Prevalence of Glaucoma Following Paediatric Cataract Surgery in an Australian Tertiary Referral Centre

Purpose

Secondary glaucoma following childhood cataract surgery remains the most common complication in the paediatric population. This study aimed to determine the incidence, time to progression and risk factors associated with the development of secondary glaucoma following childhood cataract surgery in a paediatric population. Outcome measures were the detection of secondary glaucoma, postoperative time frame to development of glaucoma and risk factors in its development.

Patients and Methods

A retrospective case series was conducted between 2003 and 2017 at a tertiary children's hospital in Sydney. The patient population included those 16 years or less of age who underwent congenital cataract extraction, with or without an intraocular lens implantation and who had been followed up for a minimum of six months following surgery. Patients were excluded if they had cataract aetiology other than congenital idiopathic cataract. Multivariate Cox Regression analysis was used to determine relevant risk factors.

Results

A total of 320 eyes in 216 patients were included in the study. Secondary glaucoma developed in 11.9% of eyes. In those that developed secondary glaucoma, the average time to onset from surgery was 3.2 years (median 2.75 years). The mean age of diagnosis of secondary glaucoma was 4.58 years (median 3.5 years, range 2.5 months to 13.23 years). Microcornea was the only adverse characteristic significantly associated with an increased risk of secondary glaucoma (HR 6.30, p 0.003).

Conclusion

Despite modern surgical techniques, glaucoma remains a significant long-term sequela in children following cataract surgery.

Thirty-Year Time Trends in Diabetic Retinopathy and Macular Edema in Youth With Type 1 Diabetes

OBJECTIVE

To examine trends in diabetic retinopathy (DR) and diabetic macular edema (DME) in adolescents with type 1 diabetes between 1990 and 2019.

RESEARCH DESIGN AND METHODS

We analyzed 5,487 complication assessments for 2,404 adolescents (52.7% female, aged 12-20 years, diabetes duration >5 years), stratified by three decades (1990-1999, 2000-2009, 2010-2019). DR and DME were graded according to the modified Airlie House classification from seven-field stereoscopic fundal photography.

RESULTS

Over three decades, the prevalence of DR was 40, 21, and 20% (P < 0.001) and DME 1.4, 0.5, and 0.9% (P = 0.13), respectively, for 1990-1999, 2000-2009, and 2010-2019. Continuous subcutaneous insulin infusion (CSII) use increased (0, 12, and 55%; P < 0.001); mean HbA1c was bimodal (8.7, 8.5, and 8.7%; P < 0.001), and the proportion of adolescents meeting target HbA1c <7% did not change significantly (8.3, 7.7, and 7.1%; P = 0.63). In multivariable generalized estimating equation analysis, DR was associated with 1-2 daily injections (odds ratio 1.88, 95% CI 1.42-2.48) and multiple injections in comparison with CSII (1.38, 1.09-1.74); older age (1.11, 1.07-1.15), higher HbA1c (1.19, 1.05-1.15), longer diabetes duration (1.15, 1.12-1.18), overweight/obesity (1.27, 1.08-1.49) and higher diastolic blood pressure SDS (1.11, 1.01-1.21). DME was associated with 1-2 daily injections (3.26, 1.72-6.19), longer diabetes duration (1.26, 1.12-1.41), higher diastolic blood pressure SDS (1.66, 1.22-2.27), higher HbA1c (1.28, 1.03-1.59), and elevated cholesterol (3.78, 1.84-7.76).

CONCLUSIONS

One in five adolescents with type 1 diabetes had DR in the last decade. These findings support contemporary guidelines for lower glycemic targets, increasing CSII use, and targeting modifiable risk factors including blood pressure, cholesterol, and overweight/obesity.

Optimal Frequency of Retinopathy Screening in Adolescents With Type 1 Diabetes: Markov Modeling Approach Based on 30 Years of Data

OBJECTIVE

Current guidelines recommend biennial diabetic retinopathy (DR) screening commencing at the age of 11 years and after 2-5 years' duration of type 1 diabetes. Growing evidence suggests less frequent screening may be feasible.

RESEARCH DESIGN AND METHODS

Prospective data were collected from 2,063 youth with type 1 diabetes who were screened two or more times between 1990 and 2019. Baseline (mean ± SD) age was 13.3 ± 1.8 years, HbA1c was 8.6 ± 1.3% (70.1 ± 14.7 mmol/mol), diabetes duration was 5.6 ± 2.8 years, and follow-up time was 4.8 ± 2.8 years. DR was manually graded from 7-field retinal photographs using the Early Treatment Diabetic Retinopathy Study (ETDRS) scale. Markov chain was used to calculate probabilities of DR change over time and hazard ratio (HR) of DR stage transition.

RESULTS

The incidence of moderate nonproliferative DR (MNPDR) or worse was 8.6 per 1,000 patient-years. Probabilities of transition to this state after a 3-year interval were from no DR, 1.3%; from minimal DR, 5.1%; and from mild DR, 22.2%, respectively. HRs (95% CIs) for transition per 1% current HbA1c increase were 1.23 (1.16-1.31) from no DR to minimal NPDR, 1.12 (1.03-1.23) from minimal to mild NPDR, and 1.28 (1.13-1.46) from mild to MNPDR or worse. HbA1c alone explained 27% of the transitions between no retinopathy and MNPDR or worse. The addition of diabetes duration into the model increased this value to 31% (P = 0.03). Risk was also increased by female sex and higher attained age.

CONCLUSIONS

These results support less frequent DR screening in youth with type 1 diabetes without DR and short duration. Although DR progression to advanced stages is generally slow, higher HbA1c greatly accelerates it.

Higher skin autofluorescence in young people with Type 1 diabetes and microvascular complications

AIM

To test the hypothesis that non-invasive skin autofluorescence, a measure of advanced glycation end products, would provide a surrogate measure of long-term glycaemia and be associated with early markers of microvascular complications in adolescents with Type 1 diabetes.

METHODS

Forearm skin autofluorescence (arbitrary units) was measured in a cross-sectional study of 135 adolescents with Type 1 diabetes [mean ± sd age 15.6 ± 2.1 years, diabetes duration 8.7 ± 3.5 years, HbA_1c 72 ± 16 mmol/mol (8.7 ± 1.5%)]. Retinopathy, assessed using seven-field stereoscopic fundal photography, was defined as ≥1 microaneurysm or haemorrhage. Cardiac autonomic function was measured by standard deviation of consecutive RR intervals on a 10-min continuous electrocardiogram recording, as a measure of heart rate variability.

RESULTS

Skin autofluorescence was significantly associated with age (R² = 0.15; P < 0.001). Age- and gender-adjusted skin autofluorescence was associated with concurrent HbA_1c (R² = 0.32; P < 0.001) and HbA_1c over the previous 2.5-10 years (R² = 0.34-0.43; P < 0.002). Age- and gender-adjusted mean skin autofluorescence was higher in adolescents with retinopathy vs those without retinopathy [mean 1.38 (95% CI 1.29, 1.48) vs 1.22 (95% CI 1.17, 1.26) arbitrary units; P = 0.002]. In multivariable analysis, retinopathy was significantly associated with skin autofluorescence, adjusted for duration (R² = 0.19; P = 0.03). Cardiac autonomic dysfunction was also independently associated with skin autofluorescence (R² = 0.11; P = 0.006).

CONCLUSIONS

Higher skin autofluorescence is associated with retinopathy and cardiac autonomic dysfunction in adolescents with Type 1 diabetes. The relationship between skin autofluorescence and previous glycaemia may provide insight into metabolic memory. Longitudinal studies will determine the utility of skin autofluorescence as a non-invasive screening tool to predict future microvascular complications.

Fractal Dimension Analysis of Transient Visual Evoked Potentials: Optimisation and Applications

PURPOSE

The visual evoked potential (VEP) provides a time series signal response to an external visual stimulus at the location of the visual cortex. The major VEP signal components, peak latency and amplitude, may be affected by disease processes. Additionally, the VEP contains fine detailed and non-periodic structure, of presently unclear relevance to normal function, which may be quantified using the fractal dimension. The purpose of this study is to provide a systematic investigation of the key parameters in the measurement of the fractal dimension of VEPs, to develop an optimal analysis protocol for application.

METHODS

VEP time series were mathematically transformed using delay time, τ, and embedding dimension, m, parameters. The fractal dimension of the transformed data was obtained from a scaling analysis based on straight line fits to the numbers of pairs of points with separation less than r versus log(r) in the transformed space. Optimal τ, m, and scaling analysis were obtained by comparing the consistency of results using different sampling frequencies. The optimised method was then piloted on samples of normal and abnormal VEPs.

RESULTS

Consistent fractal dimension estimates were obtained using τ = 4 ms, designating the fractal dimension = D2 of the time series based on embedding dimension m = 7 (for 3606 Hz and 5000 Hz), m = 6 (for 1803 Hz) and m = 5 (for 1000Hz), and estimating D2 for each embedding dimension as the steepest slope of the linear scaling region in the plot of log(C(r)) vs log(r) provided the scaling region occurred within the middle third of the plot. Piloting revealed that fractal dimensions were higher from the sampled abnormal than normal achromatic VEPs in adults (p = 0.02). Variances of fractal dimension were higher from the abnormal than normal chromatic VEPs in children (p = 0.01).

CONCLUSIONS

A useful analysis protocol to assess the fractal dimension of transformed VEPs has been developed.

Association Between HbA1c Variability and Risk of Microvascular Complications in Adolescents With Type 1 Diabetes

CONTEXT

There is a paucity of data regarding the association between glycosylated hemoglobin (HbA1c) variability and risk of microvascular complications in adolescents with type 1 diabetes (T1D).

OBJECTIVE

To investigate the association between HbA1c variability and risk of microvascular complications in adolescents with T1D.

DESIGN

Prospective cohort study from 1990 to 2014 (median follow-up, 8.1 y).

SETTING

Tertiary pediatric hospital.

PARTICIPANTS

A total of 1706 adolescents (aged 12-20 minimum diabetes duration 5 y) with median age of 15.9 years (interquartile range, 14.3-17.5) and diabetes duration of 8.1 years (6.3-10.8).

MAIN OUTCOME MEASURES

Glycemic variability was computed as the SD of all HbA1c measurements (SD-HbA1c) after diagnosis. Retinopathy was detected using 7-field fundal photography, renal function assessed using albumin excretion rate, peripheral neuropathy detected using thermal and vibration threshold testing, and cardiac autonomic neuropathy (CAN) detected using time- and frequency-domain analyses of electrocardiogram recordings. Generalized estimating equations were used to examine the relationship between complications outcomes and HbA1c variability, after adjusting for known risk factors, including HbA1c, diabetes duration, blood pressure, and lipids.

RESULTS

In multivariable analysis, SD-HbA1c was associated with early retinopathy (odds ratio [OR] 1.32; 95% confidence interval, 1.00-1.73), albuminuria (OR 1.81; 1.04-3.14), increased log10 albumin excretion rate (OR 1.10; 1.05-1.15) and CAN (OR 2.28; 1.23-4.21) but not peripheral neuropathy.

CONCLUSIONS

Greater HbA1c variability predicts retinopathy, early nephropathy, and CAN, in addition to established risk factors, in adolescents with T1D. Minimizing long term fluctuations in glycemia may provide additional protection against the development of microvascular complications.

Strategies for the Management of Congenital Iris Cysts

Iris cysts can arise from iris pigment epithelium or stroma. We present 3 cases of iris cysts which have been managed in different ways. In a one-month neonate, cyst was punctured with keratome and gentle diode laser endophotocoagulation was applied to the base. A2.5-month infant presented with watering and blepharospasm since birth. Clear fluid was aspirated from the cyst with a 27-gauge needle and Ethanol 96% (ETOH) was injected into the cyst and then aspirated. It was followed by injection/aspiration of 0.3 ml of balanced salt solution thrice. Cyst wall was excised. A13-month toddler presented with 4-month history of intermittent irritation and photophobia. The cyst was aspirated with a 25-gauge needle and the cyst walls were nibbled with 20-gauge vitrectomy cutter. Excision is better than injection of sclerosing solutions. The aim is to remove the whole cyst to avoid recurrence and to prevent amblyopia.

Insulin Pump Therapy Is Associated with Lower Rates of Retinopathy and Peripheral Nerve Abnormality

OBJECTIVE

To compare rates of microvascular complications in adolescents with type 1 diabetes treated with continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDI).

RESEARCH DESIGN AND METHODS

Prospective cohort of 989 patients (aged 12-20 years; diabetes duration >5 years) treated with CSII or MDI for >12 months. Microvascular complications were assessed from 2000-14: early retinopathy (seven-field fundal photography), peripheral nerve function (thermal and vibration threshold testing), autonomic nerve abnormality (heart rate variability analysis of electrocardiogram recordings) and albuminuria (albumin creatinine ratio/timed overnight albumin excretion). Generalized estimating equations (GEE) were used to examine the relationship between treatment and complications rates, adjusting for socio-economic status (SES) and known risk factors including HbA1c and diabetes duration.

RESULTS

Comparing CSII with MDI: HbA1C was 8.6% [70mmol/mol] vs. 8.7% [72 mmol/mol]) (p = 0.7), retinopathy 17% vs. 22% (p = 0.06); microalbuminuria 1% vs. 4% (p = 0.07), peripheral nerve abnormality 27% vs. 33% (p = 0.108) and autonomic nerve abnormality 24% vs. 28% (p = 0.401). In multivariable GEE, CSII use was associated with lower rates of retinopathy (OR 0.66, 95% CI 0.45-0.95, p = 0.029) and peripheral nerve abnormality (OR 0.63, 95% CI 0.42-0.95, p = 0.026), but not albuminuria (OR 0.46, 95% CI 0.10-2.17, p = 0.33). SES was not associated with any of the complication outcomes.

CONCLUSIONS

In adolescents, CSII use is associated with lower rates of retinopathy and peripheral nerve abnormality, suggesting an apparent benefit of CSII over MDI independent of glycemic control or SES.

Primary congenital glaucoma outcomes: lessons from 23 years of follow-up

PURPOSE

To determine in primary congenital glaucoma whether age of presentation influences surgical success, the degrees of angle surgery needed to achieve glaucoma control, and whether there are critical ages where glaucoma progresses, requiring further surgical management.

DESIGN

Retrospective cohort study.

METHODS

The medical records of patients with primary congenital glaucoma over a 23-year period were reviewed: 192 procedures were performed on 117 eyes (70 patients). The number and age of angle procedures and final visual acuity was analyzed. Surgical success was defined as stable intraocular pressure and optic disc appearance.

RESULTS

Procedures involving 83 of the 110 eyes (75.5%) undergoing angle surgery were successful, with 2-, 4-, 6-, and 10-year success rates of 92%, 86%, 84%, and 75%, respectively. Subgroup analysis (<3 months; 3-6 months; >6 months) comparing age of diagnosis to visual outcome (<20/200, 20/200-20/40, >20/40) was significant (P = .04). The age at first operation (P = .94), the number of angle operations (P = .43), and their effect on angle surgery success was not significant. Seven of 192 operations were performed after the age of 8 years (3.6%). After the initial angle surgeries within the first year of life, the third procedure occurred at a median age of 2.4 years (interquartile ratio [IQR] 0.6-3.8 years) and the fourth procedure occurred at a median age of 5.3 years (IQR 2.5-6.1 years).

CONCLUSIONS

Children diagnosed at <3 months of age had a visual outcome of <20/200 despite successful glaucoma control. Age of presentation did not affect surgical success. A total of 78.9% of cases undergoing primary trabeculotomy were controlled with 1 operation: 4 clock hours of angle (120 degrees). Analysis of glaucoma progression suggests critical ages where further glaucoma surgery is required at around 2 and 5 years of age.

Early elevation of albumin excretion rate is associated with poor gluten-free diet adherence in young people with coeliac disease and diabetes

AIMS

There are conflicting data on microvascular complications in coexisting Type 1 diabetes and coeliac disease. We compared complications rates in youth with or without coeliac disease and examined the association between gluten-free diet adherence and complications.

METHODS

This was a comparative study of adolescents (2510 without coeliac disease, 129 with coeliac disease); 60 (47%) did not adhere to a gluten-free diet--defined as elevated anti-tissue transglutaminase or endomysial immunoglobulin A titres. Retinopathy was detected using 7-field fundal photography and albumin excretion rate by timed overnight urine collections, with early elevation defined as albumin excretion rate ≥ 7.5 μg/min. Logistic regression was used to examine the association between complications and explanatory variables, including coeliac disease vs. no coeliac disease, gluten-free diet adherence vs. non-adherence, diabetes duration and HbA1c .

RESULTS

Median age at last assessment was 16.5 years. Those with coeliac disease vs. those without were younger at diabetes diagnosis (7.1 vs. 8.6 years, P < 0.001) and had longer diabetes duration (9.3 vs. 7.2 years, P < 0.001). HbA1c was lower in those with coeliac disease vs. those without (67 vs. 70 mmol/mol, 8.3 vs. 8.6%, P = 0.04) and adherence to a gluten-free diet vs. non-adherence (66 vs. 72 mmol/mol, 8.2 vs. 8.7%, P = 0.003). There were no differences in complication rates between those with coeliac disease vs. those without (retinopathy 22 vs. 23%, elevated albumin excretion rate 31 vs. 28%). Non-adherence to a gluten-free diet was associated with elevated albumin excretion rate (40 vs. 23%, P = 0.04). In multivariable logistic regression, elevated albumin excretion rate was associated with non-adherence to a gluten-free diet (odds ratio 2.37, 95% CI 1.04-5.40, P = 0.04) and diabetes duration (odds ratio 1.13, 95% CI 1.02-1.25, P = 0.03), but not HbA1c .

CONCLUSIONS

While glycaemic control is better in patients with coeliac disease, non-adherence to a gluten-free diet is associated with elevated albumin excretion rate. The possible protection of a gluten-free diet on complications warrants further investigation.

Plantar fascia thickness is longitudinally associated with retinopathy and renal dysfunction: a prospective study from adolescence to adulthood

AIM

The aim was to study the longitudinal relationship between plantar fascia thickness (PFT) as a measure of tissue glycation and microvascular (MV) complications in young persons with type 1 diabetes (T1DM).

METHODS

We conducted a prospective longitudinal cohort study of 152 (69 male) adolescents with T1DM who underwent repeated MV complications assessments and ultrasound measurements of PFT from baseline (1997-2002) until 2008. Retinopathy was assessed by 7-field stereoscopic fundal photography and nephropathy by albumin excretion rate (AER) from three timed overnight urine specimens. Longitudinal analysis was performed using generalized estimating equations (GEE).

RESULTS

Median (interquartile range) age at baseline was 15.1 (13.4-16.8) years, and median follow-up was 8.3 (7.0-9.5) years, with 4 (3-6) visits per patient. Glycemic control improved from baseline to final visit [glycated hemoglobin (HbA1c) 8.5% to 8.0%, respectively; p = .004]. Prevalence of retinopathy increased from 20% to 51% (p < .001) and early elevation of AER (>7.5 μg/min) increased from 26% to 29% (p = .2). A greater increase in PFT (mm/year) was associated with retinopathy at the final assessment (ΔPFT 1st vs. 2nd-4th quartiles, χ(2) = 9.87, p = .02). In multivariate GEE, greater PFT was longitudinally associated with retinopathy [odds ratio (OR) 4.6, 95% confidence interval (CI) 2.0-10.3] and early renal dysfunction (OR 3.2, CI 1.3-8.0) after adjusting for gender, blood pressure standard deviation scores, HbA1c, and total cholesterol.

CONCLUSIONS

In young people with T1DM, PFT was longitudinally associated with retinopathy and early renal dysfunction, highlighting the importance of early glycemic control and supporting the role of metabolic memory in MV complications. Measurement of PFT by ultrasound offers a noninvasive estimate of glycemic burden and tissue glycation.

Microvascular complications assessment in adolescents with 2- to 5-yr duration of type 1 diabetes from 1990 to 2006

OBJECTIVE

Microvascular complications occur in adolescents with type 1 diabetes, although guidelines vary as to when screening should commence and prevalence data for those with ≤5-yr duration are limited. We therefore investigated trends in prevalence of early microvascular complications over 17 yr.

RESEARCH DESIGN AND METHODS

819 adolescents (54% female) aged 11-17 yr with 2- to 5-yr diabetes duration were assessed for complications at a tertiary pediatric diabetes clinic between 1990 and 2006. Early retinopathy was detected using seven-field fundal photography, albumin excretion rate (AER) by timed overnight urine collections and peripheral nerve function by thermal/vibration threshold at the foot. Results were analyzed by age, time period of assessment, and duration.

RESULTS

Early retinopathy declined from 1990 to 2002 (16-7%, p < 0.01), then remained unchanged until 2006. Early elevation of AER (≥7.5 µg/min) and microalbuminuria (≥20 µg/min) did not change over time, whereas peripheral nerve abnormalities increased (14-28%, p < 0.01). Median hemoglobin A1c improved (8.7-8.2%, p < 0.01), in parallel with increased total daily insulin dose and injections per day (p < 0.01). Body mass index standard deviation score increased over time (0.55-0.79, p < 0.01). In multivariate logistic regression, early retinopathy was associated with earlier time period [odds ratio (OR) 0.68, confidence interval (CI) 0.55-0.85, p < 0.01] and older age (OR 1.19, CI 1.02-1.39, p = 0.03). AER ≥ 7.5 µg/min was associated with older age (1.19, 1.06-1.34, p < 0.01) and longer diabetes duration (OR 1.28, CI 1.02-1.62, p = 0.04) and height-adjusted peripheral nerve abnormalities with later time period (OR 1.26, CI 1.05-1.50, p = 0.01).

CONCLUSIONS

Early complications are not uncommon in adolescents with 2- to 5-yr diabetes duration, despite more intensive management in recent years.

Continued reduction in the prevalence of retinopathy in adolescents with type 1 diabetes: role of insulin therapy and glycemic control

OBJECTIVE

To examine trends in microvascular complications in adolescents with type 1 diabetes between 1990 and 2009 in Sydney, Australia.

RESEARCH DESIGN AND METHODS

We used analysis of complications in 1,604 adolescents (54% female, aged 12-20 years, median duration 8.6 years), stratified by four time periods using Generalized Estimation Equations as follows: T1 (1990-1994), T2 (1995-1999), T3 (2000-2004), and T4 (2005-2009). Early retinopathy was detected using seven-field fundal photography, albumin excretion rate (AER) using timed overnight urine collections, and albumin-to-creatinine ratio (ACR) and peripheral nerve function using thermal and vibration threshold.

RESULTS

Retinopathy declined (53, 38, 23, and 12%; P < 0.001), as did borderline elevation of AER/ACR (45, 30, 26, and 30%; P < 0.001) and microalbuminuria (8, 4, 3, and 3%; P = 0.006). Multiple daily injections (MDI)/continuous subcutaneous insulin infusion (CSII) use increased (17, 54, 75, and 88%; P < 0.001), median HbA(1c) decreased (9.1, 8.9, 8.5, and 8.5%; P < 0.001), and severe hypoglycemia was unchanged (6, 8, 10, and 7%; P = 0.272). Retinopathy was associated with diabetes duration (odds ratio [OR] 1.12 [95% CI 1.08-1.17]), age (1.13 [1.06-1.20]), HbA(1c) (1.16 [1.08-1.25]), systolic blood pressure (BP) SDS (1.31 [1.16-1.48]), socioeconomic disadvantage (1.42 [1.04-1.95]), and 1 to 2 injections per day (vs. MDI/CSII; 1.35 [1.05-1.73]); borderline AER/ACR with male sex (1.32 [1.02-1.70]), age (1.19 [1.12-1.26]), HbA(1c) (1.18 [1.08-1.29]), weight SDS (1.31 [1.21-1.53]), insulin dose per kilograms (1.64 [1.13-2.39]), 1 to 2 injections per day (1.41 [1.08-1.84]), and socioeconomic disadvantage (1.68 [1.23-2.31]); and microalbuminuria with age (1.14 [1.01-1.29]), HbA(1c) (1.20 [1.05-1.37]), diastolic BP SDS (1.76 [1.26-2.46]), and 1 to 2 injections per day (1.95 [1.11-3.41]).

CONCLUSIONS

The decline in retinopathy supports contemporary guidelines that recommend lower glycemic targets and use of MDI/CSII in children and adolescents with type 1 diabetes.

Vitamin D deficiency is associated with retinopathy in children and adolescents with type 1 diabetes

OBJECTIVE

To examine the hypothesis that vitamin D deficiency (VDD) is associated with an increased prevalence of microvascular complications in young people with type 1 diabetes.

RESEARCH DESIGN AND METHODS

In a cross-sectional study of 517 patients, 25-hydroxyvitamin D was measured. Retinopathy was assessed by 7-field stereoscopic retinal photography, peripheral neuropathy by thermal and vibration threshold testing, and microalbuminuria by albumin excretion rate or albumin-to-creatinine ratio.

RESULTS

Retinopathy prevalence was higher in cases with VDD versus sufficiency (18 vs. 9%, P = 0.02); deficiency was not associated with microalbuminuria or neuropathy. In logistic regression, retinopathy was associated with VDD (odds ratio 2.12 [95% CI 1.03-4.33]), diabetes duration (1.13, 1.05-1.23), and HbA(1c) (1.24, 1.02-1.50).

CONCLUSIONS

VDD is associated with an increased prevalence of retinopathy in young people with type 1 diabetes. The inflammatory and angiogenic effects of VDD may contribute to early retinal vascular damage; however, further investigations are warranted.

Role of blood pressure in development of early retinopathy in adolescents with type 1 diabetes: prospective cohort study

OBJECTIVE

To examine the relation between blood pressure and the development of early retinopathy in adolescents with childhood onset type 1 diabetes.

DESIGN

Prospective cohort study.

SETTING

Diabetes Complications Assessment Service at the Children's Hospital at Westmead, Sydney, Australia.

PARTICIPANTS

1869 patients with type 1 diabetes (54% female) screened for retinopathy with baseline median age 13.4 (interquartile range 12.0-15.2) years, duration 4.9 (3.1-7.0) years, and albumin excretion rate of 4.4 (3.1-6.8) microg/min plus a subgroup of 1093 patients retinopathy-free at baseline and followed for a median 4.1 (2.4-6.6) years.

MAIN OUTCOME MEASURES

Early background retinopathy; blood pressure.

RESULTS

Overall, retinopathy developed in 673 (36%) participants at any time point. In the retinopathy-free group, higher systolic blood pressure (odds ratio 1.01, 95% confidence interval 1.003 to 1.02) and diastolic blood pressure (1.01, 1.002 to 1.03) were predictors of retinopathy, after adjustment for albumin excretion rate (1.27, 1.13 to 1.42), haemoglobin A(1c) (1.08, 1.02 to 1.15), duration of diabetes (1.16, 1.13 to 1.19), age (1.13, 1.08 to 1.17), and height (0.98, 0.97 to 0.99). In a subgroup of 1025 patients with albumin excretion rate below 7.5 microg/min, the cumulative risk of retinopathy at 10 years' duration of diabetes was higher for those with systolic blood pressure on or above the 90th centile compared with those below the 90th centile (58% v 35%, P=0.03). The risk was also higher for patients with diastolic blood pressure on or above the 90th centile compared with those below the 90th centile (57% v 35%, P=0.005).

CONCLUSIONS

Both systolic and diastolic blood pressure are predictors of retinopathy and increase the probability of early retinopathy independently of incipient nephropathy in young patients with type 1 diabetes.

Plantar fascia thickness, a measure of tissue glycation, predicts the development of complications in adolescents with type 1 diabetes

OBJECTIVE

Direct measurement of collagen glycation requires skin biopsy, which is invasive. We hypothesized that measurement of plantar fascia thickness (PFT) by ultrasound is an alternative index of tissue glycation and a marker of microvascular disease.

RESEARCH DESIGN AND METHODS

This was a prospective longitudinal study of microvascular complications in 344 adolescents with type 1 diabetes, whose PFT was assessed by ultrasound at baseline. Retinopathy was assessed by seven-field fundal photography, albumin excretion rate (AER) measured from three consecutive timed overnight urine specimens, autonomic neuropathy by pupillometry and cardiovascular tests, and peripheral neuropathy by vibration and thermal thresholds. Longitudinal analysis was performed using generalized estimating equations with baseline PFT, duration, and A1C as explanatory variables.

RESULTS

At first assessment, median (interquartile range) age was 15.1 (13.5-17.2) years and diabetes duration was 8.5 (6.0-11.5) years. Median follow up was 3.2 (2.1-4.5) years with a median of 4 (2-13) complications assessments per patient. In multivariate analysis, baseline PFT (abnormal in 132 subjects, 38%) predicted subsequent development of retinopathy (odds ratio 2.4 [95% CI 1.1-5.0]), elevated AER (2.24 [1.05-5.11]), peripheral neuropathy (2.3 [1.2-4.41]), and autonomic neuropathy (4.94 [2.46-9.91]). Limited joint mobility was present in only 4%.

CONCLUSIONS

PFT is a significant predictor of the subsequent development of complications in type 1 diabetes, suggesting that glycation and oxidation of collagen in soft tissues may be independent risk factors for microvascular complications.

Space flight alters bacterial gene expression and virulence and reveals a role for global regulator Hfq

A comprehensive analysis of both the molecular genetic and phenotypic responses of any organism to the space flight environment has never been accomplished because of significant technological and logistical hurdles. Moreover, the effects of space flight on microbial pathogenicity and associated infectious disease risks have not been studied. The bacterial pathogen Salmonella typhimurium was grown aboard Space Shuttle mission STS-115 and compared with identical ground control cultures. Global microarray and proteomic analyses revealed that 167 transcripts and 73 proteins changed expression with the conserved RNA-binding protein Hfq identified as a likely global regulator involved in the response to this environment. Hfq involvement was confirmed with a ground-based microgravity culture model. Space flight samples exhibited enhanced virulence in a murine infection model and extracellular matrix accumulation consistent with a biofilm. Strategies to target Hfq and related regulators could potentially decrease infectious disease risks during space flight missions and provide novel therapeutic options on Earth.

Secondary glaucoma after paediatric cataract surgery

AIM

To determine the prevalence and risk factors associated with secondary glaucoma postcongenital cataract surgery.

METHODS

All children diagnosed as having congenital cataracts in a major children's hospital between 1985 and 2005 were included in a retrospective case series. Medical records of 423 eyes among 283 patients who underwent cataract surgery with or without intraocular lens implantation at age </=16 for congenital cataract were reviewed. The main outcome measure was presence or absence of secondary glaucoma and time to glaucoma postsurgery. The following risk factors were evaluated: age at cataract surgery, presence of systemic anomalies, microcornea, persistent hyperplastic primary vitreous (PHPV), primary capsulotomy/anterior vitrectomy, primary intraocular lens implantation, secondary membrane surgery and duration of postoperative observation.

RESULTS

The statistical methods were the use of Kaplan-Meier survival analysis and Multivariate Cox hazards regression analysis. The mean follow-up was 6.3 (SD 5.0) years (median 4.6 years; range 0.5 to 20.3 years). Glaucoma developed in 36 of 234 patients (15.4%). Multivariate Cox proportional hazards regression analysis identified age less than 9 months at time of surgery (RR 2.9, 95% CI 1.3 to 7.7; p = 0.03), microcornea (RR 3.7, 95% CI 2.0 to 7.0; p<0.001), and follow-up time as important predictors of glaucoma. PHPV (RR 1.4, 95% CI 0.7 to 2.7; p = 0.41) and primary posterior capsulotomy/anterior vitrectomy (RR 2.2, 95% CI 0.9 to 5.5; p = 0.17) were not significantly associated with secondary glaucoma in the multivariate model. The mean time to glaucoma after congenital cataract surgery was 4.9 years (range 2 weeks to 16.8 years).

CONCLUSION

Secondary glaucoma is an important sequela in patients who undergo surgery for congenital cataracts. It is imperative that these patients get lifelong surveillance, as glaucoma can occur years after the initial operation.

Genome complexity in acute lymphoblastic leukemia is revealed by array-based comparative genomic hybridization

Chromosomal abnormalities are important for the classification and risk stratification of patients with acute lymphoblastic leukemia (ALL). However, approximately 30% of childhood and 50% of adult patients lack abnormalities with clinical relevance. Here, we describe the use of array-based comparative genomic hybridization (aCGH) to identify copy number alterations (CNA) in 58 ALL patients. CNA were identified in 83% of cases, and most frequently involved chromosomes 21 (n=42), 9 (n=21), 6 (n=16), 12 (n=11), 15 (n=11), 8 (n=10) and 17 (n=10). Deletions of 6q (del(6q)) were heterogeneous in size, in agreement with previous data, demonstrating the sensitivity of aCGH to measure CNA. Although 9p deletions showed considerable variability in both the extent and location, all encompassed the CDKN2A locus. Six patients showed del(12p), with a common region encompassing the ETV6 gene. Complex CNA were observed involving chromosomes 6 (n=2), 15 (n=2) and 21 (n=11) with multiple regions of loss and gain along each chromosome. Chromosome 21 CNA shared a common region of gain, with associated subtelomeric deletions. Other recurrent findings included dim(13q), dim(16q) and enh(17q). This is the first report of genome-wide detection of CNA in ALL patients using aCGH, and it has demonstrated a higher level of karyotype complexity than anticipated from conventional cytogenetic analysis.

Retinal vascular caliber and risk of retinopathy in young patients with type 1 diabetes

OBJECTIVE

To examine the relationship between retinal vascular caliber and incident retinopathy in children and adolescents with type 1 diabetes mellitus.

DESIGN

Hospital-based case-control study with prospective outcomes.

PARTICIPANTS

Cases and controls were selected from a cohort of children and adolescents 12 to 20 years old with type 1 diabetes followed up at a tertiary diabetes clinic. Cases were patients who developed incident diabetic retinopathy (n = 166) after at least 1 year of follow-up (> or =2 clinic visits), and controls were patients who had not developed retinopathy (n = 165) after > or =2 years of follow-up (> or =3 clinic visits). Baseline retinal photographs of cases and controls were digitized, and retinal vascular calibers were measured using a computer-assisted program by a grader masked to case-control status. These measurements were combined into summary indices reflecting the average arteriolar and venular calibers.

MAIN OUTCOME MEASURE

Development of diabetic retinopathy.

RESULTS

Incident retinopathy cases had retinal arteriolar calibers (mean +/- standard deviation [SD], 206.5+/-18.4 microm) significantly larger than those of controls (200.2+/-16.5 microm) (P = 0.004) but similar retinal venular calibers (329.1+/-14.7 microm in cases vs. 326.4+/-15.1 microm in controls, P = 0.312). After adjusting for age, gender, diabetes duration, glycated hemoglobin levels, blood pressure, body mass index, and pubertal stage, larger arteriolar caliber was predictive of risk of diabetic retinopathy (odds ratio, 1.44 per SD increase in arteriolar caliber; 95% confidence interval, 1.11-1.86).

CONCLUSION

Larger retinal arteriolar caliber predicts incident retinopathy in children and adolescents with type 1 diabetes, independent of conventional risk factors for retinopathy. Measurement of retinal vascular caliber may provide prognostic information regarding the subsequent risk of diabetic retinopathy.

Intermittent exotropia: comparison of treatments

PURPOSE

To identify the best treatment option for intermittent exotropia.

METHODS

A retrospective analysis of the progress of 150 treated intermittent exotropia patients was performed. Treatment forms considered are: (i) surgery combined with orthoptic/occlusion therapy; (ii) surgery; (iii) orthoptic/occlusion therapy; and (iv) observation. Pearson's chi(2)-analysis of association of therapy form with success was performed. Reduction of exodeviation in prism dioptres between groups and subgroups were compared at 6 months, 1, 2 and 5 years follow up and the "within group" variations were compared. Exodeviation reduction in prism dioptres per millimetre of horizontal rectus surgery performed in the "surgery with orthoptic/occlusion therapy" and "surgery only" groups were compared.

RESULTS

Chi(2)-analysis revealed a significantly highest (P < 0.001) association with success in the "surgery with orthoptic/occlusion therapy" group at follow up. ANOVA analysis revealed that surgery with orthoptic/occlusion therapy resulted significantly (P < 0.001) in the highest reduction of exodeviation as compared with the other three treatment modalities at each follow up. Reduction of exodeviation in prism dioptres per millimetre of horizontal rectus surgery performed was significantly higher (P < 0.05) in the surgery with orthoptic/occlusion therapy group as compared with surgery only at all follow ups. Chi(2)-test revealed no significant association of success with the magnitude of initial exodeviation (P > 0.05).

CONCLUSION

Surgery with preoperative orthoptic/occlusion therapy had the highest success rates. Surgery with orthoptic/occlusion therapy was more effective in reducing exodeviation (prism dioptres per millimetre of horizontal rectus surgery), compared with surgery only.

Prevalence of diabetes complications in adolescents with type 2 compared with type 1 diabetes

OBJECTIVE

To compare the prevalence of diabetes complications and their risk factors in youth with type 1 versus type 2 diabetes.

RESEARCH DESIGN AND METHODS

We performed a comparative clinic-based study of 1,433 patients with type 1 diabetes and 68 patients with type 2 diabetes aged <18 years from New South Wales, Australia. Retinopathy was assessed by seven-field stereoscopic retinal photography; albumin excretion rate from three consecutive, timed, overnight urine collections; peripheral neuropathy by thermal and vibration threshold; and autonomic neuropathy by pupillometry. HbA(1c) (A1C) and lipids were measured in all patients and C-peptide in patients with type 2 diabetes.

RESULTS

In patients with type 1 versus type 2 diabetes, median (interquartile range) age was 15.7 years (13.9-17.0) and 15.3 years (13.6-16.4), respectively (P = 0.2), whereas median diabetes duration was 6.8 years (4.7-9.6) and 1.3 years (0.6-3.1), respectively (P < 0.0001). Retinopathy was significantly more common in patients with type 1 diabetes (20 vs. 4%, P = 0.04), while microalbuminuria and hypertension were significantly less common (6 and 16% in type 1 diabetes vs. 28 and 36% in type 2 diabetes). Rates of peripheral and autonomic neuropathy were similar (27 and 61% in type 1 diabetes vs. 21 and 57% in type 2 diabetes). In multivariate analyses, microalbuminuria was significantly associated with older age (odds ratio 1.3 [95% CI 1.2-1.5], P < 0.001) and systolic hypertension (3.63 [2.0-6.3], P < 0.001) in type 1 diabetes, while only higher A1C (1.7 [1.3-2.9], P = 0.002) was significant in patients with type 2 diabetes.

CONCLUSIONS

Youth with type 2 diabetes have significantly higher rates of microalbuminuria and hypertension than their peers with type 1 diabetes, despite shorter diabetes duration and lower A1C. The results of this study support recommendations for early complications screening and aggressive targeting of glycemic control in patients with type 2 diabetes.

Discordant trends in microvascular complications in adolescents with type 1 diabetes from 1990 to 2002

OBJECTIVE

Since the Diabetes Control and Complications Trial, diabetes management goals have changed. The aims of the present study were to assess complication rates, including nerve abnormalities, in adolescents from 1990 to 2002 and to investigate associated risk factors.

RESEARCH DESIGN AND METHODS

Cross-sectional analysis of complications was assessed in three study periods (1990-1994 [T1], 1995-1998 [T2], and 1999-2002 [T3]) in adolescents matched for age and diabetes duration (n = 878, median age 14.6 years, median duration 7.5 years). Retinopathy was assessed by seven-field stereoscopic fundal photography, albumin excretion rate (AER) from three consecutive timed overnight urine collections, peripheral nerve function by thermal and vibration thresholds, and autonomic nerve function by cardiovascular reflexes.

RESULTS

Retinopathy declined significantly (T1, 49%; T2, 31%; and T3, 24%; P < 0.0001), early elevation of AER (> or = 7.5 microg/min) declined (38, 30, and 25%, respectively, P = 0.022), and microalbuminuria (AER > or = 20 microg/min) declined (7, 3, and 3%, respectively; P = 0.017, T1 vs. T2 and T3). Autonomic nerve abnormalities were unchanged (18, 21, and 18%, respectively; P = 0.60), but peripheral nerve abnormalities increased (12, 19, and 24%, respectively; P = 0.0017). More patients were treated with three or more injections per day (12, 46, and 67%, respectively; P < 0.0001) and insulin dose increased (1.08, 1.17, and 1.22 units x kg(-1) x day(-1), respectively; P < 0.0001), but median HbA(1c) (A1C) was unchanged (8.5, 8.5, and 8.4%, respectively). BMI and height SD score increased: BMI 0.46, 0.67, and 0.79, respectively (P < 0.0001), and height -0.09, 0.05, and 0.27, respectively (P < 0.0001).

CONCLUSIONS

Retinopathy and microalbuminuria declined over time in this cohort, but the increased rate of peripheral nerve abnormalities is of concern. Despite intensified management (higher insulin dose and more injections), A1C has not changed and remains well above the recommended targets for adolescents.

The case for biennial retinopathy screening in children and adolescents

OBJECTIVE

Current guidelines recommend annual retinopathy screening 2 years after onset (for pubertal-onset type 1 diabetes) and after 5 years (or age 11, whichever is earlier) for prepubertal onset. Our aim was to describe the natural history of retinopathy and to explore optimal retinal screening intervals for children and adolescents (aged <20 years) screened according to these guidelines.

RESEARCH DESIGN AND METHODS

More than 1,000 children and adolescents, followed longitudinally, were screened for retinopathy using seven-field stereoscopic fundus photography through dilated pupils. Of these, 668 had baseline and follow-up retinal screening. Using generalized estimating equations, we compared the risk of retinopathy with baselines at yearly intervals, in older and younger groups, in higher risk groups (diabetes duration >10 years or HbA(1c) >10% at any screening), and after stratification </=10 and <10 years in duration.

RESULTS

After 1 year, retinopathy did not increase significantly in the older group (n = 618, median HbA(1c) 8.7%, range 8.0-9.5), younger group (n = 50, median HbA(1c) 8.5%, range 8.0-9.2), or the higher-risk groups. Retinopathy increased significantly after 2 years in the older group (P = 0.003) but not until 6 years in the younger group (P = 0.01). In the group with HbA(1c) >10% recorded at any visit, retinopathy increased significantly after 2 years (P = 0.001) but not until 3 years in the group whose HbA(1c) was always </=10% (P = 0.003). After the second eye assessment, retinopathy did not increase significantly until 3 and 6 years later in the older and younger groups, respectively (P = 0.028 and 0.014).

CONCLUSIONS

These results suggest that adolescents (in reasonable metabolic control) could safely be screened every 2 years rather than the currently recommended 1-year interval. In younger children, the next screening interval could be >2 years later. Individuals with especially poor control, duration >10 years, or significant retinopathy should be screened more frequently.

A visual field abnormality: ocular or cerebral cause?

The visual field can be affected by disorders involving any part of the visual pathway, from the retina to the striate cortex. The pattern of visual field damage can indicate the location of the disorder. The case is presented here of an 8-year-old girl with congenital glaucoma. Initial perimetry appeared consistent with glaucomatous field loss; however, this evolved into a homonymous quadrantanopia, indicating the presence of a cerebral lesion as the cause. Computed tomography and magnetic resonance imaging scans detected a large middle cranial fossa arachnoid cyst. Postoperatively there was resolution of the visual field defects secondary to the arachnoid cyst. The pattern of field loss was pivotal in this patient's management. Attention must be paid when caring for the patient with a chronic disease to ensure that concurrent conditions are diagnosed.

Do all prepubertal years of diabetes duration contribute equally to diabetes complications?

OBJECTIVE

This study was designed to explore the timeline of protection against complications in prepubertal children with diabetes, in particular the effects of diabetes duration before age 5 years.

RESEARCH DESIGN AND METHODS

In this study, 193 adolescents with prepubertal diabetes onset were followed longitudinally for retinopathy (early background and clinical) and microalbuminuria (albumin excretion rate >7.5 micro g/min and >20 micro g/min). Multiple logistic regression analysis was used to compare the effect of pre- and postpubertal diabetes duration on the risk of each complication in 90 subjects reassessed as young adults. For the entire cohort, Kaplan-Meier estimates were used to determine time free of each complication, and survival was compared in those diagnosed before and after age 5 years. Accelerated failure time modeling was used to estimate the effect of covariates, including diabetes duration before puberty, on the risk of complications.

RESULTS

Prepubertal duration improved the prediction for retinopathy over postpubertal duration alone in the young adults. The survival-free period of retinopathy and microalbuminuria was significantly longer (2-4 years) for those diagnosed before age 5 years compared with those diagnosed after age 5 years. Time to onset of all complications increased progressively with longer diabetes duration before gonadarche. Higher HbA(1c) during adolescence had an independent effect on the risk of retinopathy and microalbuminuria.

CONCLUSIONS

Prepubertal diabetes duration remains a significant predictor of retinopathy in young adults. The effect of time on the risk of retinopathy and microalbuminuria is nonuniform, with an increasing delay in the onset of complications in those with longer prepubertal duration. These findings are of major clinical importance when setting targets of glycemic control in young children who are at greatest risk of hypoglycemia.

Gain of 1q is associated with adverse outcome in favorable histology Wilms' tumors

Although several genes/genetic loci involved in the etiology of Wilms' tumor have been identified, little is known of the molecular changes associated with relapse. We therefore undertook an analysis by comparative genomic hybridization (CGH) of 58 tumor samples of favorable histology Wilms' tumor taken at initial diagnosis and/or relapse. Tumors with anaplastic histology were excluded as this is known to be associated with p53 mutation and a poor prognosis. A control group of 21 Wilms' tumors that did not relapse was also analyzed. The overall frequency of gains or losses of genetic material detected by CGH was similar in both groups (77% in relapsing tumors and 70% in the nonrelapse group) as was the median number of changes per tumor (relapse group: n = 4, range, 1 to 19; nonrelapse group: n = 3, range, 1 to 8). However, gain of 1q was significantly more frequent in the relapse series [27 of 46 (59%) versus 5 of 21 (24%), P: = 0.019]. In 12 matched tumor pairs, the CGH profiles, including 1q gain, were similar at diagnosis and relapse, with little evidence for further copy number changes being involved in clonal evolution. The results suggest that 1q gain at diagnosis could be used to identify patients with favorable histology Wilms' tumor at increased risk of relapse who might benefit from early treatment intensification.

The effect of prepubertal diabetes duration on diabetes. Microvascular complications in early and late adolescence

OBJECTIVE

To define the significance of prepubertal diabetes duration in the development of diabetic microvascular complications in adolescents.

RESEARCH DESIGN AND METHODS

Study A compares complications in 38 prepubertal (PreP) and 140 pubertal (Pub) subjects of the same age (10-14 years) and diabetes duration (3-12 years) to determine if the absence of puberty itself confers a lower risk of complications. Study B examines the importance of prepubertal and pubertal diabetes duration in 193 older adolescents (ages 15-22 years) with prepubertal onset of diabetes. Retinopathy status was assessed using stereoscopic fundus photography of seven fields per eye. Albumin excretion rate (AER) was assessed by three consecutive overnight urine collections, using a polyclonal radioimmunoassay.

RESULTS

In study A, there were no significant differences between the PreP and Pub groups for retinopathy (27 vs. 29%, P = 0.8) or differences in elevated AER (17 vs. 31%, P = 0.1). In study B, longer prepubertal diabetes duration improved the prediction for retinopathy over postpubertal duration alone (P < 0.0005). No relationship with duration was found for elevated AER (> 7.5, > 15, and > 30 micrograms/min).

CONCLUSIONS

Prepubertal subjects with diabetes did not have less retinopathy or elevated albumin excretion compared with pubertal subjects of the same age. Prepubertal diabetes duration is significantly related to the presence of retinopathy in adolescents.

Serologic and DNA follow-up data from HBsAg-positive patients treated with orthotopic liver transplantation

Fifteen hepatitis B surface antigen (HBsAg) positive patients treated with orthotopic liver transplantation were studied to determine whether any clinical, serologic, or histologic data were predictive for recurrent hepatitis B infection leading to graft failure. Six patients died early, one due to primary graft nonfunction and the remaining five due to septic complications. There were nine patients surviving longer than two months, eight of whom are alive at a mean follow-up of 556 days. HBsAg and hepatitis B core antibody (anti-HBc) reappeared in the sera of all survivors after a variable transient period of clearance. One patient died 3 months posttransplant of fungal sepsis and was found to have histologic evidence for recurrent hepatitis and positive immunoperoxidase staining postmortem. The remaining eight survivors are home and clinically well, with no histologic evidence of hepatitis. Seven of these eight patients have hepatitis B viral DNA in their sera. We conclude that while there is a high early mortality, usually from sepsis, none of the serologic, histologic, or DNA data analyzed can be used to predict graft loss from recurrent hepatitis. No grafts have been lost due to recurrent hepatitis B in this series, and therefore we believe that HBsAg positive patients should not be excluded from transplantation.

Bilateral blinding uveitis in a child after secondary intraocular lens implantation for unilateral congenital cataract

A 3-year-old boy underwent secondary implantation of an iris supported intraocular lens following extraction of a unilateral congenital cataract. Eight months later, he developed a bilateral plastic uveitis which, in spite of intensive medical treatment, resulted in NPL (no perception of light) in the implanted eye and 2/60 vision in the fellow eye. Sympathetic ophthalmia possibly played a role in the pathogenesis of the uveitis.

Postoperative endophthalmitis in children following cataract surgery

Three children developed endophthalmitis after cataract surgery. Each had signs and symptoms of either nasolacrimal duct obstruction or upper respiratory infection at the time of surgery. The causative organisms were Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus pneumoniae. Final visual acuities were 6/24, LP, and NLP, respectively. Endophthalmitis after cataract surgery in infants has never been reported. These three cases drawn from two pediatric ophthalmology practices represent an incidence of postoperative endophthalmitis of 0.45%. Although this incidence report is potentially spurious, it indicates that postoperative endophthalmitis is a very real threat in infants. We recommend a thorough systems review and exam of upper airways and lacrimal system before undertaking intraocular surgery in young children. We also caution against simultaneous bilateral surgery.

Hemifacial spasm in infancy

Three infants presented with the onset of hemifacial spasm after birth and at the age of 10 months. One patient was found to have occlusion of the straight sinus and large collateral veins at the base of the brain, presumably due to venous sinus thrombosis, supporting the concept of vascular compression of the facial nerve at its exit from the brain stem as a mechanism for the production of hemifacial spasm. The other patients each had an intrinsic mass compressing the fourth ventricle, located in the lower pons and extending into the cerebellar vermis and right cerebellar peduncle in one; in the other patient, the mass involved the cerebellar vermis and right middle cerebellar peduncle alone. These patients widen the etiologic spectrum of the syndrome and show that serious intracranial diseases may underlie hemifacial spasm in infancy.

Complete cryptophthalmos: case report with normal flash-VEP and ERG

We report an infant with bilateral complete cryptophthalmos as part of Fraser Syndrome. Clinical examination and recordings of the electroretinogram and flash visual evoked potential showed a functional visual pathway at retinal and post-retinal levels. Anatomical considerations and the possible complications of surgery made reconstruction of the lids and palpebral fissures inappropriate.

Lens surgery in infancy and childhood

The medical records of 224 children who had lens surgery performed at the Hospital for Sick Children during the 10-year period 1978-88 were reviewed. There were 12 children with ectopia lentis; these patients achieved a mean postoperative acuity of 0.68 (6/8.8), and no operative or postoperative complications were noted. Two hundred and twelve children had lens surgery for cataracts or for retrolental abnormalities with a clear lens. Children with bilateral congenital cataracts achieved a mean acuity in the better eye of 0.32 (6/18). In a series of carefully controlled unilateral congenital cataracts the visual results were poor. The postoperative complication rate for cataract and clear lens surgery was 4.6%. Because visual results are probably better with early surgery we emphasise that every newborn baby should be tested for media opacities.

De novo deletion of Xp22.2-pter in a female with linear skin lesions of the face and neck, microphthalmia, and anterior chamber eye anomalies

A female infant is described with an unusual combination of eye and skin findings. Raw linear skin lesions on the face and neck were present at birth, healing to leave pigmented streaks. In addition she had left sided microphthalmia and bilateral sclerocornea. Chromosome analysis showed a terminal deletion of the short arm of the X chromosome (Xp22.2--pter). Clinical findings were similar to three previously described children with translocations involving Xp22.3. The condition probably represents a new syndrome distinct from incontinentia pigmenti and Goltz syndrome.

Multiple tandem 18-kb sequences clustered in the region of the acute promyelocytic leukemia breakpoint on chromosome 17

This paper describes the cloning of an 18-kb sequence present in approximately 30 copies on chromosome 17. Most of these are clustered in the region of the breakpoint associated with acute promyelocytic leukemia (APL). These copies map both above and below the breakpoint, and pulsed field gel analysis indicates that the majority of these sequences lie within a region of approximately 2 megabases. The organization of these sequences appears to be that of large imperfect palindromes.

Assignment of complement components C4 binding protein (C4BP) and factor H (FH) to human chromosome 1q, using cDNA probes

Using cDNA probes for Factor H (FH) and C4 binding protein (C4BP) on a panel of somatic cell hybrids, we show that both of these genes map to the long arm of chromosome 1.

Regional localization of CD18, the beta-subunit of the cell surface adhesion molecule LFA-1, on human chromosome 21 by in situ hybridization

The gene coding for the beta-subunit of the cell surface adhesion glycoprotein LFA-1 has been localized to the tip of the long arm of chromosome 21 at 21q22.1-qter.