A pragmatic approach to amblyopia diagnosis: evidence into practice.

Amblyopia is a common cause of reduced vision in children. The clinical diagnosis is complicated and requires consideration of the severity of vision loss relative to the characteristics of the disrupting amblyogenic factor. Added to the challenge of a thorough examination of very young children, is the weight of consequence if the amblyogenic factor is not identified and treated appropriately within clinically recommended time frames. Further, the poor visual function may be a symptom of more sinister underlying pathology impacting the visual pathway. This review presents an evidence-based, pragmatic approach to the diagnosis of amblyopia, as a means for guiding best practice for the care of children who present with reduced vision.

A Novel Method of Extending Glaucoma Drainage Tube: "Tube-in-Tube" Technique.

PURPOSE: To describe a new and simple technique of glaucoma tube extension that carries several advantages over previously described techniques. PATIENTS AND METHODS: A retrospective noncomparative case series of 3 patients (1 adult and 2 pediatric cases) with glaucoma tube retraction managed by the "tube-in-tube" technique. The follow-up duration ranges from 1 month to 3 years. RESULTS: Adequate tube position and length were seen in all cases throughout the follow-up period. No tube migration was seen. The intraocular pressures were significantly reduced and maintained in all cases. There was no visual loss as a result of the procedure. CONCLUSIONS: This new "tube-in-tube" glaucoma drainage device tube extension technique is safe and simple to perform, and has many advantages over previously reported techniques. It can be used in both the adult and pediatric glaucoma population, and is not limited to the type of drainage implants.

Use of the electroretinogram in a paediatric hospital.

BACKGROUND: To review the use of electroretinography and identify common reasons for referral and diagnoses at a tertiary paediatric hospital. DESIGN: Retrospective cohort study. PARTICIPANTS: Three hundred and eighteen patients (male 195, female 123) aged <18 years with 388 electroretinograms were included. METHODS: All electroretinograms performed at the Royal Children's Hospital, Brisbane from 1998 to 2005 were reviewed. Normative data and electroretinograms from patients aged ≥18 years were excluded. MAIN OUTCOME MEASURES: Reasons for referral and diagnoses were determined from each patient's first electroretinogram. Concordance between the first electroretinogram diagnosis and clinical referral was reviewed to determine whether the electroretinogram was normal, inconclusive, confirmed, excluded, or changed the clinical diagnosis or provided a new diagnosis. RESULTS: The median age at the time of the first investigation was 3.78 years (range 2.6 weeks to 17.5 years). The most common reasons for referral were nystagmus (n = 93), decreased vision (n = 33) and sensorineural deafness (n = 29). After one electroretinogram, 51% were normal (n = 162) and 15% were inconclusive (n = 49). The most common electroretinography diagnosis was cone rod dystrophy. The first electroretinogram for each patient confirmed the clinical suspicion in 17.6% (n = 56) and excluded it in 23% (n = 73) of cases. The electroretinogram resulted in a changed diagnosis in 0.9% (n = 3) and provided a new diagnosis in 15.1% (n = 48). Overall, the first electroretinogram was considered useful in 85% cases (n = 269). CONCLUSIONS: Electroretinography is a valuable investigation for evaluating paediatric eye disease and in this series confirmed, excluded, changed or provided a new diagnosis in 85% of cases.

Syphilitic uveitis: a review of clinical manifestations and treatment outcomes of syphilitic uveitis in human immunodeficiency virus-positive and negative patients.

The incidence of syphilis and syphilitic uveitis in our community is increasing. The prevalence of associated neurosyphilis is unknown, and it remains unclear whether syphilitic uveitis should be treated as secondary syphilis with intramuscular penicillin or neurosyphilis with intravenous penicillin. The (English language) literature was reviewed for all unique cases of syphilitic uveitis reported from 1984 to June 2008. For each case the following data were recorded: the clinical features of the syphilis, the uveitis and any associated neurosyphilis, the human immunodeficiency virus (HIV) status, lumbar puncture findings, treatment and follow up. We identified 143 patients in 41 original reports of syphilitic uveitis (93 HIV-positive and 50 HIV-negative). Posterior uveitis was reported in 79 patients (55.2%); panuveitis was reported in 36 patients (25.2%); anterior/intermediate uveitis was reported in only 28 patients (19.6%). Lumbar puncture findings were abnormal in 82 patients (57%), and the majority of these patients (76%, 62 out of 82) were HIV-positive. One hundred and ten (77%) patients were treated with intravenous therapy, usually penicillin. Most recovered from the syphilis, however, a proportion did not recover full vision. There were 13 (9%) treatment failures, which tended to occur in patients who were HIV-positive (n = 11), had abnormal lumbar puncture findings (n = 8) and/or were treated (n = 11) intravenously. There is a high incidence of abnormal lumbar puncture findings in patients with syphilitic uveitis and a strong association with HIV infection. Most received appropriate therapy with a low relapse rate, which was not related to the type of therapy.

An unusual cause of visual loss after Herpes zoster ophthalmicus: a case report.

INTRODUCTION: The vascular complications of herpes zoster are well recognised, however, there are few reports of central retinal artery occlusion. Central retinal artery occlusion following herpes zoster ophthalmicus is poorly recognised. This is likely due to the difficulties in obtaining tissue for histopathology to establish causality. We report a case of central retinal artery occlusion and complete internal carotid artery occlusion following herpes zoster ophthalmicus. CASE PRESENTATION: A 44 year old Caucasian female presented with sudden painless loss of vision in her right eye on a background of chronic lymphocytic leukaemia and right sided herpes zoster ophthalmicus. She was initially treated with steroids and antivirals for an underlying presumed vasculitic cause, but review at 24 hours demonstrated a right central retinal artery occlusion. Embolic screen identified complete occlusion of the right internal carotid artery. She was treated with oral antiviral medication for three weeks but had no visual recovery. CONCLUSION: This case highlights an uncommon cause of acute visual loss. We propose that the underlying small and large vessel occlusion in this patient was due to herpes zoster related vasculopathy. A review of the literature is presented to trace the historical perspective of herpes zoster related vasculopathy.

Juvenile idiopathic arthritis associated uveitis in adults: a case series.

PURPOSE: To report a series of adults with uveitis following juvenile idiopathic arthritis (JIA) and uveitis as children. METHODS: The clinical features, treatment, complications, and visual outcome were ascertained for 17 patients at a single centre. RESULTS: Seventeen adults with previously diagnosed JIA and ongoing uveitis (30 eyes) were identified. All required at least topical steroids. The complication rate was high (15 patients, 23 eyes), most frequently cataract (57%), glaucoma (33%), and posterior synechiae (30%). The rate of visual acuity loss to 6/12 threshold (6/12 or worse) for patients with uveitis < 15 years (Group A) was 13.3%, (and 6.7% to 6/60 threshold) and for patients with uveitis >15 years (Group B) was 26.7% (and 20% to 6/60 threshold). Overall, the rate of visual acuity loss to 6/12 threshold was 20% (6 eyes) and to 6/60 threshold, 13.3% (4 eyes). CONCLUSIONS: JIA may be associated with ongoing uveitis and complications in adulthood.