New Ways to Detect Pediatric Sickle Cell Retinopathy: A Comprehensive Review

Quantification of intermittent retinal capillary perfusion in sickle cell disease

Pathophysiology of sickle cell disease (SCD) features intermittent vaso-occlusion of microcirculatory networks that facilitate ischemic damage. Past research has, however, relied on static images to characterize this active disease state. This study develops imaging metrics to more fully capture dynamic vascular changes, quantifying intermittent retinal capillary perfusion in unaffected controls and SCD patients using sequential optical coherence tomography angiography (OCT-A) scans. The results reveal significant dynamic variation of capillary perfusion in SCD patients compared to controls. This measurement of vaso-occlusive burden in patients would provide utility in monitoring of the disease state and in evaluating treatment efficacy.

Optical coherence tomography (OCT) and OCT angiography allow early identification of sickle cell maculopathy in children and correlate it with systemic risk factors

PURPOSE

To determine the presence of sickle cell retinopathy and maculopathy and to identify associations between markers of hemolysis and systemic and ocular manifestations in children affected by sickle cell disease.

METHODS

Eighteen children with sickle cell disease, aged 5-16 years, underwent complete eye examination including best-corrected visual acuity, slit-lamp biomicroscopy, ophthalmoscopy after pharmacological mydriasis, spectral-domain optical coherence tomography (SD-OCT), and optical coherence tomography angiography (OCTA). Blood test results and clinical history information were collected for each child, including fetal hemoglobin (HbF), hemoglobin (Hb), hematocrit (Htc), mean corpuscular volume (MCV), mean corpuscular hemoglobin concentration (MCHC), reticulocytes percentage (%ret), lactic dehydrogenase (LDH), total and direct bilirubin, glomerular filtration rate, number of painful crises, acute chest syndromes, and splenic sequestration. Therapeutic regimen and transfusion therapy were also evaluated.

RESULTS

Sixteen of 36 eyes (44.4%) had non-proliferative sickle cell retinopathy on ophthalmoscopic evaluation. No patients had proliferative sickle cell retinopathy. In 13 of 36 eyes (36.1%), SD-OCT and OCTA detected signs of sickle cell maculopathy. Nine eyes (25%) presented sickle cell retinopathy and maculopathy, 7 eyes (19.4%) sickle cell retinopathy alone, and 4 eyes (11.1%) sickle cell maculopathy alone. A statistically significant association was found between sickle cell retinopathy; lower levels of HbF, Hb, and Htc; and higher MCV and percentage of reticulocytes. Sickle cell maculopathy was associated with lower values of H and Htc and higher levels of reticulocytes and total bilirubin.

CONCLUSIONS

We identified early signs of sickle cell retinopathy and maculopathy in a pediatric population with SD-OCT and OCTA. These two retinal complications were more frequent in children with higher hemolytic rates.

Evaluation of Ocular Complications by Using Optical Coherence Tomography in Children With Sickle Cell Disease Eye Findings in Children With Sickle Cell Disease

OBJECTIVE

The aim of this study was to compare optical coherence tomography (OCT) findings in pediatric patients with sickle cell disease (SCD) and healthy individuals and to investigate associations between these data and the patients' systemic findings.

MATERIALS AND METHODS

The study included 108 eyes of 54 patients with SCD with no visual symptoms and a control group consisting of 110 eyes of 55 healthy subjects with no systemic or ocular pathology. After best-corrected visual acuity assessment, the study participants underwent a complete ophthalmologic examination including intraocular pressure. After examination and pupil dilation induced with 1% tropicamide, 9×9 mm macular sections were obtained with spectral-domain OCT. The macular sections were evaluated according to Early Treatment Diabetic Retinopathy Study (ETDRS) map and internal and external retinal thicknesses were measured using the software included in the OCT device.

RESULTS

The patient group showed significantly more foveal flattening, temporal thinning, and vascular tortuosity than the control group (P<0.0001 for all). Foveal width was significantly greater in the patient group (1592.39±175.56 µm) compared with the control group (1391.01±175.56 µm) (P<0.0001), whereas foveal depth was significantly lower in the patient group (121.15±26.83 µm) than in the control group (146.1±12.25 µm) (P<0.0001). The mean total retinal thickness was 253.53±22.31 µm in the patient group and 261.03±18.48 µm in the control group (P=0.007). Similarly, central retinal thickness was significantly lower in the patient group (219.35±10.53 µm) compared with the control group (235.32±12.51 µm) (P<0.0001).

DISCUSSION

Our study shows that pediatric patients with SCD may have subclinical retinal involvement and that temporal thinning, in particular, is an important OCT finding. This strongly suggests that OCT imaging would be a beneficial addition to routine ophthalmologic examination in the diagnosis and follow-up of this patient group.

[Sickle cell retinopathy in children: Report of 42 cases]

We aimed to describe the epidemiological, etiological and clinical features, treatment and clinical course of sickle cell retinopathy in children and to determine the risk factors for serious involvement.

METHODS

This was a retrospective study including all children diagnosed with sickle cell retinopathy. Epidemiological, clinical and therapeutic characteristics, as well as clinical course, were analysed retrospectively by chart review. Two groups were defined: Group 1 (Goldberg stage 1 and 2); Group 2 (Goldberg stage 3, 4 and 5). In order to identify factors independently associated with severe sickle cell retinopathy, we conducted a logistic regression analysis in descending order.

RESULTS

The frequency of sickle cell retinopathy was 14.48%. Forty-two patients (84 eyes) were included; among them 23 boys and 19 girls, aged 10 to 17 with a mean age of 14±1.98 years. Twenty patients were of genotype SS, 11 patients of genotype SC, 8 Sβ and 3 SO Arab. The three patients in group 2 were all of SS genotype. The majority of patients (32) had an HbF level of less than 15%. All our patients had sickle cell retinopathy distributed as follows: 62% at stage 1; 31% at stage 2; 5% at stage 3 and 2% at stage 4. Multivariate analysis revealed a single risk factor independently linked to severe involvement - an HbF level<15%.

CONCLUSION

Retinopathy is a frequent complication of sickle cell disease which may lead to blindness. The HbF level is negatively correlated with severe involvement.

Evaluation of Potential Systemic Adverse Events Related to Fluorescein Angiography in Pediatric Patients

PURPOSE

To evaluate adverse events of fluorescein angiography (FA) in pediatric patients.

DESIGN

Single-institution retrospective chart review.

PARTICIPANTS

Patients 0 to 18 years of age who underwent FA between January 2010 and December 2015 at a single institution in the United States.

METHODS

Pediatric patients who underwent FA by 3 surgeons were included in the study. Patients with fewer than 24 hours of documented follow-up were excluded. Significant adverse events within 24 hours of FA were evaluated. Detailed intraoperative and perioperative physiological parameters, including heart rate, blood pressure, oxygen saturation, and ventilation parameters, in inpatients undergoing simultaneous examination under anesthesia were reviewed. Peri-injection effects of FA were evaluated by 2-tailed paired t test comparison of mean 5-minute preinjection and 5-minute postinjection physiological data.

MAIN OUTCOME MEASURES

Significant adverse events associated with FA.

RESULTS

One hundred fifteen patients with a total of 214 FA examinations were included. No significant adverse events were associated directly with FA. Comparison of mean 5-minute preinjection and postinjection physiologic parameters in 27 patients who underwent intravenous FA during EUA did not reveal significant changes associated with FA. A significant difference was found in average patient age between inpatient (2.5 years) and outpatient (10.7 years) FA (P < 0.00001). The youngest patients who underwent successful FA were 3.8 years old in the outpatient setting and 32 weeks' postmenstrual age in the inpatient setting. Patients younger than 3.8 years accounted for most (77.6%; n = 85) inpatient FA examinations. Excluding patients with a need or likely need for laser or surgery, the reasons for inpatient FA in patients older than 3.8 years included the lack of availability of outpatient ultra-widefield FA (UWFA) and more challenging situations in patients with developmental delay.

CONCLUSIONS

Fluorescein angiography was not found to be associated directly with systemic adverse events in pediatric patients in this study. Younger patients more commonly were found to require an inpatient FA, whereas older patients older than 4 years underwent outpatient UWFA.

Sensitivity and Specificity of Ultrawide-Field Fundus Photography for the Staging of Sickle Cell Retinopathy in Real-Life Practice at Varying Expertise Level

Purpose: To evaluate the sensitivity and specificity of ultrawide-field fundus photography (UWF-FP) for the detection and classification of sickle cell retinopathy (SCR) by ophthalmologists with varying degrees of expertise in retinal disease. Methods: Patients presenting with sickle cell disease (SCD) in the Créteil University Eye Clinic, having undergone UWF-FP and ultrawide-field fluorescein angiography (UWF-FA) on the same day, were retrospectively included. Eyes with previous retinal photocoagulation were excluded. SCR was graded independently by UWF-FP and UWF-FA using Goldberg classification by two ophthalmologists with varying expertise levels. Results: Sixty-six eyes of 33 patients were included in the study. The sensitivity of UWF-FP for the detection of proliferative SCR was 100%, (95% confidence interval [CI95%] 76.8–100) for the retinal specialist and 100% (CI95% 71.5–100) for the ophthalmology resident. The specificity of UWF-FP for the detection of proliferative SCR was 100% (CI95% 92.7–100) for the retinal specialist and 98.1% (CI95% 89.7–100) for the ophthalmology resident. Conclusions: UWF-FP is a valuable exam for proliferative SCR screening, with excellent sensitivity and specificity and a good inter-grader agreement for ophthalmologists with various degree of skills, and is easy to use in a real-life setting.

Awareness of Ocular Manifestations, Complications, and Treatment of Sickle Cell Disease in the Eastern Province of Saudi Arabia: A Cross-Sectional Study

AIM:

This study aims to assess the level of awareness about the effect of sickle cell disease (SCD) on the eye and vision and factors influencing SCD awareness.

SUBJECTS AND METHODS:

The study design was cross-sectional and was carried out in 2018 among the general population in the Eastern province of Saudi Arabia. It was conducted using an online, validated questionnaire, after obtaining consent from the participants. The outcome variable was 557. The level of awareness was correlated to demographic information.

RESULTS:

The study population was 557 Saudi adults. 84 were male and 473 female. Their mean age was 22 ± 23 years. Majority of the participants (57.3%) were not aware that SCD could affect the eye and vision. There was no difference in the knowledge regarding ocular complications of SCD among different ages and sexes.

CONCLUSIONS:

The result of this study indicates the need for raising the knowledge regarding the disease, its ocular complications, screening methods, and management. Health educations campaigns would be an effective tool in increasing SCD awareness.

Retinal microvascular development in the first two years

The link between in utero and early life insults and the development of chronic illness remains to be fully understood, but there is increasing data to indicate that microvasculature pathology plays an important mechanistic role. Currently available data indicate that retinal microvasculature changes are detectable in children as young as six years of age, however, there are no data for younger children. We present retinal microvasculature measurement from the first two years of life. Retinal images suitable for analysis were available from 18 infants in our proof-of-concept study. The mean and standard deviation (SD) for birth weight and gestation was 3410 (384) g and 39.1(1.4) weeks, respectively. Retinal vessel calibres were summarized as the mean(SD) central retinal arteriolar equivalent (CRAE) at six months of age was 156 (32) μm, increased to 175 (75) μm by 12 months and a slightly declined by 24 months of age to 168 (50) μm. In a similar pattern, mean(SD) central retinal venular equivalent (CRVE) at six months was 211 (19) μm, increased to 238 (25) μm by 12 months of age followed by a slight decline at 24 months of age to 222 (36) μm. The arterio-venous ratio and tortuosity index remained the same at 6, 12 and 24 months. Findings from this study could help future investigators better understand early microvasculature changes and adaptation that occur early in life.

The use of bevacizumab in pediatric retinal and choroidal disease: A review

The use of intravitreal bevacizumab in pediatric retinal and uveitic disease has become more widespread over the past decade. This article serves to outline the rationale underlying the use of intravitreal bevacizumab, and which disease entities it should be appropriately thought of as a primary or solo therapy, as opposed to an adjuvant one. Also presented is the relevant literature regarding each of these retinopathies.