Intraocular foreign bodies in children: A retrospective case series

INTRODUCTION

Open globe injuries are a major cause of visual impairment in children, related to the severity of the trauma or secondary to induced amblyopia. Intraocular foreign bodies (IOFB) have been reported in approximately one third of cases of open globe injuries. As clinical presentation and management may differ between adults and children, data is lacking about IOFBs in children under 18years of age. The purpose of this study was to assess the clinical characteristics and visual prognosis of ocular trauma associated with intraocular foreign bodies in children.

MATERIALS AND METHODS

This single-center retrospective study included patients under 18years of age treated for ocular trauma with IOFB. Demographic characteristics, complete initial and final ophthalmological examination, imaging data and details of medical and surgical management were collected.

RESULTS

Fourteen patients were included (78.6% boys), with a mean age of 10.3years (min 7months-max 17years). In 92.9% of cases, patients were found to have a single IOFB, mostly metallic (71.4%). Posterior segment IOFBs were found in 50% of cases, anterior segment IOFBs in 28.6% and orbital IOFBs in 21.4%. The clinical examination permitted detection of the IOFBs in 50% of cases, while they were visible on CT scan in all cases. The mean initial visual acuity was 20/320, and the mean final visual acuity was 20/125. Endophthalmitis occurred in 2 cases (14%).

DISCUSSION

Open globe injuries associated with IOFB are severe and sight-threatening. Localization of the IOFB in the posterior segment has a worse prognosis. CT scan is mandatory, especially in children, as the trauma history is often missing. Retinal detachment and endophthalmitis appear to be the main prognostic factors requiring urgent specialized pediatric ophthalmology management.

Incidence and Outcomes of Eye Trauma Associated with Recreative Use of Non-Powder Toy-Guns: a 12-years retrospective study

PURPOSE

Non-powder toy-guns (NPTG) are responsible for many ocular traumas. This study aims to detail the outcomes of these injuries, depending on the causative NPTG.

DESIGN

Retrospective observational case series.

METHODS

Cases of NPTG-associated ocular trauma managed in a Parisian eye emergency department between August 1, 2010, and January 1, 2023, were reviewed. The date of trauma, causative NPTG, patient demographics, initial and follow-up eye examinations, any surgical procedure, and visual outcomes for each ocular trauma were analyzed RESULTS: Over 12 years, NPTG were responsible for 324 eye injuries and 980 visits. Patients were mostly males (77.5%), and mean age at trauma was 16.2 years. Foam bullets or foam darts blasters accounted for 54.9% of traumas and were mainly responsible for corneal injuries and hyphema (30.9% and 27%, respectively). BB-gun/airsoft guns were frequently responsible for anterior segment lesions, as well as intravitreal hemorrhages (14.7%) and commotio retinae (21.1%). Paintball guns accounted for the largest proportion of posterior segment lesions (such as intra- or subretinal hemorrhages leading to macular atrophy/contusion maculopathy), and one-third of casualties had undergone ocular surgery. Among all traumas, final visual acuity was lower than 20/200 in 6.5% of cases. Phthisis occurred in 8 cases: 2 were related to foam bullets or foam darts blaster injuries (1 contusion and 1 rupture), 2 other cases followed a rupture due to BB-guns/airsoft-guns, 1 case occurred after a rupture related to a paintball gunshot, and 3 others were due to other types of compressed air guns (1 rupture, 1 intraocular foreign body and 1 total retinal detachment).

CONCLUSION

NPTG-related ocular trauma outcomes differ according to the causative toy. Paintball guns and BB-guns/airsoft guns-related traumas were more likely to be associated with severe lesions, but an increasing number of ocular injuries related to the use of foam bullets or foam darts blasters are reported, in younger and younger children. Public health policies should promote the use of protective eyewear.

Outcomes of Modified Limbal Lensectomy-Vitrectomy in Stages 4B and 5 Retinopathy of Prematurity with Extended Retrolental Fibroplasia

PURPOSE

To report on the anatomical and functional outcomes of a modified limbal lensectomy-vitrectomy (LV) approach for stages 4B and 5 retinopathy of prematurity (ROP) as defined in the International Classification of Retinopathy of Prematurity, 3rd Edition (ICROP 3).

DESIGN

Retrospective, monocentric, consecutive case series.

PATIENTS

Infants with ROP that underwent limbal LV for diffuse retrolental fibroplasia.

METHODS

Clinical charts and Retcam photographs were reviewed. Surgical approach consisted of a limbal LV through peripheral iridectomies with centripetal dissection of the preretinal fibrosis.

MAIN OUTCOME MEASURES

Anatomical success and visual function at last follow-up were evaluated. Multivariate logistic regression was used to explore potential prognostic factors affecting the anatomical outcome.

RESULTS

A total of 128 eyes of 81 patients with a mean gestational age of 28.7 ± 3.0 weeks and a mean birthweight of 1244 ± 429 g were included. Eighteen eyes (14.1%) had a stage 4B, 24 (18.8%) a stage 5B, and 86 a stage 5C (67.2%) ROP. Mean age at surgery was 57.4 ± 36.3 weeks and mean postoperative follow-up was 22.7 ± 20.4 months. Only 5 eyes (3.9%) had prior peripheral retinal ablation. Macular reattachment was achieved in 74 eyes (57.8%). Controlling for other baseline factors, a stage 5C (versus stage 4B, odds ratio [OR] = 6.9 [1.5-32.1], P = 0.01 and versus stage 5B, OR = 7.4 [1.5-37.1], P = 0.02), the presence of vascular activity (OR = 6.4 [2.3-18.1], P < 0.001), and the presence of Schlieren sign (OR = 13.0 [2.1-82.2], P = 0.006) were associated with a failure of macular reattachment. Visual acuity was assessed in 92 eyes (71.9%), among which 59 eyes (64.1%) had light perception or better.

CONCLUSIONS

Modified limbal LV resulted in macular reattachment in more than half of eyes with ROP-related retinal detachment and diffuse retrolental fibrosis. A stage 5C based on ICROP 3, the presence of vascular activity, and a Schlieren sign were significantly associated with a failure of macular reattachment.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Management and outcomes of posterior persistent fetal vasculature

PURPOSE

To describe the clinical features, management and outcomes of posterior persistent fetal vasculature (PFV) and suggest a management algorithm.

DESIGN

Retrospective consecutive case series.

PARTICIPANTS

All children diagnosed with posterior PFV and treated or followed at the Rothschild Foundation Hospital in France between June 2011 and September 2021.

METHODS

Retrospective analysis of the clinical characteristics of posterior PFV. We reported at diagnosis: age, gender, presenting symptoms, intraocular pressure (IOP), visual acuity (VA). Patients were divided in four group depending on severity and involvement or not of the anterior segment. We reported the vitreoretinal surgical techniques used.

MAIN OUTCOME MEASURES

Anatomical results, ocular hypertension, BCVA, presence of post-operative adverse events and additional surgical interventions were recorded at each follow-up visit.

RESULTS

A total of 96 patients were included. Median age at diagnosis was 8 months (mean 18.9±30.9 months) with a mean follow-up of 27±31.2 months. Although PFV is often an isolated disease, it was associated with a systemic disease in 8% of cases. Posterior PFV was associated with anterior involvement in 62 eyes (64%). Forty-one eyes (42.7%) were microphthalmic and were more frequently associated with severe PFV [53% vs. 25%; (p=0.01)]. Surgery was performed in 85 patients (89%). Of them, 69 (81%) were a total success, 5 (6%) were a partial success due to a persistent limited peripheral retinal detachment (RD), and 11 (13%) were a failure due to persistent total RD after surgery. Twenty-four eyes presented post-operative adverse events including ocular hypertension requiring eye drop medication (6.6%), secondary cell proliferation around the IOL (7.7%), intravitreal hemorrhages (6.6%), persistent tractional RD (9.9%). A second surgery was performed in 15 patients (16%). At last follow-up, VA could be measured in logMAR in 43 children (45%), was light perception in 21 eyes (22%), and no light perception or impossible to assess in 32 eyes (33%).

CONCLUSIONS

In our case-series, most of patients presenting PFV with posterior involvement received complex vitreoretinal surgery. Goals of the surgery varies, and include retinal flattening, reduction of vitreoretinal traction, freeing of the visual axis and aesthetic concerns. We proposed a surgical and medical management algorithm for PFV.

Surgical removal of submacular choroidal neovessels in children: Outcome and literature review

PURPOSE

To report on the outcome of surgical submacular choroidal neovascular membrane (CNV) removal in children and to perform a comprehensive review of literature concerning this intervention in children.

METHODS

In this retrospective, noncomparative, interventional case series, we included 8 eyes of 7 consecutive children with subfoveal choroidal neovascularization treated by pars plana vitrectomy (PPV) and CNV removal. Main outcome measures were visual acuity and complications.

RESULTS

Mean age at surgery was 8.6 ± 5.2 years (range: 2-16). Two out of 8 eyes were idiopathic. Corrected-distance visual acuity (CDVA) improved from 1.01 ± 0.45logMAR (range:0.3-1.5) at presentation to 0.60 ± 0.37 (range:0-1) at last follow-up (p = 0.03). Mean follow-up was 3.9 ± 3.9 years. Six eyes received at least one intravitreal injection of bevacizumab prior to surgery. Recurrence occurred in one eye with Best's disease.Literature review revealed a total of 42 cases with the most frequent etiologies being Presumed ocular histoplasmosis syndrome (POHS) and idiopathic CNV. Considering all cases together, mean CDVA improved from 1.00 ± 0.37logMAR to 0.52 ± 0.42 (p < 0.01). CNV recurrence occurred in 11 eyes (22.0%), 7 of which had an inflammatory etiology. Other complications included pigment epithelium tear, atrophy and retinal tear.

CONCLUSION

Surgical removal of CNV is a viable, effective and safe option in children with persistent submacular neovascular membranes.

Prospective cholestanol screening of cerebrotendinous xanthomatosis among patients with juvenile-onset unexplained bilateral cataracts

BACKGROUND

Cerebrotendinous xanthomatosis (CTX) is a rare genetic disorder related to CYP27A1 biallelic mutations, leading to decreased synthesis of bile acids and increased cholestanol. Juvenile bilateral cataracts are one of the most common findings in the disease, frequently occurring before the onset of neurological manifestations. While early treatment with chenodeoxycholic acid can prevent the onset of neurological impairment, poor awareness of CTX accounts for a markedly delayed diagnosis. The objective of this study was to evaluate the utility of plasma cholestanol analysis at the moment of cataract diagnosis and before the onset of neurological impairment in CTX.

METHODS

Multicenter prospective cohort study of patients with juvenile-onset unexplained bilateral cataracts recruited from seven French ophthalmology departments. Plasma cholestanol analysis was performed at diagnosis from January 2018 to January 2020. CYP27A1 genetic testing was performed at the ophthalmologist's discretion. Cholestanol levels were compared with those of a similar population of patients without cataracts (control cohort).

RESULTS

30 patients were finally recruited, with a mean age at cataract diagnosis of 7.1 years (± 4.8 SD, range 1-19 years). One patient had a very high cholestanol level (68 μmol/L, reference < 10) and carried two pathogenic heterozygous mutations in CYP27A1 confirming CTX. This patient was a 19-year-old female, reporting chronic diarrhea only in childhood, and diagnosed with bilateral posterior cataracts with cortical fleck-like opacities. Therefore, the incidence of CTX in our cohort of patients was 3.3%. Five further patients (5/29; 17.2%) had moderate elevations of cholestanol level (between 10.3 and 16.5 μmol/L), compared to 12/286 (4.2%) in the control cohort (p = 0.014) after adjustment for age.

CONCLUSION

Our study argue for the relevance of plasma cholestanol CTX screening in all patients with juvenile-onset unexplained cataracts, even without other CTX identified manifestations. Whether moderate elevations of plasma cholestanol unrelated to CTX may be a risk factor for bilateral cataracts occurrence needs further examination.

Congenital cataract surgery: long-term refractive outcomes of a new intraocular lens power correction formula

PURPOSE

The final refraction after intraocular lens (IOL) implantation remains a challenge in the management of paediatric cataracts. No consensual guidelines exist for the choice of IOL power. The aim of this study was to validate a method of IOL power calculation by evaluating the final refractive error in all patients with IOL implantation operated at our institution.

METHODS

We retrospectively studied all children under 7 years of age who underwent cataract surgery with IOL implantation at our institution between 2010 and 2015. Intraocular lens (IOL) power was calculated as follows: After B-scan determination of the emmetropic IOL power, a reduction of 40%, 35%, 30%, 25%, 20%, 15%, 10% and 5% was applied to children 0-3, 3-6, 6-12, 12-18, 18-24, 24-30, 30-36, 36-48 months, respectively. The following data were collected: follow-up, age at surgery, uni- or bilaterality, implanted IOL power and final refraction.

RESULTS

During this period, 81 children (125 eyes) met the inclusion criteria with a median follow-up of 60 months (36-97). The median age at surgery was 6.61 months (0.76-48). We included 52 children with bilateral cataract (96 eyes) and 29 children with unilateral cataract (29 eyes). The mean implanted IOL power was 23.3 ± 4.6 diopters (D). The mean spherical equivalent at last follow-up was 0.07 ± 3.5 D.

CONCLUSION

Our undercorrection formula for IOL implantation after congenital cataract surgery leads to long-term refractive results globally close to emmetropia.

Evaluation and modification of French screening guidelines for retinopathy of prematurity

PURPOSE

To evaluate the current French screening guidelines for retinopathy of prematurity (ROP) and to suggest modifications to it.

METHODS

In this multicentric retrospective, noncomparative, interventional case series we included infants with a gestational age (GA) ≤32 weeks who were screened for ROP by fundus examination between 2011 and 2018. Main Outcome Measures were the presence of ROP and the need for treatment.

RESULTS

A total of 2246 children with a mean GA of 28.9 ± 2.0 weeks and mean birth weight (BW) of 1141.1 ± 332.0 g were screened. Retinopathy of prematurity (ROP) was found in 683 infants (30.4%), of whom 145 (6.5%) had type 2 ROP and 58 (2.6%) had type 1 ROP. Mean GA of infants with type 1 ROP needing treatment was 25.9 + 1.5 weeks (range: 23.6-30) and mean BW was 774.1 ± 173.7 g (range: 540-1400). Both GA and BW had an impact on the development of type 1 and 2 ROP. None of the infants needing treatment had a GA of 31 weeks or more. None of the children needed treatment before 33 weeks of postmenstrual age (PMA) or 6 weeks of postnatal age (PNA).

CONCLUSION

It seems possible to decrease the screening of premature infants to ≤31 weeks of GA and to start screening at 31 weeks PMA for infants having a GA < 26 weeks and at 6 weeks PNA for more mature children.

Immunomodulatory treatment and surgical management of idiopathic uveitis and juvenile idiopathic arthritis-associated uveitis in children: a French survey practice

BACKGROUND

Surgeries for idiopathic uveitis and juvenile idiopathic arthritis-associated uveitis in children are complex because of the high risk of inflammatory postoperative complications. There is no consensus about treatment adaptation during the perioperative period. The objectives of this study are to report the therapeutic changes made in France and to determine whether maintaining or stopping immunosuppressive therapies is associated with an increased risk of surgical site infection or an increased risk of uveitis or arthritis flare-up.

METHODS

We conducted a retrospective cohort study between January 1, 2006 and December 31, 2018 in six large University Hospitals in France. Inclusion criteria were chronic idiopathic uveitis or chronic uveitis associated with juvenile idiopathic arthritis under immunosuppressive therapies at the time of the surgical procedure, operated before the age of 16. Data on perioperative treatments, inflammatory relapses and post-operative infections were collected.

RESULTS

A total of 76 surgeries (42% cataract surgeries, 30% glaucoma surgeries and 16% posterior capsule opacification surgeries) were performed on 37 children. Adaptation protocols were different in the six hospitals. Immunosuppressive therapies were discontinued in five cases (7%) before surgery. All the children in the discontinuation group had an inflammatory relapse within 3 months after surgery compared to only 25% in the other group. There were no postoperative infections.

CONCLUSIONS

The results of this study show varying practices between centres. The benefit-risk balance seems to favour maintaining immunosuppressive therapies during surgery. Further studies are needed to determine the optimal perioperative treatments required to limit post-operative inflammatory relapses.

Incidence and Risk Factors of Glaucoma Following Pediatric Cataract Surgery With Primary Implantation

PURPOSE

To determine the incidence and risk factors for glaucoma after pediatric cataract surgery with intraocular lens (IOL) implantation.

DESIGN

Retrospective, consecutive case series.

METHODS

In this single-center study, we reviewed 136 children (199 eyes) who underwent pediatric cataract surgery before 1 year of age with a minimum of 1 year of follow-up. The intervention used was pediatric cataract surgery with IOL implantation, and the primary outcome measure was the presence or absence of secondary glaucoma.

RESULTS

The mean age at surgery was 148 ± 93 days (range 30-359 days) with a mean follow-up of 6.3 ± 3.6 years (range 1.1-12.8 years). Glaucoma developed in 31 eyes (16%) with 5- and 10-year incidence rates of 12% and 28%, respectively. The incidence of glaucoma seemed to be bimodal, with a first peak occurring after a mean delay of 2.5 months (range 1.6-4.1 months) and a second peak occurring after a mean delay of 5.7 years (range 2.6-11.7 years). Younger age at surgery, shorter axial length, longer follow-up, use of trypan blue, reintervention, and bilateral surgery were associatied with a higher incidence of glaucoma. Multivariate analysis including the aforementioned variables indentified longer follow-up (odds ratio [OR] = 1.3 [95% confidence interval {CI} 1.1-1.6], P = .001), reintervention (OR = 4.1 [95% CI 1.2-13.4], P = 0.02), and the use of trypan blue (OR = 4.1 [95% CI 1.3-13.1], P = .02) as predictors for the development of glaucoma.

CONCLUSION

Glaucoma is a common complication after pediatric cataract surgery. It seemed to have a bimodal incidence. Risk factors for glaucoma development were reintervention, the use of trypan blue, and a long follow-up.

[Vision screening for children: Recommended practices from AFSOP]

In light of the international literature, a workgroup of experts from the AFSOP met in February 2019 to formulate updated recommendations for visual screening in children. An ophthalmologic examination during the first month of life is recommended for children at risk of developing infantile organic amblyopia. An ophthalmologic examination including cycloplegic refraction between 12 and 15 months of age is recommended for children at risk of developing functional amblyopia. At any age, a prompt ophthalmologic examination is recommended for a child suspected of functional or organic ocular pathology. In children without risk factors or warning signs, a systematic orthoptic screening examination is recommended during the third year of life, including a monocular visual acuity test, a cover-test and a refraction by photoscreener. The child is referred to the ophthalmologist only in the case of an abnormal screening result, according to the following criteria: visual acuity <5/10, or >1 difference between eyes, abnormal cover test, photodetection refraction values <-3D or>+2.5D for the sphere,>1.5D for astigmatism and>1D for anisometropia. Finally, we review normal childhood refractive errors as a function of age as well as the correct use of photo screening devices.

Outcome and risk factors of vitreoretinal surgery in pediatric patients with familial exudative vitreoretinopathy

PURPOSE

To evaluate the outcome for vitreoretinal surgery in children with familial exudative vitreoretinopathy (FEVR) and to evaluate the risk factors associated with failure.

METHODS

This is a retrospective interventional case series of 43 consecutive eyes (34 patients) with vitreoretinal surgery for FEVR. Ocular status prior to intervention and at last follow-up and all surgical steps were recorded. Follow-up time was at least 6 months. Main outcome measure was surgical failure (defined as one of the following: (1) deterioration of visual acuity and stage, (2) persistence or development of total retinal detachment, (3) phthisis).

RESULTS

After a mean follow-up of 3.3 ± 3.4 years (median 2.3; 0.5-15.7 years), surgery was successful in 30 eyes (70%) and failed in 13 eyes (30%). Twenty-one eyes (49%) improved, 13 (30%) remained stable, and 9 (21%) deteriorated. Postoperatively, stages and VA improved significantly (p = 0.001; p = 0.04, respectively). Surgical failure was only observed on patients with stages 4 and 5. Mean macular thickness decreased significantly in eyes (stages 2 and 3) with tractional epiretinal membrane.

CONCLUSION

Eyes with tractional epiretinal membrane in stages 2 and 3 seem to benefit from vitrectomy and membrane peeling with a positive risk-benefit profile. Advanced stages have a low success rate and limited functional improvement, but in selected cases, surgery seems beneficial.

Ocular Spiroplasma ixodetis in Newborns, France

Cataract and uveitis are rare in newborns but potentially blinding. Three newborns with cataract and severe anterior uveitis underwent cataract surgery. Spiroplasma ixodetis was detected in lens aspirates using bacterial 16S-rRNA PCR and transmission electron microscopy. These findings, which suggest maternal-fetal infection, are consistent with previous experimental Spiroplasma-induced cataract and uveitis.

P2597Heart failure and atrial tachyarrhythmia on abiraterone: a characterization using pharmacovigilance databases

Background

Abiraterone and enzalutamide are recently approved androgen deprivation therapies (ADT) for metastatic prostate cancer. The cardiac safety profile for the two drugs is unknown.

Methods

Using French and World Health Organization (WHO) pharmacovigilance databases, we performed a disproportionality-analysis of suspected adverse-drug-reactions (ADR) to evaluate the reporting-odds-ratio (ROR) of cardiac ADR associated with abiraterone compared to enzalutamide, other ADT used in prostate cancer, and entire database. Clinical and demographic characterization of patients with ADT-induced cardiac ADR was performed.

Results

In the 5,759,781 ADR reports in men, 55,070 pertained to ADT. The ROR of AT for abiraterone was of 4.1 [3.1–5.3] vs. enzalutamide, 3.7 [3–4.5] vs. other ADT, and 3.2 [2.7–3.7] vs. entire database. The corresponding ROR for HF were of 2.5 [2–3], 1.5 [1.3–1.7], and 2 [1.7–2.3], respectively. Mean time to AT and HF onset was shorter on abiraterone (5.2±0.8 and 4.5±0.6 months, respectively) vs. other ADT (13.3±3.2 and 9.2±1.1 months; p<0.05). Cases on abiraterone vs. other ADT were more frequently associated with ≥2 ADR-terms including AT, HF, hypokalemia, hypertension and edema (13.6% vs. 6%, p<10–4). For abiraterone, age but not dose was associated to reporting of AT/HF vs. any other ADR.

Table 1 Number (available data) AT HF Hypokalemia Edema Hypertension Age (y) 5989 r: 0.03, p: 0.02 r: 0.05, p≤0.0001 r: 0.06, p≤0.0001 r: 0.04, p≤0.01 ns Dose of hydrocortisone equivalent (mg/day) 3828 ns ns ns r: −0.07, p≤0.001 r: −0.12, p≤0.0001 Dose of abiraterone (mg/day) 6285 ns ns ns ns ns Details concerning correlation (r) between clinical covariates and reporting for AT, HF, hypokalemia, edema and hypertension within overall adverse drug reaction on abiraterone (n: 9203) extracted from VigiBase (through 08/2017).

Time to onset

Conclusion

Compared to other ADT, abiraterone was associated with a higher reporting of AT and HF associated with hypokalemia, hypertension and edema. These findings are consistent with the hyper-mineralocorticism induced by abiraterone and not with other ADT.

New GJA8 variants and phenotypes highlight its critical role in a broad spectrum of eye anomalies

GJA8 encodes connexin 50 (Cx50), a transmembrane protein involved in the formation of lens gap junctions. GJA8 mutations have been linked to early onset cataracts in humans and animal models. In mice, missense mutations and homozygous Gja8 deletions lead to smaller lenses and microphthalmia in addition to cataract, suggesting that Gja8 may play a role in both lens development and ocular growth. Following screening of GJA8 in a cohort of 426 individuals with severe congenital eye anomalies, primarily anophthalmia, microphthalmia and coloboma, we identified four known [p.(Thr39Arg), p.(Trp45Leu), p.(Asp51Asn), and p.(Gly94Arg)] and two novel [p.(Phe70Leu) and p.(Val97Gly)] likely pathogenic variants in seven families. Five of these co-segregated with cataracts and microphthalmia, whereas the variant p.(Gly94Arg) was identified in an individual with congenital aphakia, sclerocornea, microphthalmia and coloboma. Four missense variants of unknown or unlikely clinical significance were also identified. Furthermore, the screening of GJA8 structural variants in a subgroup of 188 individuals identified heterozygous 1q21 microdeletions in five families with coloboma and other ocular and/or extraocular findings. However, the exact genotype-phenotype correlation of these structural variants remains to be established. Our data expand the spectrum of GJA8 variants and associated phenotypes, confirming the importance of this gene in early eye development.

Vitreoretinal Dysplasia Masquerading as Peters’ Anomaly

Purpose

Vitreoretinal dysplasia is characterized by a congenital bilateral nonattachment of the retina. In some cases, anteroposition of the iris and lens can lead to corneolenticular contact and corneal opacity, masquerading as Peters’ anomaly. We report 3 cases of vitreoretinal dysplasia initially diagnosed as Peters’ anomaly.

Methods

Case report.

Results

Case 1: In a 3-year-old boy with bilateral corneal opacities, high frequency ultrasound showed iridolenticular adherences as in Peters’ anomaly, but color Doppler imaging of the posterior pole revealed a bilateral total retinal detachment. Case 2: In an 18-month-old boy with bilateral corneal opacity and dense cataract, ultrasound revealed a shallow anterior chamber and bilateral vitreous hemorrhage with retinal detachment. Case 3: In a 6-month-old girl with bilateral central corneal opacity, shallow anterior chamber, iridocorneal synechiae, and a cataract, ultrasound revealed a total retinal detachment in the right eye, and was uncertain in the left eye. Corneal transplantation was attempted in the left eye, but a retinal detachment was discovered peroperatively There were associated central nervous system anomalies.

Conclusions

Vitreoretinal dysplasia is a potentially evolving disease and can lead to anterior chamber thinning, corneal opacity, and secondary glaucoma. Anterior and posterior segment ultrasound is essential to fix the correct diagnosis and prognosis.

Cataract Surgery with Primary Lens Implantation in Children with Chronic Uveitis

PURPOSE

To evaluate the evolution of chronic uveitis in children undergoing cataract surgery with primary intraocular lens (IOL) implantation.

METHODS

Twelve children with chronic uveitis underwent cataract surgery with primary posterior chamber intraocular lens (IOL) implantation.

RESULTS

Fourteen eyes were implanted with a foldable hydrophobic acrylic IOL. The mean follow-up was 35.39 months (8.72-69.57). The mean BCDVA before surgery and at the end of follow-up was 1.11 (0.40-2.30; SD: 0.57) and 0.48 (0-3; SD: 0.77; p=0.007) respectively. The mean oral corticosteroids dosage after surgery and at the end of follow-up was 0.80 mg/kg/day (SD: 0.37) and 0.17 mg/kg/day (SD: 0.24; p=0.001) respectively. All patients except one were treated with methotrexate. Four patients (5 eyes) were additionally treated with anti-tumor necrosis factor agent.

CONCLUSIONS

Cataract surgery with primary posterior chamber hydrophobic IOL implantation is possible and leads to a good visual recovery in cases of pediatric chronic uveitis. This surgery requires aggressive anti-inflammatory management with immunosuppressive drugs to control inflammation and reduce the corticosteroids dosage.

[Examination and clinical signs in infancy]

The first 2 years of life are essential to visual development. The ophthalmological examination of a baby is different from that of an adult, in terms of both methodology and clinical signs. The specifics of examination at this age require a rigorous history taking as a first step: personal and family medical history, first sign of the disease and its progression. Cycloplegic refraction and fundus exam are both critical regardless of the reason for consultation. In addition, fundus exam must be performed at the first visit in cases of strabismus, nystagmus, or abnormal visual function, in order to rule out underlying retinoblastoma. Gross inspection of the patient can offer much information: malformations, visual behavior, oculomotor abnormalities. Quantification of vision and refraction is age-specific. It cannot be based solely on visual behavior, it cannot be just an approximation, and it often needs to be repeated. Lastly, examination of the anterior and posterior segments may require specialized equipment, special techniques, and may reveal pathology specific to the infant. Throughout the examination, patience and gentleness help greatly to insure a reliable diagnosis.

[Iris mammillations: three case reports]

INTRODUCTION

Iris mammillations are congenital abnormalities characterized by vitiliform protuberances regularly spaced on the surface of a velvety iris. They can be either isolated or associated with melanocytosis involving iris, sclera or periocular tissues, resulting in a risk for uveal melanoma. They can be complicated by ocular hypertension. We report three cases of iris mammillations in three children.

CASES REPORT

For each patient, age, circumstances of revelation, anterior and posterior segment examination, intraocular pressure, associated anomalies, and progression were noted. Patient no. 1: In a 13-month-old boy examined for a squint, bilateral iris mammillations were fortuitously discovered. Intraocular pressure remained normal over 22 months of follow-up. Patient no. 2: In an eight-year-old boy, bilateral iris mammillations with papillary excavation were fortuitously discovered. Intraocular pressure was normal and the excavation did not change over 20 months of follow-up. Patient no. 3: A five-year-old boy was examined for a scleral pigmentation in the right eye. The examination found unilateral iris mammillations and ipsilateral ocular melanocytosis. Intraocular pressure and fundus were normal and remained normal over 13 months of follow-up.

DISCUSSION

and conclusion: Iris mammillations are congenital abnormalities, generally unilateral, sometimes hereditary. The differential diagnosis includes Lisch nodules of neurofibromatosis and iris melanoma. The etiology of iris mammillations is unknown; these lesions can be complicated by ocular hypertony and, in case of associated melanocytosis of the iris, sclera or periocular tissues, by uveal melanoma. These potential complications warrant a regular clinical follow-up.

Iris fixation of foldable intraocular lenses for ectopia lentis in children

PURPOSE

To describe a technique for iris fixation of acrylic intraocular lenses (IOLs) in ectopia lentis and evaluate the medium-term anatomical and functional results in children.

SETTING

Pediatric Ophthalmology Department, Fondation Rothschild, Paris, France.

METHODS

This retrospective study included 17 eyes of 9 children. The technique consisted of lens ablation, leaving in place the capsule in the zone of nonruptured zonule, and an IOL placement in the remaining sulcus with 2 iris sutures. The age of patients, postoperative complications, follow-up, anatomical results, final refraction, and visual acuity were noted.

RESULTS

Median age was 4.8 years. One case of postoperative hyphema and 1 case of aseptic endophthalmitis occurred and resolved after treatment. The anatomical outcome was favorable in all cases, with centered IOLs and round pupils. Mean follow-up was 16.3 months. Mean final refraction was +0.18 diopter, and mean final best corrected visual acuity was 20/32 (range 20/50 to 20/20).

CONCLUSIONS

The results suggest that iris fixation of foldable IOLs for ectopia lentis in children can lead to good anatomical and functional results. The use of the remaining part of the sulcus is helpful in reaching correct positioning of the IOL. The complication rate is similar to that with other techniques described in the literature, whereas the small incision and the absence of transscleral sutures could simplify the short-term and long-term evolution.

Non-penetrating deep sclerectomy for glaucoma associated with Sturge-Weber syndrome

PURPOSE

To report the results of non-penetrating deep sclerectomy (NPDS) in the treatment of glaucoma associated with Sturge-Weber syndrome (SWS).

METHODS

We carried out a retrospective case series analysis of patients who underwent NPDS for glaucoma associated with SWS between 1998 and 2003. The control of glaucoma after NPDS, the results of surgery on intraocular pressure, the need for additional medical treatment and surgical complications were studied.

RESULTS

Twelve eyes of nine patients, aged 11 days to 24 years, underwent filtering surgery: nine NPDS procedures were performed and three surgical procedures had to be converted to trabeculectomy because NPDS was not technically achievable. The mean follow-up after surgery was 26.3 months (range 6-48 months). Two trabeculectomies were complicated by choroidal effusion, which resolved in both cases. Good control of glaucoma was obtained during follow-up.

CONCLUSIONS

Non-penetrating deep sclerectomy is transiently efficient in the treatment of SWS-associated glaucoma. Further studies of NPDS for the treatment of glaucoma associated with SWS are warranted.

[Congenital glaucoma and trabeculodysgenesis. Clinical and genetic aspects]

Congenital glaucoma is generally related to an iridocorneal angle malformation, with an obstacle to aqueous humor outflow. This spectrum of diseases can involve the angle, the iris and the cornea. The diagnosis relies on characteristic signs and is confirmed by an examination under general anaesthesia and paraclinical examinations (especially echography). An early diagnosis is essential for beginning surgical treatment. Several filtering surgery techniques with equivalent intraocular pressure results are available, but visual function must be protected in all cases. In many cases, genetic counseling relies on a careful clinical analysis and sometimes on a molecular analysis. A number of ocular and/or general abnormalities can be accompanied by glaucoma in infants and children. They must be screened in case of associated signs, but the existence of these abnormalities leads to suspicion of associated glaucoma.

[Computer-assisted diagnosis and therapy for glaucoma]

Boolean algebra, or combinatory analysis and their related computer routines, can provide invaluable help in resolving classic diagnostic problems. However complex each case may be, the diagnosis is always made from a finite set of data, and the fundamental problem is thus how to exploit this data. Invention no longer has a place in ascertaining a diagnosis. Traditional ways of reasoning are numerous, personal, and fragile, but fortunately redundant. They may give rise to four types of error: omission or mistake (an error of judgment), either during the semiotic or the dialectic stages. Whereas the physiological capacity of the human brain and memory only enables it to make a limited number of hypotheses concerning certain aspects of glaucoma, computer programs can take the total number of hypotheses into account, i.e., 3000. For every input the program explores each of the 3,000 items, thus eliminating the four types of error. The probabilistic nature of data, which compromises the confidence one can have in conclusions resulting from such complex reasoning, is treated by the adjusted probabilities. The use of such diagnostic aids, whose thesaurus is updated regularly, is reserved for ophthalmologists, the only authority capable of assessing the pertinence of the computer responses. Consequently, the specialist can rest assured that the patient has benefited from the most comprehensive and updated knowledge in medical science.