2 Pathways to detection of non-infectious childhood uveitis in the UK: findings from the UNICORN cohort study

INTRODUCTION

Prompt detection of childhood uveitis is key to minimising negative impact. From an internationally unique inception cohort, we report pathways to disease detection.UNICORNS is a national childhood non-infectious uveitis study with longitudinal collection of a standardised clinical dataset and patient reported outcomes. Descriptive analysis of baseline characteristics are reported.Amongst 150 recruited children (51% female, 31% non-white ethnicity) age at detection ranged from 2-18yrs (median 10). In 69%, uveitis was diagnosed following onset of symptoms: time from first symptoms to uveitis detection ranged from 0-739days (median 7days), with longer time to detection for those presenting initially to their general practitioner. Non symptomatic children were detected through JIA/other disease surveillance (16%), routine optometry review (5%) or child visual health screening (1%). Commonest underlying diagnoses at uveitis detection were JIA (17%), TINU (9%, higher than pre-pandemic reported UK disease frequency) and sarcoid (1%). 60% had no known systemic disease at uveitis detection. At disease detection, in at least one eye: 34% had structural complications (associated with greater time to detection - 17 days versus 4 days for uncomplicated presentation).The larger relative proportions of children with non-JIA uveitis reported here increase the importance of improving awareness of childhood uveitis amongst the wider clinical communities. There is scope for improvement of pathways to detection. Forthcoming analysis on the full cohort (251 recruited to date across 33 hospitals and 4 nations) will provide nationally representative data on management and the determinants of visual and broader developmental/well-being outcomes.

Is early surgery for congenital cataract a risk factor for glaucoma?

AIMS

To estimate the risk of aphakic glaucoma after lensectomy for congenital cataract and its association with surgery within the first month of life.

METHOD

A retrospective case notes review was conducted of all patients who had lensectomy for congenital cataract during their first year of life at Great Ormond Street Hospital between 1994 and 1997. Patients with pre-existing glaucoma, anterior segment dysgenesis, and Lowe syndrome were excluded. The risk of aphakic glaucoma after surgery was estimated using Kaplan-Meier survival analysis.

RESULTS

80 patients, undergoing 128 lensectomies were eligible. Of these, six patients (nine eyes) were lost to follow up. Based on eye count, the risk of glaucoma by 5 years after lensectomy was 15.6% (95% CI 10.2 to 23.4). Based on patient count, the 5 year risk of glaucoma in at least one eye following bilateral surgery was 25.1% (95% CI 15.1 to 40.0). The incidence of glaucoma remained at a constant level for the first 5 years after surgery. After early bilateral lensectomy, within the first month of life, the 5 year risk of glaucoma in at least one eye was 50% (95% CI 27.8 to 77.1) compared to 14.9% (95% CI 6.5 to 32.1) with surgery performed later (log rank test, p = 0.012). There was no significant difference (Kolmogorov-Smirnov test: unilateral lensectomy p = 0.587, bilateral lensectomy p = 0.369) in 5 year visual outcomes between eyes operated before and after 1 month of age.

CONCLUSION

Bilateral lensectomy during the first month of life is associated with a higher risk of subsequent glaucoma than with surgery performed later. The reason for this is unclear but it may be prudent, in bilateral cases, to consider delaying surgery until the infant is 4 weeks old. As the incidence of glaucoma is similar for each year after surgery, long term glaucoma surveillance is mandatory.

The British Ophthalmological Surveillance Unit: an evaluation of the first 3 years

We report an evaluation of the British Ophthalmological Surveillance Unit (BOSU), a nationwide active surveillance scheme to assist with the case ascertainment of rare eye conditions. The evaluation assessed participation rates, study applications and research outputs. In addition, through an anonymous postal survey we ascertained the opinions of ophthalmologists regarding the usefulness, levels of feedback, barriers to participation and levels of case ascertainment. Over the first 3 years, the 4-month mean participation rate has improved from 58% to 71%. Ten studies have used this system for case ascertainment. To date three journal publications and 10 conference presentations have reported findings from these studies. It was observed that 582/870 (68%) questionnaires were returned by ophthalmologists, of whom 95% considered BOSU as very or quite useful. In all, 71% reported overall feedback to be sufficient. However, 34% requested greater feedback from research groups. Reported barriers to effective participation were 'having to remember the patient's identity' (52%) and paying for return postage of cards (22%). However, 72% of respondents did not consider the work involved in reporting a case to be prohibitive. Self-reported levels of case ascertainment by ophthalmologists for completed studies ranged between 72% and 95%. This population-based surveillance system provides an effective method for prospective case identification and subsequent data collection. It enables the study of sufficiently representative samples to allow meaningful epidemiological analysis and avoid bias. Its success relies upon the high level of support that it currently receives from ophthalmologists.

Outcome of lens aspiration and intraocular lens implantation in children aged 5 years and under

AIMS

To determine the visual outcome and complications of lens aspiration with intraocular lens implantation in children aged 5 years and under.

METHODS

The hospital notes of all children aged 5 years and under, who had undergone lens aspiration with intraocular lens implantation between January 1994 and September 1998, and for whom follow up data of at least 1 year were available, were reviewed.

RESULTS

Of 50 children who underwent surgery, 45 were eligible based on the follow up criteria. 34 children had bilateral cataracts and, of these, 30 had surgery on both eyes. Cataract was unilateral in 11 cases; thus, 75 eyes of 45 children had surgery. Cataracts were congenital in 28 cases, juvenile in 16, and traumatic in one case. The median age at surgery was 39 months (range 11-70 months). Follow up ranged from 12-64 months (median 36 months). Of 34 children with bilateral disease, 25 (73.5%) had a final best corrected visual acuity of 6/12 or better, while seven (20.5%) achieved 6/18 or less; in one child the vision improved from UCUSUM to CSM but another, who had only one eye operated on, was unable to fix or follow with this eye preoperatively or 2 years postoperatively. Of 11 children with unilateral cataract, five (45.5%) had a final best corrected visual of 6/12 or better, and six (54.5%) 6/18 or less. A mild fibrinous uveitis occurred in 20 (28.2%) eyes in the immediate postoperative period, but resolved with topical steroids. One child had a vitreous wick postoperatively requiring surgical division. Glaucoma, endophthalmitis, or retinal detachment have not been observed so far in any patient postoperatively.

CONCLUSION

From this series the authors suggest that, in children aged 5 years and under, lens aspiration with intraocular lens implantation is a safe procedure, with a good visual outcome in the short term. Further studies are needed to investigate these outcomes in the long term.

Retinopathy of prematurity in middle-income countries

BACKGROUND

In the 1940s and 1950s retinopathy of prematurity (ROP) was the single commonest cause of blindness in children in many industrialised countries; it now accounts for only 6-18% of blindness registrations. It is not known what proportion of blindness is due to ROP in countries that do not have blindness registers. Information on blindness in children in these countries can be obtained by examining children in schools for the blind.

METHODS

Between 1991 and 1996, 4121 children in 23 countries with a visual acuity in the better eye of less than 6/60 were examined with a standard method.

FINDINGS

The proportion of severe visual impairment or blindness due to ROP ranged from 0% in most African countries to 38.6% in Cuba.

INTERPRETATION

These data suggest that ROP is becoming a major cause of potentially preventable blindness among children in middle-income countries that have introduced neonatal intensive-care services for preterm and low-birthweight babies.

Epidemiology of cataract in childhood: a global perspective

Cataract is the most important cause of treatable childhood blindness. There are an estimated 200,000 children blind from cataract worldwide; 20,000 to 40,000 children with developmental bilateral cataract are born each year. Rubella is still an important cause of preventable disease in many countries. In the developing world, there is a need to improve early case detection and referral services and to establish centers with expertise in the assessment, surgical treatment, and long-term management of the child with cataract.

Hereditary disease as a cause of childhood blindness: regional variation. Results of blind school studies undertaken in countries of Latin America, Asia and Africa

There is evidence from developed countries that genetic disease is the major cause of childhood blindness. Little data are available from most developing and newly industrialised countries concerning the relative importance of hereditary diseases as a cause of childhood blindness. Children in schools for the blind in 13 countries of Africa, Latin America and Asia were examined between 1990 and 1994 using a standardised method The anatomical site of abnormality and underlying aetiology were analysed for children with a corrected acuity in the better eye of less than 6/60 (severe visual impairment and blindness, svi/BL). In these countries II-39% of svi/BL was attributed to genetic disease. Genetic diseases were responsible for a higher proportion of childhood visual loss in countries with higher levels of socio-economic development. An autosomal recessive mode of inheritance was reported in 22-52% of children with genetic disease. Retinal dystrophies were the commonest form of genetic eye disease (49-80%) in all countries apart from Thailand and the Philippines where cataract was the commonest (43.9%). The role of consanguinity, and opportunities for further research are discussed.

Early diagnosis of the retinopathy of incontinentia pigmenti: successful treatment by cryotherapy

Prospective examination of the ocular fundi was carried out in the newborn female sibling of a girl with incontinentia pigmenti and bilateral retinopathy. At age 3 months the new baby's peripheral retina was found to be avascular in both eyes. At age 2 years progressive vascular proliferation at the watershed area between normal and abnormal retina led to bilateral vitreous haemorrhage. The new vessel tufts promptly regressed when the avascular area in each eye was treated by single-freeze cryotherapy and the blood in the vitreous absorbed. Cicatricial retinopathy was thereby prevented. Prospective retinal examination of newborn female siblings of children with incontinentia pigmenti is advised, with early cryotherapy recommended if progressive neovascularisation is detected.