Ocular/adnexa contusion (OR 4.06; p < 0.001) and commotio retinae/Berlin's edema (OR 5.27; p < 0.001) had the greatest association with ICH than other neurotrauma. Optic neuropathy (OR 21.33; p < 0.001) and ICH (OR 3.34; p < 0.001) had the highest associated with mortality.

CONCLUSIONS

Our study supports previous studies showing that retinal and subdural hemorrhages were the most common ocular injury and neurotrauma in SBS, respectively. However, we did not find a significant propensity for their concurrence. Commotio retinae/Berlin's edema was significantly associated with both intracerebral and subdural hemorrhages.

Shaking Up Our Approach: The Need for Characterization and Optimization of Pre-clinical Models of Infant Abusive Head Trauma

Traumatic brain injuries (TBIs) are a large societal and individual burden. In the first year of life, the vast majority of these injuries are the result of inflicted abusive events by a trusted caregiver. Abusive head trauma (AHT) in infants, formerly known as shaken baby syndrome, is the leading cause of inflicted mortality and morbidity in this population. In this review we address clinical diagnosis, symptoms, prognosis, and neuropathology of AHT, emphasizing the burden of repetitive AHT. Next, we consider existing animal models of AHT, and we evaluate key features of an ideal model, highlighting important developmental milestones in children most vulnerable to AHT. We draw on insights from other injury models, such as repetitive, mild TBIs (RmTBIs), post-traumatic epilepsy (PTE), hypoxic-ischemic injuries, and maternal neglect, to speculate on key knowledge gaps and underline important new opportunities in pre-clinical AHT research. Finally, potential treatment options to facilitate healthy development in children following an AHT are considered. Together, this review aims to drive the field toward optimized, well-characterized animal models of AHT, which will allow for greater insight into the underlying neuropathological and neurobehavioral consequences of AHT.

Handheld contact-type OCT and color fundus system for retinal imaging

We present proof of concept for a handheld contact-type system capable of simultaneous optical coherence tomography (OCT) imaging of the retina and wide-field digital fundus color photography. The study focuses on demonstrating the feasibility of the proposed approach, particularly for eventual use in pediatric patients during examination under anesthesia in the operating room and in the neonatal intensive care unit. Direct contact of the probe with the cornea allows the photographer to maintain a stable position during imaging, reducing motion artifacts in the OCT images. Additionally, it simplifies the alignment process and increases the field of view of the optics. By integrating OCT and fundus imaging into a single device, the proposed compact modular design eliminates the need for separate, space-consuming systems dedicated to each imaging modality.

OPTICAL COHERENCE TOMOGRAPHY AND VISUAL OUTCOMES IN PEDIATRIC ABUSIVE HEAD TRAUMA

PURPOSE

Compare follow-up optical coherence tomography with visual function in children with abusive head trauma (shaken baby syndrome).

METHODS

Retrospective follow-up studies of three children who were victims of abusive head trauma within the first year of life.

RESULTS

Optical coherence tomography showed disrupted retinal layering, thick detached internal limiting membrane, focal posterior vitreous separation, and multilayered tractional retinoschisis. Significant vision loss occurred in three of four eyes with a history of traumatic retinoschisis. Normal visual acuity and low-normal visual-evoked potentials were measured in a child with foveal distortion, reduced global nerve fiber layer thickness, detached internal limiting membrane, and history of vitreous hemorrhage.

CONCLUSION

Significant abnormalities of retinal anatomy can be detected on optical coherence tomography years after abusive head trauma. Optical coherence tomographies and assessment of visual pathways help to elucidate causes of visual dysfunction in children with abusive head trauma.

Ophthalmic imaging in abusive head trauma

BACKGROUND

Ophthalmic imaging plays an increasingly important role the evaluation of abusive head trauma, however these imaging modalities may be unfamiliar to non-ophthalmologists.

OBJECTIVE

To provide pediatricians and child abuse pediatric professionals with background on ophthalmic imaging techniques in the context of suspected abuse, as well as information on commercial options and costs for those interested in augmenting their ophthalmic imaging capabilities.

METHODS

We performed a review of the ophthalmic imaging literature for fundus photography, ocular coherence tomography, fluorescein angiography, ocular ultrasound, computed tomography, magnetic resonance imaging and postmortem imaging. We also contacted individual vendors for equipment pricing information.

RESULTS

For each ophthalmic imaging modality, we demonstrate its role in the evaluation of abusive head trauma including indications, potential findings, sensitivity and specificity of findings for abuse, and commercial options.

CONCLUSIONS

Ophthalmic imaging is an important supportive component of the evaluation for abusive head trauma. When used in conjunction with clinical examination, ophthalmic imaging can improve diagnostic accuracy, support documentation, and possibly improve communication in medicolegal contexts.

Optical Coherence Tomography and Optical Coherence Tomography Angiography in Pediatric Retinal Diseases

Indirect ophthalmoscopy and handheld retinal imaging are the most common and traditional modalities for the evaluation and documentation of the pediatric fundus, especially for pre-verbal children. Optical coherence tomography (OCT) allows for in vivo visualization that resembles histology, and optical coherence tomography angiography (OCTA) allows for non-invasive depth-resolved imaging of the retinal vasculature. Both OCT and OCTA were extensively used and studied in adults, but not in children. The advent of prototype handheld OCT and OCTA have allowed for detailed imaging in younger infants and even neonates in the neonatal care intensive unit with retinopathy of prematurity (ROP). In this review, we discuss the use of OCTA and OCTA in various pediatric retinal diseases, including ROP, familial exudative vitreoretinopathy (FEVR), Coats disease and other less common diseases. For example, handheld portable OCT was shown to detect subclinical macular edema and incomplete foveal development in ROP, as well as subretinal exudation and fibrosis in Coats disease. Some challenges in the pediatric age group include the lack of a normative database and the difficulty in image registration for longitudinal comparison. We believe that technological improvements in the use of OCT and OCTA will improve our understanding and care of pediatric retina patients in the future.

Pediatric abusive head trauma: visual outcomes, evoked potentials, diffusion tensor imaging, and relationships to retinal hemorrhages

PURPOSE

Function and anatomy of the visual system were evaluated in children with abusive head trauma (AHT). The relationships between retinal hemorrhages at presentation were examined with outcome measures.

METHODS

Retrospective review of data in children with AHT for 1) visual acuity at last follow-up, 2) visual evoked potentials (VEP) after recovery, 3) diffusion metrics of white matter tracts and grey matter within the occipital lobe on diffusion tensor imaging (DTI), and 4) patterns of retinal hemorrhages at presentation. Visual acuity was converted into logarithm of minimum angle of resolution (logMAR) after correction for age. VEPs were also scored by objective signal-to-noise ratio (SNR).

RESULTS

Of 202 AHT victims reviewed, 45 met inclusion criteria. Median logMAR was reduced to 0.8 (approximately 20/125 Snellen equivalent), with 27% having no measurable vision. Thirty-two percent of subjects had no detectable VEP signal. VEPs were significantly reduced in subjects initially presenting with traumatic retinoschisis or hemorrhages involving the macula (p < 0.01). DTI tract volumes were decreased in AHT subjects compared to controls (p < 0.001). DTI metrics were most affected in AHT victims showing macular abnormalities on follow-up ocular examination. However, DTI metrics were not correlated with visual acuity or VEPS. There was large inter-subject variability within each grouping.

DISCUSSION

Mechanisms causing traumatic retinoschisis, or traumatic abnormalities of the macula, are associated with significant long-term visual pathway dysfunction. AHT associated abnormalities of the macula, and visual cortical pathways were more fully captured by VEPs than visual acuity or DTI metrics.

Superficial and Deep Capillary Plexus Nonperfusion in Nonaccidental Injury on OCTA

A 5-year-old Caucasian male with a history nonaccidental injury (NAI) at age 1 presented with new onset no light perception in the left eye due to a closed funnel retinal detachment. The right eye showed optic nerve pallor, peripheral vascular attenuation, and leakage. Optical coherence tomography angiography (OCTA) revealed significant parafoveal attenuation of the superficial vascular plexus, intermediate capillary plexus, and the deep capillary plexus. This correlated with inner and middle retinal layer thinning temporal to the fovea and preservation of the ellipsoid zone. The peripapillary vascular plexus was preserved. Laser photocoagulation was performed to the nonperfused peripheral retina and intravitreal bevacizumab was injected. OCTA may be used in patients with NAI to characterize macular ischemia changes. Attenuation of the superficial, intermediate, and deep capillary plexuses in our patient may represent chronic ischemic retinal changes that arise from traumatic injury to the vitreoretinal interface and inner retina in NAI.

The eye in child abuse

Child physical abuse may result in a range of injuries to the globe and surrounding tissues. These injuries have varying degrees of specificity for abuse, and no pattern of injury is unique to abuse. Easily overlooked eye injuries in non-ambulatory infants often portend more severe abuse and require careful evaluation for occult injury when they are unexplained. Retinal hemorrhages are most often a sign of significant trauma and the severity of the hemorrhages generally parallels the severity of neurological trauma. Ophthalmologists contribute important data that more easily distinguish medical disease from trauma, but caution is needed in differentiating accidental from inflicted trauma. This distinction requires careful consideration of the complete clinical data and occasionally on additional law enforcement or child welfare investigation.

Ophthalmological lesions in shaken baby syndrome: a retrospective analysis of 133 consecutive cases (1992-2018)

INTRODUCTION

Shaken Baby Syndrome (SBS) is a non-accidental head trauma in which shaking causes cranio-cerebral lesions. Shaking can lead to ophthalmologic lesions such as retinal hemorrhage (RH). The aim of the present study was to compare our long-term results in to the literature data.

PATIENTS AND METHODS

This study was a single-center retrospective descriptive analysis of 133 consecutive SBS cases (1992 - 2018). Only seniors in ophthalmology were authorized to perform these examinations. We studied type of lesion (retinal, intra-vitreal, papilledema), location (uni- or bi-lateral), and correlation with gender and age. Infants with a traumatic context without suspicion of child abuse were excluded.

RESULTS

Mean age at diagnosis was 131 days (range, 14 days - 10 months). Boys accounted for 72.2% of the population. The prevalence of ophthalmologic lesions was 70.3%. 94.4% were RH; intra-vitreous hemorrhage (6.7%) and papilledema (11.1%) were less frequent. Lesions were bilateral in 81.1% of cases. Retinal lesions were classified in terms of location. Macular involvement was diagnosed in 8.2% of cases. 18.8% of retinal lesions could not be classified because of lack of precision in the ophthalmology report. The prevalence of ophthalmic lesions was higher for children aged over 6 months: 80%.

CONCLUSION

This series highlighted a high rate of ophthalmic lesions in SBS, with a high rate of bilateral involvement. RH was the most frequent lesion. RH in a context of subdural hematoma is a strong argument in favor of SBS. The forensic implications are that rigorous ophthalmologic examination by a senior practitioner is mandatory.

Determining the Tractional Forces on Vitreoretinal Interface Using a Computer Simulation Model in Abusive Head Trauma

PURPOSE

Abusive head trauma (AHT) is the leading cause of infant death and long-term morbidity from injury. The ocular consequences of AHT are controversial, and the pathophysiology of retinal research findings is still not clearly understood. It has been postulated that vitreoretinal traction plays a major role in the retinal findings. A computer simulation model was developed to evaluate the vitreoretinal traction and determine whether the distribution of forces in different layers and locations of the retina can explain the patterns of retinal hemorrhage (RH) seen in AHT.

DESIGN

Computer simulation model study.

METHODS

A computer simulation model of the pediatric eye was developed to evaluate preretinal, intraretinal, and subretinal stresses during repetitive shaking. This model was also used to examine the forces applied to various segments along blood vessels.

RESULTS

Calculated stress values from the computer simulation ranged from 3-16 kPa at the vitreoretinal interface through a cycle of shaking. Maximal stress was observed at the periphery of the retina, corresponding to areas of multiple vessel bifurcations, followed by the posterior pole of the retina. Stress values were similar throughout all 3 layers of the retina (preretinal, intraretinal, and subretinal layers).

CONCLUSIONS

Ocular manifestations from AHT revealed unique retinal characteristics. The model predicted stress patterns consistent with the diffuse retinal hemorrhages (RH) typically found in the posterior pole and around the peripheral retina in AHT. This computer model demonstrated that similar stress forces were produced in different layers of the retina, consistent with the finding that retinal hemorrhages are often found in multiple layers of the retina. These data can help explain the RH patterns commonly found in AHT.

Swept-source OCT findings in shaken baby syndrome: case report

Background

Our purpose was to document the swept source optical coherence tomography (SSOCT) findings in a patient with Shaken baby syndrome (SBS).

Case presentation

SSOCT was obtained without sedation in a six-month-old girl with bilateral multilayered retinal hemorrhages due to SBS. It documented vitreoretinal interface abnormalities, including internal limiting membrane (ILM) detachment with retinal traction, in association with other specific changes in the inner and outer retinal layers. Six weeks later, retinal hemorrhages had substantially resolved, and there was optic disc pallor. OCT showed ILM reattachment with release of retinal traction and the development of severe diffuse retinal atrophy involving the fovea.

Conclusions

SS OCT can provide useful information in SBS, revealing a wide variety of vitreoretinal interface, inner, and outer retinal changes not detected by clinical examination. It also may have a prognostic value over follow-up.

Optical coherence tomography imaging of the pediatric retina

Optical coherence tomography is an increasingly important part of the retinal specialist's and general ophthalmologist's toolkit for diagnosing and managing retinal disease. This review summarizes the unique considerations and available imaging systems with which pediatric ophthalmologists should be familiar when attempting optical coherence tomography in children. Normal developmental changes in foveal and extrafoveal structure and the need for an established pediatric normative database of retinal thicknesses are reviewed. Finally, applications of optical coherence tomography imaging to selected representative pediatric retinal diseases are introduced as examples of how optical coherence tomography in children is furthering the diagnosis and management of vision-threatening retinal diseases.

Intraoperative Optical Coherence Tomography Guided Ocular Surgeries: Critical Analysis of Clinical Role and Future Perspectives

Intraoperative imaging of ocular tissues for diagnostic and therapeutic applications has gained immense admiration in recent years. The real time cross-sectional imaging, as well as three and four dimensional reconstruction abilities of intraoperative optical coherence tomography (iOCT), has enhanced our knowledge on many fronts in surgical maneuvers. In this review, we discuss the iOCT discovered constructive knowledge in the cornea, cataract, refractive, glaucoma, pediatric ocular, and various retinal conditions. The practical utility with decision modifying aspects along the specified ocular tissues and with respect to specific ocular entities have been narrated. Moreover, limitations and future directions have also been emphasized to make ophthalmic care more comprehensive in the future.

Swept-source optical coherence tomography features of regressed macular retinoblastoma

Purpose:

To describe the swept-source optical coherence tomography (SS-OCT) features of regressed macular retinoblastoma (RB).

Methods:

A cross-sectional observational study was carried out in 13 patients with regressed macular RB with good fixation in at least one eye. Fundus photography and SS-OCT were documented. High-resolution scans with good signal strength were selected. The types of clinical regression and SS-OCT characteristics of the regressed lesions (presence of vitreous detachment, intratumor schisis/cavitation, calcification, foveal dip, and OCT pattern) were noted.

Results:

Of the 13 eyes, 7 (53%) were group B, 4 (30%) were group C, and 2 (17%) were group D. Lesion involving fovea was seen in seven eyes (53%). On SS-OCT, the lesion was isodense to hyperdense in all cases. Three patterns of regressed RB were noted on OCT. Intralesion calcification was noted in eight cases. Subretinal fluid was not detected in any of the cases.

Conclusion:

SS-OCT is a useful technology to image and analyze cases of regressed macular RB including large lesions. SS-OCT system helps in successful imaging even in smaller children.

Retinal and visual function in infants with non-accidental trauma and retinal hemorrhages

PURPOSE

To investigate retinal function and visual outcomes in infants with retinal hemorrhages due to non-accidental trauma (NAT).

METHODS

This is a retrospective review of full-field or multifocal electroretinogram (ERG) recordings, visual acuity in log minimum angle of resolution (logMAR), clinical status, and neuroimaging. Multifocal ERGs from the central 40° were compared to corresponding fundus imaging. Visual acuity was measured by Teller cards at follow-up. ERGs were compared to controls recorded under anesthesia.

RESULTS

Sixteen children met inclusion criteria (14 recorded during the acute phase and 2 during long-term follow-up). During the acute phase, ERGs (n = 4 full field; n = 10 multifocal ERG) showed abnormal amplitude, latency, or both in at least one eye. Ten subjects had significantly reduced responses in both eyes, 3 of which had an ERG dominated by a negative waveform (absent b-wave or P1). The remaining six subjects had responses in one eye that were near normal (≥ 50% of controls). ERGs were sometimes abnormal in local areas without hemorrhage. ERGs could be preserved in local areas adjacent to traumatic retinoschisis. Two subjects with reduced visual acuity had belated ERGs: One had an abnormal macular ERG and the other had a normal macular ERG implying cortical visual impairment. At follow-up, 10 of 14 subjects had significant visual acuity loss (≥ 0.7 age-corrected logMAR); four subjects had mild vision loss (≤ 0.5 age-corrected logMAR). Visual acuity outcome was not reliably associated with the fundus appearance in the acute phase. All subjects with a negative ERG waveform had severe vision loss on follow-up.

CONCLUSIONS

Retinal dysfunction was common during the acute phase of NAT. A near normal appearing fundus did not imply normal retinal function, and ERG abnormality did not always predict a poor visual acuity outcome. However, a negative ERG waveform was associated severe visual acuity loss. Potential artifacts of retinal hemorrhages and anesthesia could not fully account for multifocal ERG abnormalities. Retinal function can be preserved in areas adjacent to traumatic retinoschisis.

Intraoperative Optical Coherence Tomography in Vitreoretinal Surgery

Intraoperative OCT (iOCT) is an emerging modality capable of displaying real-time OCT images to the surgeon during surgery. The use of iOCT during vitreoretinal surgery improves our understanding of the tissue alterations that occur during surgical manipulations, which may impact surgical decision-making. We review the current iOCT modalities and clinical applications of iOCT.

Development of a clinical prototype of a miniature hand-held optical coherence tomography probe for prematurity and pediatric ophthalmic imaging

We report a novel design and operation of a highly integrated miniature handheld OCT probe, with high-speed angiography function that can be used in clinical settings for young children and infants, providing rapid, non-invasive structural and angiographic imaging of the retina and choroid. The imaging system is operated at 200 kHz, with 3D OCT and OCTA scan time of 0.8 and 3.2 seconds, respectively, and the scanning angle on the pupil is ± 36°, covering the full perifoveal region. Operator assisting features of the direct-view iris camera and on-probe display are integrated into the hand-held probe, and the fixation target can display animations to attract the attention of young subjects. Compared to conventional OCT systems, the high-speed hand-held OCT system significantly improves the operator's experience and scanning efficiency, which is important for imaging infants. Imaging results indicate a significant reduction in total time consumption in pediatric ophthalmic imaging sessions, as well as the image quality of OCT angiography.

The Eye Examination in the Evaluation of Child Abuse

Child abuse can cause injury to any part of the eye. The most common manifestations are retinal hemorrhages (RHs) in infants and young children with abusive head trauma (AHT). Although RHs are an important indicator of possible AHT, they are also found in other conditions. Distinguishing the number, type, location, and pattern of RHs is important in evaluating a differential diagnosis. Eye trauma can be seen in cases of physical abuse or AHT and may prompt referral for ophthalmologic assessment. Physicians have a responsibility to consider abuse in the differential diagnosis of pediatric eye trauma. Identification and documentation of inflicted ocular trauma requires a thorough examination by an ophthalmologist, including indirect ophthalmoscopy, most optimally through a dilated pupil, especially for the evaluation of possible RHs. An eye examination is helpful in detecting abnormalities that can help identify a medical or traumatic etiology for previously well young children who experience unexpected and unexplained mental status changes with no obvious cause, children with head trauma that results in significant intracranial hemorrhage and brain injury, and children with unexplained death.

PATHOLOGY OF PERIMACULAR FOLDS DUE TO VITREORETINAL TRACTION IN ABUSIVE HEAD TRAUMA

PURPOSE

To demonstrate vitreoretinal traction as a mechanism for perimacular folds in abusive head trauma.

METHODS

We performed gross and histopathologic examination of eyes of children with suspected abusive head trauma and identified those with typical perimacular folds. Information was collected regarding the incident that led to the child's death and systemic manifestations noted at autopsy. Eyes were prepared in a fashion that allowed for demonstration of the vitreoretinal interface.

RESULTS

Ten eyes of five patients (2-13 months) were examined. All patients had systemic manifestations of abusive trauma including intracranial injury. All cases provided evidence of vitreoretinal traction producing perimacular folds. Condensed vitreous was seen attached to the apices of the retinal folds, and the detached internal limiting membrane comprising the inner surfaces of the schisis cavity. Four cases showed severe bilateral multilayered symmetric retinal hemorrhages extending to the ora serrata. All cases showed optic nerve sheath subdural hemorrhage and subarachnoid hemorrhage. Orbital hemorrhage was unilateral in two cases and bilateral in three cases. Four cases showed orbital fat hemorrhage. One case showed extraocular muscle sheath and cranial nerve sheath hemorrhage. Two cases showed juxtapapillary intrascleral hemorrhage.

CONCLUSION

Vitreoretinal traction is the likely mechanism of perimacular folds in abusive head trauma.

Retinal Parameters as Compared with Head Circumference, Height, Weight, and Body Mass Index in Children in Kenya and Bhutan

The retina shares embryological derivation with the brain and may provide a new measurement of overall growth status, especially useful in resource-limited settings. Optical coherence tomography (OCT) provides detailed quantification of retinal structures. We enrolled community-dwelling children ages 3–11 years old in Siaya, Kenya and Thimphu, Bhutan in 2016. We measured head circumference (age < 5 years only), height, and weight, and standardized these by age and gender. Research staff performed OCT (iScan; Optovue, Inc., Fremont, CA), measuring the peripapillary retinal nerve fiber layer (RNFL) and macular ganglion cell complex (GCC) thicknesses. A neuro-ophthalmologist performed quality control for centration, motion artifact, and algorithm-derived quality scores. Generalized estimating equations were used to determine the relationship between anthropometric and retinal measurements. Two hundred and fifty-eight children (139 females, average age 6.4 years) successfully completed at least one retinal scan, totaling 1,048 scans. Nine hundred and twenty-two scans (88.0%) were deemed usable. Fifty-three of the 258 children (20.5%) were able to complete all six scans. Kenyan children had a thinner average GCC (P < 0.001) than Bhutanese children after adjustment for age and gender, but not RNFL (P = 0.70). In models adjusting for age, gender, and study location, none of standardized height, weight, and body mass index (BMI) were statistically significantly associated with RNFL or GCC. We determined that OCT is feasible in some children in resource-limited settings, particularly those > 4 years old, using the iScan device. We found no evidence for GCC or RNFL as a proxy for height-, weight-, or BMI-for-age. The variation in mean GCC thickness in Asian versus African children warrants further investigation.

Pediatric abusive head trauma in Taiwan: clinical characteristics and risk factors associated with mortality

PURPOSE

To report the clinical characteristics of abusive head trauma (AHT) in Taiwan and identify the risk factors associated with mortality of these patients.

METHODS

Children with clinically diagnosed AHT from January 1, 2000, to October 31, 2015 were reviewed. The demographic data, clinical features, and associated retinal and radiologic findings were analyzed. The multivariable logistic regression model analysis was performed to identify the risk factors associated with in-hospital mortality.

RESULTS

A total of 75 children were included. The mean age was 7.31 ± 6.57 months (range, 1-36 months). Retinal hemorrhages were detected in 69 children with AHT (92%). The majority of retinal hemorrhages were characterized by hemorrhagic numbers higher than ten (74.7%), multi-layered (54.7%), and extension beyond the posterior pole to the peripheral retina (73.3%). Twenty children (26.7%) had macular retinoschisis. As a direct result of AHT, ten children died in the hospital (13.3%). Logistic regression showed that respiratory distress or apnea (adjusted odds ratio [OR] = 22.46; 95% confidence interval [CI], 2.24-225.33; P = .0082), vomiting (adjusted OR = 11.94; 95% CI, 1.31-108.403; P = .0276), retinal finding of macular retinoschisis (adjusted OR = 8.9; 95% CI, 1.01-78.65; P = .0493), and the presence of subarachnoid hemorrhage (SAH) (adjusted OR = 15.17; 95% CI, 1.40-64.84; P = .0255) were independently associated with mortality.

CONCLUSIONS

Respiratory distress or apnea, vomiting, SAH, and macular retinoschisis are independently associated with mortality in abusive head trauma. A complete ophthalmologic examination with the immediate visualization of intraocular injury should be performed to clarify the likelihood of child abuse and predict a potential poor neurologic outcome.

Characterization of Long Working Distance Optical Coherence Tomography for Imaging of Pediatric Retinal Pathology

PURPOSE

We determined the feasibility of fovea and optic nerve head imaging with a long working distance (LWD) swept source optical coherence tomography (OCT) prototype in adults, teenagers, and young children.

METHODS

A prototype swept source OCT system with a LWD (defined as distance from the last optical element of the imaging system to the eye) of 350 mm with custom fixation targets was developed to facilitate imaging of children. Imaging was performed in 49 participants from three age groups: 26 adults, 16 children 13 to 18 years old (teenagers), and seven children under 6 years old (young children) under an approved institutional review board protocol. The imaging goal was to acquire high quality scans of the fovea and optic nerve in each eye in the shortest time possible. OCT B-scans and volumes of the fovea and optic nerve head of each eligible eye were captured and graded based on four categories (lateral and axial centration, contrast, and resolution) and on ability to determine presence or absence of pathology.

RESULTS

LWD-OCT imaging was successful in 88 of 94 eligible eyes, including seven of 10 eyes of young children. Of the successfully acquired OCT images, 83% of B-scan and volumetric images, including 86% from young children, were graded as high-quality scans. Pathology was observed in high-quality OCT images.

CONCLUSIONS

The prototype LWD-OCT system achieved high quality retinal imaging of adults, teenagers, and some young children with and without pathology with reasonable alignment time.

TRANSLATIONAL RELEVANCE

The LWD-OCT system can facilitate imaging in children.

INTRAOPERATIVE IMAGING OF RETAINED PERFLUOROCARBON LIQUID USING SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY

PURPOSE

To report images of retained perfluorocarbon liquid (PFCL) on the surface of the retina obtained during an intraoperative use of hand-held spectral domain optical coherence tomography.

METHODS

A 54-year-old man underwent pars plana vitrectomy with injection of PFCL to repair retinal detachment. Postoperatively, visually significant PFCL droplets were found to be retained in the eye. During the surgical removal of PFCL, a hand-held spectral domain optical coherence tomography was used to image the retina with the patient supine.

RESULTS

Spectral domain optical coherence tomography images of the retained PFCL illustrated magnification of the areas of the outer retina underlying PFCL bubbles. The images obtained had some similarities to the patient's own observation of "floaters."

CONCLUSION

Droplets of PFCL over the retina result in imaging artifact, most likely due to a lensing effect caused by differences in refractive index between the PFCL and vitreous humor. Although the utility of hand-held spectral domain optical coherence tomography for infants has previously been established, this case presents further application of spectral domain optical coherence tomography in adults when imaging in the supine position is required.

Spectral-domain optical coherence tomography findings in Alström syndrome

BACKGROUND

Alström syndrome is a multi-system recessive disorder caused by mutations in ALMS1 gene. The aim of this study was to characterize morphological retinal changes in Alström patients using spectral-domain optical coherence tomography.

METHODS

We studied volunteer patients attending the conference of Alström Syndrome International, a support group for affected families, using hand-held spectral-domain optical coherence tomography (SD-OCT) in an office setting. Patients had a clinical dilated retinal examination. Past medical records were reviewed.

RESULTS

Twenty-two Alström patients (mean age 17 years, range 2-38 years, 12 males) were studied. OCT imaging demonstrated that central macular OCT changes are often mild during the first decade of life and gradually progress, demonstrating disruption of normal retinal architecture, and progressive loss of photoreceptors and retinal pigment epithelium. Other changes found included hyperreflectivities in all retinal layers, severe retinal wrinkling, optic nerve drusen, and vitreoretinal separation. Vision correlated with severity of OCT macular changes (r = 0.89, p = 0.002).

CONCLUSIONS

This study reports on OCT findings in a large group of patients with Alström syndrome. We document a panretinal gradual progression of retinal changes, which are often mild during the first years of life. Previously unreported observations include intraretinal opacities, optic nerve drusen, and foveal contour abnormalities. Morphological retinal changes demonstrated by SD-OCT may help in understanding the pathophysiology of the disease and defining strategies for treatment such as gene therapy.

Use of a new intra-ocular spectral domain optical coherence tomography in vitreoretinal surgery

PURPOSE

To describe the use of a novel intra-ocular side-scanning probe enabling the acquisition of spectral-domain optical coherence tomography (SD-OCT) images during surgery in a series of patients with complex forms of retinal detachment.

METHODS

A 23-gauge, side-scanning SD-OCT probe (C7 System; LightLab Imaging, Inc/St Jude Medical, St. Paul, MN, USA) in a 20-gauge catheter, was used to acquire the intra-operative OCT images in seven patients with vitreoretinal diseases. Twenty-five gauge pars plana vitrectomy (PPV) was performed in every patient in a standard fashion. After enlarging the temporal sclerotomy to a 20-gauge port, all the patients were scanned with intra-ocular side-scanning SD-OCT, during different steps of the surgery based on surgeon needs. Scans were recorded real time and directly evaluated on a screen during surgery. Optical coherence tomography (OCT) scans were judged beneficial when they would recognize structures otherwise not seen on biomicroscopy.

RESULTS

The intra-ocular SD-OCT has been helpful in acquiring extra information during vitreoretinal surgery such as the detection of the presence of otherwise invisible membranes (epiretinal membrane, subretinal membrane), the location of small tears and the identification of the retinal plane under suboptimal conditions for visualization.

CONCLUSION

The use of an intra-ocular SD-OCT can expand upon visual cues during surgery, helping in the decision-making process and allowing additional deliberate surgical manoeuvres aimed at improving surgical outcomes.

Feasibility of Spectral Domain Optical Coherence Tomography Acquisition Using a Handheld Versus Conventional Tabletop Unit

PURPOSE

Patients afflicted with ocular complications of diabetes represent a diverse demographic who often cannot undergo spectral-domain optical coherence tomography (SD-OCT) imaging of the retina due to postural restraints. Our pilot study compared imaging acquisition methods using SD-OCT in the handheld (HH) mode versus the conventional tabletop (TT) method.

METHODS

Our study included 22 undilated eyes of 22 subjects (mean ± SD age, 35.8 ± 16.8 years) imaged using HH and TT iVue SD-OCT (Optovue, Fremont, CA). Statistical analysis was performed using Microsoft Excel 12.2.7 (Microsoft Corporation, Redmond, WA) software with an accepted significance of P < .05.

RESULTS

Strong intraclass correlation coefficient was observed for (1) overall (.97), superior (.93), and inferior (.94) ganglion cell complex thickness, and (2) central (.98), inferior (.90), superior (.92), nasal (.94), and temporal (.93) macular retinal thickness. Mean scan quality index was adequate but lower in HH versus TT SD-OCT (62.8 vs 68.1, respectively; P < .0001). Multiple attempts for adequate imaging were required more frequently in HH versus TT SD-OCT (34% vs 5%, respectively; P < .001).

CONCLUSION

HH SD-OCT may be a feasible alternative to TT SD-OCT in select situations, especially in patients suffering from diabetic complications with limited mobility.

Refractive error and ocular parameters: comparison of two SD-OCT systems

PURPOSE

Spectral domain optical coherence tomography (OCT) was used to examine the influence of refractive error (RE) on foveal retinal and choroidal thicknesses and scleral canal width (SCW). The performance of the Cirrus and Bioptigen spectral domain OCT instruments was compared in the same eyes.

METHODS

Both eyes of 40 healthy human subjects, aged 22 to 38 years, were dilated and imaged, with the Cirrus OCT, using 6-mm five-line rasters collapsed into one line, one centered on the fovea and one bisecting the optic nerve head. Seventy-two of the same eyes were imaged with the Bioptigen OCT, using 6- by 6-mm scans, one centered on the fovea and one on the optic nerve head. Subfoveal retinal and choroidal thicknesses and SCW were measured. Axial lengths (ALs) and REs were obtained using an IOLMaster and a Grand Seiko autorefractor, respectively.

RESULTS

Only right eyes were included in analyses. Spherical equivalent REs ranged from -12.18 to +8.12 diopters (mean [±SD], -3.44 [±4.06] diopters), and ALs ranged from 20.56 to 29.17 mm (mean [±SD], 24.86 [±1.91] mm). Myopia was associated with relatively thin choroids at the fovea (p < 0.05) but normal retinal thickness. Scleral canal width was significantly correlated with AL as measured with the Bioptigen OCT (p < 0.05). Retinal and choroidal thicknesses recorded with the Bioptigen OCT tended to be smaller than values obtained with the Cirrus OCT (mean difference, 5.63 and 24.76 μm, respectively), whereas the converse was true for the SCW (mean difference, 25.45 μm).

CONCLUSIONS

The finding that high myopes tend to have a thinner subfoveal choroid is consistent with previous studies. That high myopia was linked to enlarged scleral canals may help to explain the increased risk of glaucoma in myopia. Observed differences obtained with the Cirrus and Bioptigen instruments urge caution in comparing results collected with different instruments.

Retinal Imaging of Infants on Spectral Domain Optical Coherence Tomography

Spectral domain coherence tomography (SD OCT) has become an important tool in the management of pediatric retinal diseases. It is a noncontact imaging device that provides detailed assessment of the microanatomy and pathology of the infant retina with a short acquisition time allowing office examination without the requirement of anesthesia. Our understanding of the development and maturation of the infant fovea has been enhanced by SD OCT allowing an in vivo assessment that correlates with histopathology. This has helped us understand the critical correlation of foveal development with visual potential in the first year of life and beyond. In this review, we summarize the recent literature on the clinical applications of SD OCT in studying the pathoanatomy of the infant macula, its ability to detect subclinical features, and its correlation with disease and vision. Retinopathy of prematurity and macular edema have been discussed in detail. The review also summarizes the current status of SD OCT in other infant retinal conditions, imaging the optic nerve, the choroid, and the retinal nerve fibre in infants and children, and suggests future areas of research.

Applications of optical coherence tomography in pediatric clinical neuroscience

For nearly two centuries, the ophthalmoscope has permitted examination of the retina and optic nerve-the only axons directly visualized by the physician. The retinal ganglion cells project their axons, which travel along the innermost retina to form the optic nerve, marking the beginning of the anterior visual pathway. Both the structure and function of the visual pathway are essential components of the neurologic examination as it can be involved in numerous acquired, congenital and genetic central nervous system conditions. The development of optical coherence tomography now permits the pediatric neuroscientist to visualize and quantify the optic nerve and retinal layers with unprecedented resolution. As optical coherence tomography becomes more accessible and integrated into research and clinical care, the pediatric neuroscientist may have the opportunity to utilize and/or interpret results from this device. This review describes the basic technical features of optical coherence tomography and highlights its potential clinical and research applications in pediatric clinical neuroscience including optic nerve swelling, optic neuritis, tumors of the visual pathway, vigabatrin toxicity, nystagmus, and neurodegenerative conditions.

Risk factors associated with retinal hemorrhage in suspected abusive head trauma

PURPOSE

To determine risk factors associated with retinal hemorrhage (RH) in pediatric abusive head trauma (AHT) suspects.

METHODS

Records of children aged 0-3 years hospitalized for suspected AHT from January 2007 to November 2011 were retrospectively reviewed in this case-control study. Children were classified into case and control groups based on RH presence. Medical history, presenting symptoms, reasons, and characteristics of injury were recorded. Logistic regression analysis was performed to identify risk factors.

RESULTS

A total of 168 children (104 males) were included. Of these, 103 were classified as cases and 65 as controls. The mean age (with standard deviation) was 9.3 ± 8.3 months (range, 1 day-36 months). Of the 103 cases, 22 (21%) had subretinal hemorrhage, 9 (9%) had retinoschisis, and 1 (1%) had vitreous hemorrhage. Children presenting with lethargy or altered mental status (P < 0.0001), subdural hemorrhage (P < 0.0001), and other radiologic findings (eg, cerebral ischemia, diffuse axonal injury, hydrocephalus, or solid organ injury; P = 0.01546) were likely to have RH. All 23 children with skull or nonskull fracture without intracranial hemorrhage did not have RH (P < 0.0001 both categories).

CONCLUSIONS

Retinal hemorrhages were almost never found in the absence of intracranial hemorrhage and not found in the setting of fracture without intracranial hemorrhage.

Reproducibility of circumpapillary retinal nerve fiber layer measurements using handheld optical coherence tomography in sedated children

PURPOSE

To determine the intra- and intervisit reproducibility of circumpapillary retinal nerve fiber layer (RNFL) measures using handheld optical coherence tomography (OCT) in sedated children.

DESIGN

Prospective cross-sectional and longitudinal study.

METHODS

Children undergoing sedation for a clinically indicated magnetic resonance imaging for an optic pathway glioma and/or neurofibromatosis type 1 (NF1) had multiple 6 × 6 mm volumes (isotropic 300 × 300 or nonisotropic 1000 × 100 samplings) acquired over the optic nerve. Children with 2 handheld OCT sessions within 6 months were included in the intervisit cohort. The intra- and intervisit coefficient of variation (CV) and intraclass correlation coefficient (ICC) were calculated for the average and anatomic quadrant circumpapillary RNFL thickness.

RESULTS

Fifty-nine subjects (mean age 5.1 years, range 0.8-13.0 years) comprised the intravisit cohort and 29 subjects (mean age 5.7 years, range 1.8-12.7 years) contributed to the intervisit cohort. Forty-nine subjects had an optic pathway glioma and 10 subjects had NF1 without an optic pathway glioma. The CV was comparable regardless of imaging with an isotropic and nonisotropic volume in both the intra- and intervisit cohorts. The average circumpapillary RNFL demonstrated the lowest CV and highest ICC compared to the quadrants. For the intervisit cohort, the average ICC was typically higher while the CV was typically lower, but not statistically different compared to the other quadrants.

DISCUSSION

Circumpapillary RNFL measures acquired with handheld OCT during sedation demonstrate good intra- and intervisit reproducibility. Handheld OCT has the potential to monitor progressive optic neuropathies in young children who have difficulty cooperating with traditional OCT devices.

Retinal morphology of patients with achromatopsia during early childhood: implications for gene therapy

IMPORTANCE

While older children and adults with achromatopsia have been studied, less is known of young children with achromatopsia.

OBJECTIVES

To characterize the macular and foveal architecture of patients with achromatopsia during early childhood with handheld spectral-domain optical coherence tomographic imaging and to make phenotype-genotype correlations.

DESIGN, SETTING, AND PARTICIPANTS

Comparative case series of 9 patients with achromatopsia and 9 age-matched control participants at a tertiary ophthalmology referral center.

MAIN OUTCOMES AND MEASURES

Patients underwent complete ocular examination, full-field electroretinography, handheld spectral-domain optical coherence tomographic imaging, and screening for genetic mutations.

RESULTS

The mean (SD) age of the patients with achromatopsia was 4.2 (2.4) years, and the mean (SD) age of the control participants was 4.0 (2.1) years. Cone-driven responses to photopic single-flash or 30-Hz stimuli were nonrecordable in 7 patients and severely attenuated in 2. Rod-driven responses to dim scotopic single-flash stimuli were normal in 7 patients and mildly subnormal in 2. Six patients (67%) had foveal ellipsoid zone disruption, of which 1 had a hyporeflective zone. Four patients (44%) had foveal hypoplasia. The average total retinal thicknesses of the macula and fovea in the patients with achromatopsia were 14% and 17% thinner than in the control participants (P < .001 and P = .001), which was mostly due to the outer retina that was 18% and 26% thinner than in control participants (both P < .001), respectively. Genetic testing revealed a common homozygous mutation in CNGB3 in 5 patients with complete achromatopsia and heterozygous mutations in CNGA3 in 2 patients with incomplete achromatopsia. The youngest and worst-affected patient harbored compound heterozygous mutations in CNGB3 and a single mutation in CNGA3.

CONCLUSIONS AND RELEVANCE

In early childhood, there is a spectrum of foveal pathology that is milder than reported in older individuals with achromatopsia, which suggests the need for early therapeutic intervention. Neither age alone nor genotype alone predicts the degree of photoreceptor loss or preservation. Thus, in anticipation of future gene therapy trials in humans, we propose that handheld spectral-domain optical coherence tomography is an important tool for the early assessment and stratification of macular architecture in young children with achromatopsia.

Hand-held spectral-domain optical coherence tomography of small macular retinoblastoma in infants before and after chemotherapy

PURPOSE

To demonstrate the utility of hand-held spectral-domain optical coherence tomography (SD-OCT) in assessing retinal structure in cases of macular retinoblastoma.

METHODS

In this retrospective, observational case series, three young children with macular retinoblastoma were treated at a tertiary care hospital. At examination under anesthesia, each patient was evaluated with SD-OCT for analysis of retinal tumor and macula. The main outcomes were retinal morphology before and after chemotherapy.

RESULTS

The mean patient age was 16 months (median: 9 months; range: 7 to 33 months). All patients had small exophytic macular retinoblastoma with subretinal fluid in the foveola. At presentation, the mean tumor thickness was 4.8 mm (range: 4.0 to 6.0 mm) and mean tumor base was 10.3 mm (range: 8.0 to 12.0 mm). SD-OCT documented tumor surface as smooth (n = 2) or irregular (n = 1), involvement of full-thickness retina (n = 3), and optical density as low (n = 3). The surrounding retina showed abrupt transition to tumor (n = 3), without intraretinal edema (n = 3), and with underlying subretinal fluid (n = 3). Following chemotherapy, all tumors showed regression with mean thickness of 2.6 mm (range: 2.2 to 3.0 mm). SD-OCT documented tumor surface as smooth (n = 1) or irregular (n = 2), and optical density as medium (n = 1) or high (n = 2). At the tumor site, the retina showed full-thickness disorganization but with abrupt transition to normal retina (n = 3). The foveola was anatomically intact (n = 1) or with outer retinal thinning (n = 2). Subretinal fluid was resolved in each case (n = 3).

CONCLUSIONS

SD-OCT can provide precise anatomic monitoring of the macular region in infants and young children with small macular retinoblastoma. This may serve as a guide for visual potential in the preverbal child.

Handheld optical coherence tomography during sedation in young children with optic pathway gliomas

IMPORTANCE

Monitoring young children with optic pathway gliomas (OPGs) for visual deterioration can be difficult owing to age-related noncompliance. Optical coherence tomography (OCT) measures of retinal nerve fiber layer (RNFL) thickness have been proposed as a surrogate marker of vision but this technique is also limited by patient cooperation.

OBJECTIVE

To determine whether measures of circumpapillary RNFL thickness, acquired with handheld OCT (HH-OCT) during sedation, can differentiate between young children with and without vision loss from OPGs.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional analysis of a prospective observational study was conducted at a tertiary-care children's hospital. Children with an OPG (sporadic or secondary to neurofibromatosis type 1) who were cooperative for visual acuity testing, but required sedation to complete magnetic resonance imaging, underwent HH-OCT imaging of the circumpapillary RNFL while sedated.

MAIN OUTCOMES AND MEASURES

Area under the curve of the receiver operating characteristic, sensitivity, specificity, positive predictive value, and negative predictive value of the average and quadrant-specific RNFL thicknesses.

RESULTS

Thirty-three children (64 eyes) met inclusion criteria (median age, 4.8 years; range, 1.8-12.6 years). In children with vision loss (abnormal visual acuity and/or visual field), RNFL thickness was decreased in all quadrants compared with the normal-vision group (P < .001 for all comparisons). Using abnormal criteria of less than 5% and less than 1%, the area under the curve was highest for the average RNFL thickness (0.96 and 0.97, respectively) compared with specific anatomic quadrants. The highest discrimination and predictive values were demonstrated for participants with 2 or more quadrants meeting less than 5% (sensitivity = 93.3; specificity = 97.9; positive predictive value = 93.3; and negative predictive value = 97.9) and less than 1% (sensitivity = 93.3; specificity = 100; positive predictive value = 100; and negative predictive value = 98.0) criteria.

CONCLUSIONS AND RELEVANCE

Measures of RNFL thickness acquired with HH-OCT during sedation can differentiate between young children with and without vision loss from OPGs. For young children who do not cooperate with vision testing, HH-OCT measures may be a surrogate marker of vision. Longitudinal studies are needed to delineate the temporal relationship between RNFL decline and vision loss.

Ganglion cell layer-inner plexiform layer thickness and vision loss in young children with optic pathway gliomas

PURPOSE

To determine if measures of macular ganglion cell layer-inner plexiform layer (GCL-IPL) thickness can discriminate between children with and without vision loss (visual acuity or field) from their optic pathway glioma (OPG) using spectral-domain optical coherence tomography (SD-OCT).

METHODS

Children with OPGs (sporadic or secondary to neurofibromatosis type 1) enrolled in a prospective study of SD-OCT were included if they were cooperative for vision testing and macular SD-OCT images were acquired. Manual segmentation of the macular GCL-IPL and macular retinal nerve fiber layer (RNFL) was performed using elliptical annuli with diameters of 1.5, 3.0, and 4.5 mm. Logistic regression assessed the ability of GCL-IPL and RNFL thickness measures (micrometers) to differentiate between the normal and abnormal vision groups.

RESULTS

Forty-seven study eyes (normal vision = 31, abnormal vision = 16) from 26 children with OPGs were included. Median age was 5.3 years (range, 2.5-12.8). Thickness of all GCL-IPL and RNFL quadrants differed between the normal and abnormal vision groups (P < 0.01). All GCL-IPL measures demonstrated excellent discrimination between groups (area under the curve [AUC] > 0.90 for all diameters). Using the lower fifth percentile threshold, the number of abnormal GCL-IPL inner macula (3.0 mm) quadrants achieved the highest AUC (0.989) and was greater than the macula RNFL AUCs (P < 0.05).

CONCLUSIONS

Decreased GCL-IPL thickness (<fifth percentile) can discriminate between children with and without vision loss from their OPG. Ganglion cell layer-inner plexiform layer thickness could be used as a surrogate marker of vision in children with OPGs.

Choroid development and feasibility of choroidal imaging in the preterm and term infants utilizing SD-OCT

PURPOSE

To determine whether choroidal imaging is feasible in preterm and term infants using an 840-nm portable spectral domain optical coherence tomography (SD-OCT) system without the use of enhanced-depth imaging techniques and to assess choroidal development by comparing choroidal thickness of preterm infants, term infants, and adults.

METHODS

SD-OCT images were obtained from 86 preterm infants, 59 term infants, and nine adults using a portable SD-OCT system plus nine adults using a tabletop system. An unprocessed image across the macula from one randomly selected eye of each participant was selected for determination of whether the choroidal-scleral junction (CSJ) could be visualized and for measurement of choroidal thickness.

RESULTS

Subfoveal CSJ was visualized in 96% of young-preterm infants (imaged from 30-36 weeks postmenstrual age [PMA]); 78% of term-aged preterm infants (imaged from 37-42 weeks PMA); 49% of term infants; and 39% of adult subjects. Racial pigmentation did not affect CSJ visibility in young-preterm infants (P = 0.57). Subfoveal choroidal thickness (SFCT) in young-preterm infants, term-aged preterm infants, term infants, and adults was 176 ± 53 μm, 289 ± 92 μm, 329 ± 66 μm, and 258 ± 66 μm, respectively, and these were all statistically significantly different from one another except term-aged preterms to adults.

CONCLUSIONS

Infant choroid can be imaged with a portable SD-OCT system without enhanced depth imaging. Melanin in the RPE and choroid does not hinder outer choroidal imaging in young-preterm infants without advanced retinopathy of prematurity (ROP). In preterm infants, choroidal thickness increased with age but was thinner when compared to term infants suggesting delayed development due to ROP.

Susceptibility weighted imaging depicts retinal hemorrhages in abusive head trauma

Introduction

This study aims to evaluate the capability of magnetic resonance imaging (MRI) susceptibility weighted images (SWI) in depicting retinal hemorrhages (RH) in abusive head trauma (AHT) compared to the gold standard dilated fundus exam (DFE).

Methods

This is a retrospective, single institution, observational study on 28 patients with suspected AHT, who had a DFE and also underwent brain MRI-SWI as part of routine diagnostic protocol. Main outcome measures involved evaluation of patients to determine whether the RH could be identified on standard and high-resolution SWI sequences.

Results

Of the 21 subjects with RH on DFE, 13 (62 %) were identified by using a standard SWI sequence performed as part of brain MRI protocols. Of the 15 patients who also underwent an orbits SWI protocol, 12 (80 %) were positive for RH. None of the seven patients without RH on of DFE had RH on either standard or high-resolution SWI. Compared with DFE, the MRI standard protocol showed a sensitivity of 75 % which increased to 83 % for the orbits SWI protocol.

Conclusions

Our study suggests the usefulness of a tailored high-resolution orbits protocol to detect RH in AHT.

Vitreous hemorrhage in children and adolescents in India

PURPOSE

To report the clinical profile, etiologies, treatment modalities, and outcomes for vitreous hemorrhage in patients <18 years of age in India.

METHODS

The medical records of patients presenting with vitreous hemorrhage between January 2000 and January 2010 were retrospectively reviewed.

RESULTS

A total of 261 eyes of 246 patients (201 males) were included. Of these patients, 231 (94%) were unilateral. Trauma was the leading cause of injury in 179 eyes (68.5%); blunt trauma was more common than penetrating trauma in both males (64.7%) and females (57.7%). Wooden sticks were the most common cause of trauma (20.7%). Spontaneous causes accounted for 82 (31.5%) eyes, including 33 eyes (40%) with Eales disease, and 16 eyes (19.7%) with sequelae of retinopathy of prematurity. Trauma was most common cause of vitreous hemorrhage in all age groups, except in children <4 years of age, in whom spontaneous hemorrhage predominated. Overall, the most common management was surgery, performed in 173 (66.2%) eyes; 63 (24.1%) eyes were observed. Male sex, age >8 years, unilateral presentation, surgical treatment (P < 0.001), and blunt trauma (P = 0.047) were associated with severe visual loss. Mean follow-up was 636.5 ± 802.0 days overall, 597.0 ± 749.0 days for eyes observed and 638.8 ± 802.6 days for eyes that underwent surgery.

CONCLUSIONS

Posttraumatic vitreous hemorrhage comprises almost two-thirds of children and adolescents presenting with vitreous hemorrhage. Blunt trauma is more common than penetrating trauma. Male sex, age >8 years, unilateral presentation, and surgical treatment were all significantly associated with severe visual loss.

Positional independence of optic nerve head and retinal nerve fiber layer thickness measurements with spectral-domain optical coherence tomography

PURPOSE

To evaluate repeatability and positional independence of optic nerve head (ONH) and retinal nerve fiber layer (RNFL) thickness measurements in sitting and supine body positions using portable spectral-domain optical coherence tomography (iVue SD-OCT; Optovue Inc).

DESIGN

Evaluation of diagnostic technology.

METHODS

Sixty eyes of 30 subjects (10 healthy younger adults aged 20-27 years, 10 healthy older adults aged 50-66 years, and 10 glaucoma patients aged 38-82 years) were included prospectively. For each participant, all measurements were taken in a single session. After 5 minutes in the supine position, 5 scans were obtained from both eyes. Following a 5-minute sitting adaptation, 5 scans were then obtained in the sitting position. The same instrument was used for all measurements. Repeatability and correlation between supine and sitting measurements of 4 ONH and 3 RNFL parameters were assessed using intraclass correlation coefficients (ICC), concordance correlation coefficients (ρ), and Bland-Altman plots.

RESULTS

Measurements were highly repeatable within individual eyes, both for ONH (ICC range, 73%-99%) and RNFL (ICC range, 72%-99%) parameters. The correlation between supine and sitting ONH measurements was strong and ranged from ρ = 97%-99% (younger healthy) to ρ = 98%-99% (older healthy) and ρ = 84%-99% (glaucoma). Bland-Altman plots indicated good agreement between sitting and supine readings of ONH and RNFL parameters.

CONCLUSIONS

Repeatability of measurements of ONH and RNFL is high and measurements between sitting and supine are highly correlated. The ability of the iVue SD-OCT to evaluate ONH and RNFL parameters is good to excellent in both body positions.

Educational paper : retinal haemorrhages in abusive head trauma in children

Retinal haemorrhages are an important component of the clinical effects of non-accidental head injuries which have significant visual morbidity. Their importance extends into the legal investigations of carers of children with subdural haemorrhages and encephalopathy who are suspected of having been non-accidentally injured. The vital precision in diagnosis relies not just on the presence of retinal haemorrhages but on the severity, extent, bilaterality and their location in the retina. Inadequate documentation of ophthalmological clinical findings and too short a follow-up to allow proper assessment of severity each give rise to difficulties for both expert witnesses and the courts.

The use of optical coherence tomography in intraoperative ophthalmic imaging

Optical coherence tomography (OCT) has transformed diagnostic ophthalmic imaging but until recently has been limited to the clinic setting. The development of spectral-domain OCT (SD-OCT), with its improved speed and resolution, along with the development of a handheld OCT scanner, enabled portable imaging of patients unable to sit in a conventional tabletop scanner. This handheld SD-OCT unit has proven useful in examinations under anesthesia and, more recently, in intraoperative imaging of preoperative and postoperative manipulations. Recently, several groups have pioneered the development of novel OCT modalities, such as microscope-mounted OCT systems. Although still immature, the development of these systems is directed toward real-time imaging of surgical maneuvers in the intraoperative setting. This article reviews intraoperative imaging of the posterior and anterior segment using the handheld SD-OCT and recent advances toward real-time microscope-mounted intrasurgical imaging.

Subfoveal fluid in healthy full-term newborns observed by handheld spectral-domain optical coherence tomography

PURPOSE

To report retinal findings for healthy newborn infants imaged with handheld spectral-domain optical coherence tomography (SD OCT).

DESIGN

Prospective, observational case series.

METHODS

Thirty-nine full-term newborn infants underwent dilated retinal examinations by indirect ophthalmoscopy and retinal imaging by handheld SD OCT, without sedation, at the Duke Birthing Center.

RESULTS

Of the 39 infants imaged, 44% (17/39) were male. Race and ethnicity composition was 56% white, 38% black, 3% Asian, and 3% Hispanic. Median gestational age was 39 weeks (range, 36 to 41 weeks). Six (15%) of the 39 infants had bilateral subfoveal fluid on SD OCT not seen by indirect ophthalmoscopy. Eight infants (21%) had retinal hemorrhages noted on dilated retinal examination, 1 of which had subretinal fluid on SD OCT. Subretinal fluid was noted on follow-up examination to have resolved on SD OCT 1 to 4 months later. Infants with bilateral subretinal fluid had an older gestational age compared with infants without subretinal fluid (median, 40.4 vs 39.1 weeks, respectively; P = .03) and were more likely to have had mothers with diabetes (2/6 vs 0/33, respectively; P = .02). Vaginal versus Caesarian section delivery was not significantly different between the 2 groups.

CONCLUSIONS

Some healthy full-term infants have bilateral subfoveal fluid not obvious on dilated retinal examination. This fluid resolves within several months. The visual significance of this finding is unknown, but clinicians should be aware that it is common when evaluating newborn infants for retinal pathologic features using SD OCT.

Dynamics of human foveal development after premature birth

PURPOSE

To determine the dynamic morphologic development of the human fovea in vivo using portable spectral domain-optical coherence tomography (SD-OCT).

DESIGN

Prospective, observational case series.

PARTICIPANTS

Thirty-one prematurely born neonates, 9 children, and 9 adults.

METHODS

Sixty-two neonates were enrolled in this study. After examination for retinopathy of prematurity (ROP), SD-OCT imaging was performed at the bedside in nonsedated infants aged 31 to 41 weeks postmenstrual age (PMA) (= gestational age in weeks + chronologic age) and at outpatient follow-up ophthalmic examinations. Thirty-one neonates met eligibility criteria. Nine children and nine adults without ocular pathology served as control groups. Semiautomatic retinal layer segmentation was performed. Central foveal thickness, foveal to parafoveal (FP) ratio (central foveal thickness divided by thickness 1000 μm from the foveal center), and 3-dimensional thickness maps were analyzed.

MAIN OUTCOME MEASURES

In vivo determination of foveal morphology, layer segmentation, analysis of subcellular changes, and spatiotemporal layer shifting.

RESULTS

In contrast with the adult fovea, several signs of immaturity were observed in the neonates: a shallow foveal pit, persistence of inner retinal layers (IRLs), and a thin photoreceptor layer (PRL) that was thinnest at the foveal center. Three-dimensional mapping showed displacement of retinal layers out of the foveal center as the fovea matured and the progressive formation of the inner/outer segment band in the opposite direction. The FP-IRL ratios decreased as IRL migrated before term and minimally after that, whereas FP-PRL ratios increased as PRL subcellular elements formed closer to term and into childhood. A surprising finding was the presence of cystoid macular edema in 58% of premature neonates that appeared to affect inner foveal maturation.

CONCLUSIONS

This study provides the first view into the development of living cellular layers of the human retina and of subcellular specialization at the fovea in premature infant eyes using portable SD-OCT. Our work establishes a framework of the timeline of human foveal development, allowing us to identify unexpected retinal abnormalities that may provide new keys to disease activity and a method for mapping foveal structures from infancy to adulthood that may be integral in future studies of vision and visual cortex development.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Retinal hemorrhage in abusive head trauma

Retinal hemorrhage is a cardinal manifestation of abusive head trauma. Over the 30 years since the recognition of this association, multiple streams of research, including clinical, postmortem, animal, mechanical, and finite element studies, have created a robust understanding of the clinical features, diagnostic importance, differential diagnosis, and pathophysiology of this finding. The importance of describing the hemorrhages adequately is paramount in ensuring accurate and complete differential diagnosis. Challenges remain in developing models that adequately replicate the forces required to cause retinal hemorrhage in children. Although questions, such as the effect of increased intracranial pressure, hypoxia, and impact, are still raised (particularly in court), clinicians can confidently rely on a large and solid evidence base when assessing the implications of retinal hemorrhage in children with concern of possible child abuse.