Anticholinergic syndrome: blurred vision and headache.

A young woman presented with blurred vision due to anticholinergic syndrome. We highlight the importance of considering this condition in the context of multiple medications and increased anticholinergic burden. The documented pupil abnormality gives an opportunity to review the syndrome of the reverse (inverse) Argyll Robertson pupil (preserved pupil light response with loss of accommodation). We review other situations in which the reverse Argyll Robertson pupil may occur and its possible mechanism in this case.

Bilateral optic neuritis as a first presentation of lymph node tuberculosis.

Tuberculosis (TB) may affect the nervous system in many ways. We describe an immunocompetent teenage girl with lymph node TB who had first presented with bilateral optic neuritis. Detailed history identified features inconsistent with immune-mediated optic neuritis. Several unusual features prompted further investigation, including transient visual obscurations without raised intracranial pressure, prominent disc swelling and absence of laboratory findings to support an immune-mediated cause. Whole body PET/MR imaging identified widespread mediastinal and supraclavicular lymphadenopathy. Despite no known TB contacts, a negative interferon gamma release assay and a normal chest X-ray, a targeted lymph node biopsy confirmed TB.

Orbital abscess following posterior subtenon injection of triamcinolone acetonide.

Orbital cellulitis is a serious sight threatening and potentially life threatening condition which can be complicated by orbital abscess formation. Posterior subtenon (PST) injection of corticosteroid is commonly used in the treatment of posterior segment inflammation including post-operative macular oedema. We report a case of orbital abscess formation as a late complication of PST triamcinolone acetonide and discuss the presentation, diagnosis and management.

Incidental unilateral idiopathic maculopathy in children.

PURPOSE: To investigate the clinical findings and differential diagnosis of incidental unilateral discoid maculopathy in a case series of children. METHODS: The medical records and retinal imaging of children referred to a single center for flat, well circumscribed, hypopigmented discoid macular lesion in the left eye were reviewed retrospectively. RESULTS: Three children (age range, 4-11 years; 2 female), with no subjective ophthalmic complaints, were referred for investigation of a flat, well-circumscribed, hypopigmented discoid macular lesion in the left eye. Case 1 had a history of viral mesenteric adenitis, and case 2 had a history of hand, foot, and mouth disease. For case 3, no previous history of systemic viral infection was established. Snellen visual acuity was 20/20 for all 3 children. The lesion was located superior to the fovea for case 1 and centered to the fovea for cases 2 and 3, all in the left eye. In all 3 patients, hyperautofluorescent changes were noted around the edges of the lesion, which was roughly discoid. OCT showed subtle changes of the interdigitation zone and retinal pigment epithelium (RPE) for cases 1 and 2. In case 3 the presence of hyperreflective, hypertrophic tissue at the level of the interdigitation zone and/or the RPE was noted. CONCLUSIONS: In these 3 children with subclinical, unilateral discoid maculopathy sharing common features and identified incidentally, previous viral illness may have been causative. These cases may represent resolved unilateral acute idiopathic maculopathy.

Sclero-conjunctival ischaemia secondary to intra-arterial chemotherapy for retinoblastoma.

PURPOSE: Intra-arterial chemotherapy (IAC), delivered directly to the globe via the internal carotid artery is now an established treatment for retinoblastoma. We report a case of anterior segment ischaemia following treatment with multiple intra-arterial chemotherapy (IAC) infusions. OBSERVATIONS: A 5 month old female presented with bilateral retinoblastoma and was treated with 12 infusions of IAC. Her right eye was enucleated at diagnosis. After her seventh IAC treatment, she developed ipsilateral sixth and third cranial nerve palsies. After the twelfth IAC, she developed an area of conjunctival and scleral ischaemia between 12 and 3 o'clock meridians in her left eye. However, she maintained visual acuity of LogMAR 0.34. CONCLUSIONS AND IMPORTANCE: The median number of IAC treatments in large studies is three. It is possible that repeated doses of IAC have an accumulative negative effect on the ocular blood supply, risking anterior segment and neurologic sequelae. This case highlights the significant challenge of balancing the salvage of eyes and vision with the potentially significant morbidity associated with IAC.

Secondary glaucoma and visual axis opacification in aphakic and pseudophakic patients following congenital cataract surgery: A 28-year longitudinal case series.

PURPOSE: To determine the incidence, timing and risk factors for glaucoma and visual axis opacification development following surgery for congenital cataract in the first year of life. METHODS: A prospective case series of all cataract surgery performed in Temple Street Children's University Hospital over a 28-year period was conducted. A total of 93 subjects (135 eyes) were analysed. Sixty-two eyes had a primary intraocular lens inserted at the time of surgery; 73 eyes were aphakic. We recorded patient demographics, age at surgery, length of follow-up, rates and time to diagnosis of glaucoma and rates of visual axis opacification. Relative risk analysis was performed to identify potential risk factors for secondary glaucoma and visual axis opacification. RESULTS: Mean length of follow-up was 160.02 ± 64.42 months (13.3 years), range 40-336 months. Final mean LogMAR across all groups was 0.85 ± 0.51 (0.90). Overall 45 (33.33%) eyes developed secondary glaucoma, 12 (19.4%) in pseudophakic eyes and 33 (45.21%) in aphakic eyes. The incidence of glaucoma was highest in bilateral aphakia (relative risk 1.96, p = 0.0240) and in eyes with corneal diameter <9.5 mm (relative risk 1.93, p = 0.0364). There was no significant difference in glaucoma rates between pseudophakia and aphakia in those operated on less than 2.5 months of age. Secondary glaucoma occurred between 3 months to 16.5 years post surgery. Rates of visual axis opacification were lower in aphakia compared to pseudophakia (relative risk 0.59, p = 0.0098). CONCLUSION: Overall glaucoma rates of one-third are similar to those recorded in the infantile aphakic treatment study. It can occur up to 17 years post cataract surgery, evidence that long-term follow-up is imperative.

Migration to aphakia and contact lens treatment is the trend in the management of unilateral congenital cataract in Britain and Ireland.

BACKGROUND: The Infant Aphakia Treatment Study (IATS) compared the treatment of unilateral cataract in infants aged 1-6 months with primary intraocular lens (IOL) implantation vs aphakia with contact lens (CL) correction. AIMS: This study aims to assess the current trends in the treatment of unilateral congenital cataract in infants less than 6 months at surgery in the UK and Ireland. METHODS: An anonymous survey was emailed to the 200 members of the BIPOSA mailing list with 14 questions to assess treatment choice (primary intraocular lens (IOL) vs aphakia with contact lens (CL)), reasons for this choice, and assessment of local CL services. RESULTS: There were 56 respondents, 39 of whom completed the entire survey. Aphakia with CL was the treatment choice for 74.4% of respondents. A quarter (25.6%) of respondents said they were performing primary IOL implantation prior to the publication of the Infant Aphakia Treatment Study (IATS), but now choose aphakia with CL. Amongst the 20.5% (n = 8) of respondents who chose primary IOL implantation, 5 attributed their choice to "inadequate CL service". The majority (84.6%) of respondents rated their infant CL service as either "good" or "very good". CONCLUSION: Aphakia with CL rehabilitation was the most common approach to the treatment of unilateral congenital cataract in infants less than 6 months in this study. The results of the IATS appear to have influenced a change in practice from primary IOL implantation to aphakia and CL visual rehabilitation in approximately one quarter of those surveyed.

Cross-linking in children with keratoconus: a systematic review and meta-analysis.

Keratoconus can behave more aggressively in pediatric than in adult patients. We systematically reviewed the literature to determine the effectiveness of corneal collagen cross-linking (CXL) in children. For this study, MEDLINE® and Cochrane databases were searched for all studies examining the effects of standard, trans-epithelial or accelerated CXL protocols in patients age 18 years or younger. Primary outcomes were; uncorrected visual acuity (UCVA) and maximum keratometry (Kmax) and secondary outcomes were; best-corrected visual acuity (BCVA), mean refractive spherical equivalent (MRSE), central corneal thickness (CCT) and endothelial cell density (ECD). Standardized mean differences (SMD) and 95% confidence intervals were calculated, comparing baseline values with those at 6, 12 and 24 months. A total of 13 papers, published between May 2011 and December 2014 examining 490 eyes of 401 patients with a mean age of 15.25 (±1.5) years, were included in the qualitative analysis in this review. Nine papers were included in the meta-analysis, showing significant improvement in UCVA and BCVA and stable Kmax at 12 months, and stable UCVA, improved BCVA and improved Kmax at 24 months in the standard protocol group UCVA, BCVA and KMax were stable at 12 months in the trans-epithelial group. Mean refractive spherical equivalent (MRSE), CCT and ECD remained stable in both groups. In conclusion it was found that standard CXL may be effective in halting progression of keratoconus in pediatric patients at 1 year. However, larger, more long-term studies are required to ascertain its effectiveness.

Corneal collagen crosslinking in children with keratoconus.

PURPOSE: To report the visual, refractive, and tomographic outcomes of corneal collagen crosslinking (CXL) in pediatric patients with keratoconus. METHODS: The medical records of patients ≤ 18 years of age treated with corneal collagen cross-linking from December 2009 to August 2013 were retrospectively reviewed, and the following data were collected at baseline, 3 months, 6 months, and 1 year for all patients and at 2 and 3 years where available: uncorrected- and best-corrected visual acuity, spherical equivalent, cylinder, and tomographic findings. RESULTS: A total of 25 eyes of 14 patients (11 males) were included. Mean age at surgery was 16.2 ± 1.6 years (range, 13-18). Mean uncorrected visual acuity was 0.53 ± 0.32 logMAR at baseline and 0.46 ± 0.36 logMAR at 1 year (P = 0.07). Mean preoperative best-corrected visual acuity was 0.3 ± 0.26 logMAR, which improved to 0.15 ± 0.12 logMAR at 1 year (P = 0.01). Baseline spherical equivalent and cylinder values were unchanged at 1 year. Mean baseline Kmax, Kmin, and Kmean values were 49.62 ± 4.5 D, 44.68 ± 3.5 D, and 46.3 ± 2.84 D, respectively; these values were stable at 1 year (P > 0.05). At 1 year, compared with preoperative Kmax values, 5 eyes (20%) showed regression; 13 eyes (52%), stabilization; and 7 eyes (18%), progression. There was a significant reduction in the mean thinnest corneal area from baseline (473.6 ± 37.68 µm) to 6 months (424.55 ± 70.2 µm), but this recovered at 1 year (452.82 ± 53.5 µm). There were no significant postoperative complications. CONCLUSIONS: In this patient cohort CXL effectively stabilized uncorrected visual acuity, refractive indices, and keratometry values at 1 year, while improving best-corrected visual acuity.

Forceps Delivery-Related Ophthalmic Injuries: A Case Series.

PURPOSE: To report a case series of neonatal ophthalmic trauma induced by forceps-assisted vaginal delivery. METHODS: Retrospective, non-comparative case series focusing on presentation and long-term outcomes. RESULTS: Eleven cases of ophthalmic injury secondary to forceps delivery (7 male, 4 female) from October 1997 to July 2014 are presented. Eight cases were born at a single center from January 2006 to July 2014, a rate of 1 case per 413 forceps-assisted deliveries. Follow-up ranged from 2 months to 17 years. Three cases had self-limiting eyelid bruising only. There was one case each of vitreous hemorrhage and hyphema, which resolved spontaneously. There were two cases of oculomotor nerve palsy associated with intracranial hemorrhage, both requiring surgical ptosis repair at 3 and 5 weeks old, respectively. There was one case of facial nerve palsy. Four cases sustained corneal trauma, manifesting as corneal edema in three cases at birth. The fourth of these cases presented at age 4.5 years with corneal scarring and amblyopia. Resulting astigmatism in these four cases ranged from 3.5 to 7.5 diopters and best-corrected visual acuity ranged from 6/12 to 6/36 Snellen at last follow-up. CONCLUSIONS: Although rare, ophthalmic trauma secondary to forceps-assisted delivery can result in a wide spectrum of anatomical injuries, which may be self-limiting or cause significant long-term visual impairment. The authors recommend awareness among obstetricians and pediatricians of these injuries, and referral to the ophthalmologist of any newborn delivered by forceps with evidence of compressive trauma such as scalp or eyelid bruising to rule out the presence of more serious ophthalmic trauma.