Education and training of referring physicians decreases at-home call demand.

BACKGROUND: Excessive, sometimes unnecessary consultation challenges the ophthalmology resident's ability to obtain adequate rest and personal time while taking at-home calls. Basic training of nonophthalmologists in assessing and treating common ophthalmic emergencies offers a potential solution to this problem by providing primary caregivers the knowledge base, tools, and confidence to manage them independently. OBJECTIVE: We measured ophthalmic consultation requests at a large teaching institution and the impact of an educational intervention on the number and type of requests. METHODS: During a 31-day period in 2009 all requests for urgent ophthalmic consultation were logged and characterized by reason, urgency, and source of the call. A 3-part educational intervention was targeted to residents and attending physicians in the departments of emergency medicine (half-day lecture and practice), anesthesiology (grand rounds lecture), and otolaryngology (guidelines for traumatic orbital fractures). Six months later we conducted a 26-day call log to evaluate the impact. RESULTS: Pre intervention, we received 63 total and 56 after-hours calls for urgent ophthalmic consultation as compared to 39 total and 35 after-hours calls post intervention. Ophthalmology residents reported seeing more urgent and fewer nonessential consultations in the postintervention period, and there was greater agreement between calling physicians' initial diagnosis and consulting physicians' final diagnosis. No adverse patient outcomes occurred as a result of the change in practices. CONCLUSION: Basic education of nonophthalmologists in ophthalmic diagnostic and treatment concepts, through relatively brief educational interventions, was associated with a decrease in total consultation requests and more appropriate consultations in this pilot study at a single institution.

The spontaneous resolution of primary congenital glaucoma.

PURPOSE: To describe the ocular findings in a series of children with spontaneous resolution of primary congenital glaucoma (PCG). METHODS: The medical records of 356 patients with PCG were reviewed. Nine patients with spontaneous resolution of PCG were studied. Fourteen of 18 eyes possessed evidence of early glaucoma, were found to have normal intraocular pressures, and were clinically classified as having spontaneous resolution of PCG. None of the eyes with spontaneous resolution received surgery or any glaucoma medication. RESULTS: Spontaneous resolution of PCG in all nine patients was recognized after 4 months of age. At the time of diagnosis, large corneas were observed in all affected eyes and Haab's striae in 10 of 14 eyes. Intraocular pressures were normal in 14 eyes. In all 14 eyes, the anterior chambers were deep, the lenses were clear, and the angles were abnormal with the typical appearance of PCG. The eyes with spontaneous resolution of PCG possessed angle abnormalities that were less severe compared to three fellow eyes that required glaucoma treatments. CONCLUSION: The occurrence of spontaneous resolution of PCG in these patients is supported by objective clinical evidence. The explanation for this spontaneous resolution is unknown. Its mechanism could be related to continued postnatal development of the angle structures in eyes possessing milder angle abnormalities. The anterior segment findings in patients with spontaneous resolution of PCG are similar to those of patients with treated PCG, the intraocular pressures are normal, the optic nerve damage is stable, and the filtration angles possess mild or moderate abnormalities.

Isolated subconjunctival hemorrhages in nonaccidental trauma.

PURPOSE: To establish child abuse as part of the differential diagnosis of isolated bilateral subconjunctival hemorrhages in infants. METHODS: To review three cases of nonaccident trauma initially presenting with isolated bilateral subconjunctival hemorrhages as the only significant clinical finding. RESULTS: Ophthalmic examination in cases 1 and 2 were entirely normal except for the large bilateral subconjunctival hemorrhages. Hematological parameters were normal in all three infants. Initial radiological findings were normal in case 1 but multiple healing rib fractures were identified when the chest X-ray was repeated 3 weeks later. Case 2 had skin and skeletal X-ray findings compatible with abuse at time of presentation to the ophthalmologist. Case 3 was admitted to hospital for multiple unexplained limb fractures but had been seen 2 weeks prior for poorly explained bilateral isolated subconjunctival hemorrhages and facial petechiae. CONCLUSION: Nonaccidental trauma should be considered in the differential diagnosis of bilateral isolated subconjunctival hemorrhages in infants especially if associated with facial petechiae. These isolated subconjunctival hemorrhages may be part of the traumatic asphyxia syndrome caused by severe, prolonged compression of the child's chest and upper abdomen. Appropriate assessment includes a complete ophthalmic and pediatric examination as well as hematological testing and imaging studies. If the coagulation profile and initial imaging studies are normal yet there remains a high suspicion of abuse, an immediate nuclear scan or a repeat skeletal survey or chest film 2 weeks later is indicated.

Vitrectomy for dense vitreous hemorrhage in infancy.

PURPOSE: To report clinical data, including etiology and visual outcome, in newborns requiring vitrectomy for dense vitreous hemorrhage. METHODS: In this retrospective case series, we surveyed subscribers to the American Association for Pediatric Ophthalmology and Strabismus ListServe regarding patients under their care. RESULTS: A total of 28 eyes of 21 patients were included. Most common etiologies were thrombocytopenia, shaken baby syndrome, and birth trauma. In 9 cases (12 eyes), the vitreous hemorrhage was idiopathic. Mean time between diagnosis and surgery was 1.4 months. Complications included strabismus, cataract, glaucoma, high myopia, and retinal detachment. Recognition visual acuities were available for 8 eyes: 20/25 (2 eyes), 20/30, 20/40 (2 eyes), 20/60 (2 eyes), and 20/100. One eye had no light perception. CONCLUSIONS: The etiologies encountered in our patients were similar to those reported previously. Visual outcomes were much worse in cases with retinal complications. Other patients had better visual outcomes. Despite potential surgical and postoperative complications, this series demonstrates favorable visual outcomes can be achieved following early vitrectomy in this setting.

Phenotypic variations in patients with a 1630 A>T point mutation in the PAX6 gene.

BACKGROUND: The extreme clinical case-to-case variability of aniridia, even within families, can cause difficulties in making the correct diagnosis, prognosis and treatment plan. We describe seven patients from two families demonstrating variable expression of this syndrome, all with the same single point mutation within the PAX6 gene. METHODS: Case presentations. The authors review the clinical ophthalmic findings of the aniridia-keratopathy syndrome from two families, one involving four generations, the other with two generations. Polymerase chain reaction amplification of all 14 exons of the PAX6 gene was performed for five patients. RESULTS: The iris findings varied from classic total absence to nearly normal iris appearance. Corneal changes were minimal in the younger patients but vision-impairing in the older. None of the patients had glaucoma. The five patients who underwent DNA analysis shared the same PAX6 point mutation defect (1630A>T). INTERPRETATION: Bilateral corneal changes progressing from mild opacification at the limbus to vascularized central keratopathy, especially in the presence of nystagmus, are highly suggestive of a PAX6 mutation. Such patients may theoretically benefit from early limbal stem cell replacement therapy.

Clinical comparison of the Welch Allyn SureSight handheld autorefractor versus cycloplegic autorefraction and retinoscopic refraction.

PURPOSE: To investigate the accuracy of the Welch Allyn SureSight (WASS; Welch Allyn, Skaneateles Falls, New York) hand-held autorefractor in noncyclopleged children and to compare the results with those obtained in cyclopleged children using the Nidek AR-820 (NAR; Nidek, Aichi, Japan) and retinoscopic refraction (RR) of an experienced pediatric ophthalmologist. METHODS: Ninety-one children (mean age 97 months +/- 19, range 37 to 107) whose vision screening, performed by a school nurse and/or by their primary care provider, was unsuccessful were prospectively evaluated in the private practice of a university pediatric ophthalmologist. After completion of a history, each child was refracted using the WASS. A complete ophthalmic examination, including cycloplegic refraction using the NAR and retinoscopic refraction refined to obtain a visual acuity of at least 20/30 diopters, was then performed. The physician was masked to the previous WASS and NAR results. Analysis variables included race, age (months), refraction (sphere, cylinder, axis), and initial and final corrected visual acuity. Only WASS values for which reliability was > or = 8 were used. A coin toss determined which eye would be used for analysis. RESULTS: Using analysis of variance and Scheffé multiple comparison testing, sphere results obtained by the WASS indicated a statistical difference compared with those obtained using the NAR (P =.0027) and retinoscopy (P =.0088). Similarly, spherical equivalence results obtained by the WASS also indicated a statistical difference compared with that of the NAR (P =.0027) and retinoscopy (P =.0056). Myopic sphere and spherical equivalent values were recorded more frequently with the WASS than with the NAR or refined retinoscopy. Cylindrical values comparing the WASS with the NAR, the WASS with RR, and the NAR with RR were statistically similar to each other (P =.9993,.748, and.7261 respectively). Axial results for patients with +0.50 or more of astigmatism were also statistically similar by all 3 methods. CONCLUSIONS: Our data indicate that when the WASS is used on noncyclopleged children as suggested for primary care providers, myopia may be overdiagnosed.

Intrauterine West Nile virus: ocular and systemic findings.

PURPOSE: To report the first documented case of intrauterine transmission of West Nile virus (WNV) with resulting congenital chorioretinal scarring and central nervous system malformation in a newborn. DESIGN: Case report. METHODS: Ophthalmic findings and laboratory data in an otherwise presumed healthy 2-day-old female are presented. The infant's mother developed paraplegia due to WNV during the second trimester of her pregnancy. The newborn's external and general physical examination were unremarkable. RESULTS: Ophthalmic examination disclosed marked chorioretinal changes, and magnetic resonance imaging of the brain demonstrated severe abnormalities. Serology for WNV was positive. Other causes of congenital chorioretinal changes were ruled out with the appropriate serology. CONCLUSIONS: Intrauterine transmission of WNV may result in significant ocular and neurologic morbidity. Titers for this important and emerging viral pathogen should be obtained when standard serologies are negative in an infant with congenital chorioretinal scarring.