Histologic chorioamnionitis in extremely preterm births, microbiological findings and infant outcome

BACKGROUND

Histologic chorioamnionitis (HCA) is most often caused by ascending bacterial infection originating from the cervicovaginal tract.

OBJECTIVES

To investigate whether HCA with a fetal inflammatory response (FIR) has a worse clinical outcome than HCA alone. Further, if FIR or a positive maternal microbiologic culture obtained prior to birth were related to adverse neonatal outcomes in a cohort of extremely preterm (EP) neonates.

METHODS

Prospective observational cohort study recruiting EP singleton pregnancies (gestational age at birth ≤28 weeks) with confirmed HCA. FIR was defined by fetal neutrophils in the chorionic vessels and/or umbilical vessels. Positive culture was defined as growth of potentially pathogenic bacteria in a sample from the cervicovaginal tract prior to birth, or if a cervicovaginal culture was lacking, a culture result from the placenta was used. Logistic regression was used to estimate odds ratios and 95% confidence intervals for the associations between FIR, a positive culture result and adverse outcomes, defined as bronchopulmonary dysplasia (BPD), brain pathology assessed by magnetic resonance imaging, retinopathy of prematurity, necrotizing enterocolitis, early-onset neonatal sepsis, and perinatal death. A composite outcome variable included one or more adverse outcomes.

RESULTS

We included 71 cases with HCA, of which 51 (72%) had FIR. Maternal age, rate of clinical chorioamnionitis (CCA), preterm pre-labor rupture of membranes (PPROM), the number of women receiving antenatal steroids and antibiotics, and the rate of positive maternal cultures of potentially pathogenic bacteria were all significantly higher in the HCA with FIR. Neonates in the FIR group had significantly higher levels of blood leukocytes compared to those without. FIR was associated with a longer interval from PPROM to delivery (log-rank test: p = .022). Microbiological sampling had been performed in 63 (89%) cases, of which 60 (95%) were cervicovaginal samples. No associations were found between a positive culture and adverse neonatal outcomes, in contrast to FIR, that was significantly associated to BPD and brain pathology.

CONCLUSIONS

In a cohort of EP pregnancies with confirmed HCA, the presence of FIR was associated with advanced maternal age, CCA, PPROM, antenatal steroids and antibiotics, and a positive maternal culture of potentially pathogenic bacteria. However, the presence of FIR, and not a positive culture, was associated with adverse neonatal outcomes.

Biometric measurements of the eyes in teenagers and young adults with Down syndrome

PURPOSE

To examine ocular biometric variables in subjects with Down syndrome.

METHODS

In a population-based study we have compared ocular biometric variables in a group of 47 individuals with Down syndrome (20.0+/-3.9 years) with 51 control subjects (21.0+/-4.6 years).

RESULTS

A thinner cornea (0.48+/-0.04 mm vs. 0.55+/-0.03 mm, p<0.001) and higher keratometry values (46.39+/-1.95 D vs. 43.41+/-1.40 D, p<0.001) were found in the Down syndrome group than in the control group. Oblique astigmatism was commonly found in the Down syndrome individuals, showing a strong right-left specificity (right eyes' axes in the 135 degrees -meridian, left eyes' axes in the 45 degrees -meridian). The lens was thinner (3.27+/-0.29 mm vs. 3.49+/-0.20 mm) and the calculated lens power was weaker (17.70+/-2.36 D vs. 19.48+/-1.24 D) in the Down syndrome group than in the control group (p<0.001 in both cases).

CONCLUSIONS

Thinning of the corneal stroma may account for the steeper cornea and the high frequency of astigmatism in Down syndrome due to lower corneal rigidity. It may also be of etiological importance to the increased incidence of keratoconus in Down syndrome.

Corneal grafting for keratoconus in mentally retarded patients

PURPOSE

To compare the results of penetrating and non-penetrating corneal grafting procedures in mentally retarded keratoconus patients.

METHODS

In the years 1974-2000 41 mentally retarded patients with keratoconus (33 with Down syndrome) were operated with corneal grafting. Mean age at operation was 36.7+/-10.8 years. Three different surgical procedures were used (no randomization): penetrating keratoplasty (n=16), lamellar keratoplasty (n=5) and epikeratophakia (n=20). In a retrospective study, the non-penetrating procedures (lamellar keratoplasty and epikeratophakia) were compared to the penetrating keratoplasties with regard to graft survival and frequency of serious complications. Mean follow-up time of all grafting procedures was 80+/-58 months.

RESULTS

All cases of serious complications (irreversible rejection, wound leakage or perforation) occurred in the penetrating keratoplasty group (p=0.0005). Older age at operation (p=0.011) adversely influenced the frequency of serious complications. Overall five-year survival was 74.9%. Graft survival was not related to surgical procedure, but rather to age at operation (poorer survival in older age, p=0.012) and degree of retardation (poorer survival in patients with more severe retardation, p=0.051).

CONCLUSIONS

Because of the safety and low frequency of complications, epikeratophakia is recommended as the grafting procedure of choice in the majority of mentally retarded with keratoconus. In selected cases (good cooperation, age < or =40 years, and a good peripheral corneal thickness) penetrating keratoplasty may be performed, which, if uncomplicated, often will give better functional/optical results.

Refractive development in children with Down's syndrome: a population based, longitudinal study

AIMS

To study the refractive development in children with Down's syndrome longitudinally.

METHODS

An unselected population of 60 children with Down's syndrome was followed with repeated retinoscopies in cycloplegia for 2 years or more (follow up 55 (SD 23) months). Accommodation was assessed with dynamic retinoscopy.

RESULTS

From longitudinal spherical equivalent values of the right eye, three main categories of refraction were defined: stable hypermetropia (<1.5 D difference between the first and last visit) (n=34), increasing hypermetropia ("hypermetropic shift"; >/=1.5 D difference) (n=11), and decreasing hypermetropia/development of myopia ("myopic shift"; >/=1.5 D difference) (n=9). Patients with anisometropia (n=6) were evaluated separately. In the stable hypermetropia group three sublevels were chosen: low (</=+2.0 D at the last visit), moderate (+2.25 to + 4.0 D), and high (>+4.0 D). An accommodation weakness was found in 55% of the children. Accommodation weakness was significantly less frequent in the stable, low grade hypermetropia group (22%) than in all the other groups (p=0.008). The frequency of astigmatism >/=1.0 D at the last visit was 57%, the direction of axis being predominantly "with the rule." All the eyes with oblique astigmatism had a side specific direction of axis; the right eyes belonging to the 135 degrees axis group and the left eyes to the 45 degrees axis group.

CONCLUSION

A stable, low grade hypermetropia was significantly correlated with a normal accommodation. Accommodation weakness may be of aetiological importance to the high frequency of refractive errors encountered in patients with Down's syndrome. A striking right-left specificity in the oblique astigmatic eyes suggests that mechanical factors on the cornea from the upward slanting palpebral fissures may be a major aetiological factor in the astigmatism.

Strabismus and binocular function in children with Down syndrome. A population-based, longitudinal study

PURPOSE

We have performed a population-based, longitudinal study on strabismus in children with Down syndrome. The aims of the study were to examine the frequency and type of strabismus, the age at onset, and the binocular potential.

METHODS

An unselected population of 60 children with Down syndrome born 1988-1999 was followed with repeated examinations. Mean follow-up time was 55+/-23 months (range 24--115). The alignment of the eyes was examined using Hirschberg corneal reflex test and cover test for near fixation. To evaluate binocular function, Titmus House Fly Test and Lang's stereo test were used.

RESULTS

Twenty-five patients (42%) had strabismus (21 esotropias, two exodeviations and two vertical deviations). Only one case of infantile esotropia was found, the other esotropias were acquired forms. The mean age at "onset" (e.g. when strabismus was first noticed) was 54+/-35 months. In the acquired esotropia group (n=20), 15 (75%) were associated with hypermetropia (mean spherical equivalent +4.3+/-1.7 D). Seventeen of the strabismic patients had an accommodation weakness. Eleven of the strabismus patients gave a clearly positive response to one or both stereotests.

CONCLUSIONS

The majority of the Down syndrome children with strabismus have an acquired esotropia and hence a potential for binocularity. Hypermetropia and accommodation weakness are probably important factors in esotropia in Down syndrome patients.

A new hereditary conjunctivo-corneal dystrophy associated with dermal keloid formation. Report of a family

PURPOSE

To report a previously undescribed hereditary conjunctivo-corneal dystrophic disease associated with keloid formation in a woman and her two sons.

METHODS

We have been able to follow the affected members of the family with clinical examinations over many years. In addition, they have been examined with chromosome analyses and X-ray examination of their hands.

RESULTS

The mother and the oldest son have both shown a very similar clinical development, with fibrovacular tissue gradually covering the cornea, leading to severe visual loss in both eyes. In the youngest boy, the condition started at a later age, and to date only one eye is affected. All three patients have developed keloid scars on their hands.

CONCLUSION

The described condition seems to represent a previously unreported, autosomal dominant inherited disease. A congenital defect in the cell differentiation of the limbus region is discussed as a possible pathogenesis.

[Paresis of the superior oblique eye muscle]

Congenital or acquired palsy of the superior oblique eye muscle presents a clinical picture which is consistent and recognizable. The diagnosis is based upon two clinical findings: hypertropia of the affected eye with a greater than normal vertical deviation in adduction, and an increase of the hypertropia when tilting the head towards the affected side (positive Bielschowsky test). In the majority of cases the dominant feature of the clinical picture is overreaction of the ipsilateral inferior oblique. We have retrospectively examined 22 patients with superior oblique palsy who underwent surgery. Median follow-up time was three months. 20 (91%) of the patients were operated primarily by performing a recession of the ipsilateral inferior oblique muscle. Additional surgery had to be performed on five patients. The final postoperative examination showed the result to be a success in 19 (86%) of the patients, judged on relief of symptoms and objective measurements. We conclude that in the majority of cases surgical treatment of superior oblique palsy by recession of the ipsilateral inferior oblique gives good results.

Incidence of retinopathy of prematurity (ROP) in the western part of Norway. A population-based retrospective study

We have investigated the incidence of retinopathy of prematurity (ROP) among premature infants with birth weight less than 1500 g in two Norwegian counties during the years 1989-1993. Two hundred and seven out of 244 such infants (84.8%) were examined at the neonatal intensive care unit; 66 of those examined (31.9%) had a birth weight below 1000 g. ROP was found in 21 patients (10.1%), and stage 3 disease was present in 7 (3.4%). No patient had more advanced ROP than stage 3. Assuming that no cases of stage 3 ROP were missed among the total of 244 children, the incidence of stage 3 disease was 2.9%. The frequency of ROP in this study is compared to that of other population-based studies in the Nordic countries, and incidence differences are discussed.

Refractive state and correction of refractive errors among mentally retarded adults in a central institution

In a population of 212 mentally retarded, retinoscopy could be performed in 342 eyes in 182 patients. Of these, 334 eyes were phakic. Hypermetropia of +5 or more was encountered in 20 eyes (6.0%), while 26 (7.8%) had a myopia of -5 or more. The most striking finding was a high number of severe astigmatism, cylindrical power of -3.25 or more being present in 29 eyes (8.7%). Glasses were initially prescribed to 88 patients. Six months after the prescription, 59.1% used their glasses regularly. Aspects of glass prescription to mentally retarded are discussed in the paper.

[Surgical treatment of concomitant strabism in children younger than 15 years. Results 6 weeks after surgery]

In order to evaluate the short-term results we carried out a retrospective study on 104 children who had been operated on in 1993 for concomitant convergent (n = 74) and divergent (n = 30) strabismus. Six weeks after the operation an alignment within 0-10 delta was achieved in 64% of the convergent children and 44% of the divergent children. When we evaluated the subgroups of children with convergent strabismus we found a postoperative alignment within 0-10 delta in 54% of the patients with strabismus from before six months of age (infantile esotropia), and in 93% of the children in whom the strabismus was present from after two years of age. In the total material we could demonstrate an improvement in binocular function in 17%. Based on a total evaluation we consider that 80% obtained a good postoperative result. We believe that continual, computer-based evaluation of the strabismus patients would be a valuable tool to further improve our results.

Retrobulbar anesthesia with and without hyaluronidase in extracapsular cataract surgery. A prospective, randomized, double-blind study

Eighty patients with senile cataract were subjected to a planned extracapsular cataract extraction (ECCE) with implantation of a posterior chamber intraocular lens. Retrobulbar anesthesia was administered by injection of 4 mg lidocaine 2% with adrenalin. In 40 patients 150 I.U. hyaluronidase (Kinetin) was added to the anesthesia. The hyaluronidase group had a significantly lower frequency of iris prolapse, and deeper anterior chamber, both before and after expression of the lens nucleus. Possible mechanisms explaining the beneficial effect of hyaluronidase in extracapsular cataract surgery are discussed.

Epikeratophakia for keratoconus in mentally retarded patients. The use of fresh, free-hand made lamellar grafts

Epikeratophakia for keratoconus was done in 11 mentally retarded patients, using fresh, free-hand made lamellar grafts. The mean follow-up period was 31.5 months. The grafts remained clear and well adapted in 7 cases (63.6%). Necrosis of the lower part of the graft occurred in 3 eyes (27.3%), and was probably caused by persisting epithelial defects. Only one of these grafts had to be removed. Despite concurrent eye diseases, such as cataract and possible amblyopia, an improved overall visual function was reported in 5 of the 11 patients (45.5%). No vision-threatening complications related to the epikeratophakia surgery was found.

Keratoconus in the mentally retarded

Among 212 institutionalized mentally retarded, there were 16 patients with keratoconus (7.5%). Eight of the keratoconus cases were unilateral. The possible role of eye rubbing as well as other etiological factors are discussed.

[Diagnosis of Spielmayer-Vogt disease. Electron microscopy of conjunctival biopsy]

The authors describe ultrastructural changes in conjunctival specimens from five patients with Spielmeyer-Vogt-Batten's disease. Four of the specimens contained lysosomal "fingerprint-bodies", regarded as a specific lesion for this disease. When the biochemical defect remains unknown, the recognition of these ultrastructural changes is a valuable diagnostic tool to supplement clinical and electrophysiological examinations.

Bilateral non-traumatic carotid cavernous sinus fistula with spontaneous closure

A case of bilateral spontaneous carotid cavernous sinus fistula is presented. The diagnostic value of Doppler ultrasound examination is discussed, as well as therapeutic measurements, such as manual compression of the carotid artery and embolization treatment. The frequent spontaneous closure of these fistulas is emphasized, and a conservative attitude is recommended.