Characterization of Visual Pathway Abnormalities in Infants With Congenital Zika Syndrome Using Computed Tomography and Magnetic Resonance Imaging.

BACKGROUND: Severe visual impairment is present in nearly all infants with congenital Zika syndrome (CZS); however, ocular abnormalities are present only in a subset of these infants. The purpose of this study was to characterize the visual pathway abnormalities seen on computed tomography (CT) and MRI scans in infants with CZS. METHODS: Preliminary neuroimaging information was obtained from a referred sample of 105 infants with clinical and epidemiologic data consistent with CZS in the Pernambuco state of Brazil. Subjects were excluded if Zika virus infection was not confirmed by serologic or cerebrospinal fluid studies or if images were nondiagnostic. Of the 105 subjects initially screened, head CT images adequate for interpretation were available for 54, and brain MRI images adequate for interpretation were available for 20. Four patients had both CT and MRI images. Magnetic resonance imaging and CT scans from infants with CZS were systematically reviewed for globe malformations, optic nerve and chiasmal atrophy, occipital cortical volume loss, white matter abnormalities, ventriculomegaly, and calcifications. Neuroimaging findings were correlated with measures of visual function and with ocular examinations in these infants. RESULTS: Thirty-three males and 37 females were included in the analysis. The mean age of the infants at the time of neuroimaging was 16.0 weeks (range 0 days-15.5 months), and the mean gestational age at the time of birth was 38 weeks. All patients were from the Pernambuco state of Brazil. Overall, 70 of 74 (95%) scans showed occipital volume loss, whereas 9 (12%) showed optic nerve atrophy, 3 (4%) showed chiasmal atrophy, and 1 (1%) showed an ocular calcification. Sixty-two of the infants underwent ophthalmologic examinations. A total of 34 (55%) infants had at least one documented structural ocular abnormality, and 26 (42%) had at least one structural ocular abnormality documented in both eyes. Of those with available visual acuity data, all had visual impairment. Among those with visual impairment and normal eye examinations, 100% had visual pathway abnormalities on neuroimaging, including 100% with occipital cortical volume loss, 8% with optic nerve atrophy, and 8% with chiasmal atrophy. CONCLUSION: Our results suggest that cortical visual impairment related to structural abnormalities of the occipital cortex is likely an important cause of visual impairment in children with CZS with normal eye examinations.

Inner retinal vasculopathy in Zika virus disease.

PURPOSE: Zika virus infection is associated with vision-threatening ocular complications including uveitis and outer retinopathy. The aim of this report is to describe a case of an adult patient with serologically confirmed Zika infection who presented with retinal vascular abnormalities that coincided with systemic post-viral neurological manifestations of the disease. OBSERVATIONS: A 34-year-old white female presented with symptoms of peripheral neuropathy following serologically confirmed Zika virus infection that was acquired in Puerto Rico four months prior to presentation. Ocular evaluation revealed perifoveal microaneurysms which were not associated with visual symptoms. CONCLUSIONS AND IMPORTANCE: These data potentially expand the phenotypic spectrum of Zika virus retinopathy. In addition to outer retinal abnormalities which are well-described in infants and adults, inner retinal vascular abnormalities may also occur and may be temporally associated with post-viral neurological sequelae of Zika virus infection. Clinicians should be aware of potential retinal involvement in affected patients who present with neurological symptoms after recovery from acute Zika virus infection.

Multifocal Choroiditis with Retinal Vasculitis, Optic Neuropathy, and Keratoconus in a Young Saudi Male.

The purpose of this study is to describe an association of unilateral multifocal choroiditis (MFC), retinal vasculitis, optic neuropathy, and bilateral keratoconus in a young Saudi male. A 27-year-old male patient with stable bilateral keratoconus presented with a painless vision loss in his left eye. Ophthalmic examinations revealed multiple foci of idiopathic chorioretinitis, retinal vasculitis, and mild optic disc leakage on fluorescein angiography, all of which resolved on systemic therapy with mycophenolate mofetil and prednisone after 3 months. Systemic medication was stopped after 8 months. One year after presentation, patient's visual acuity has improved and remained stable. Systemic immunomodulatory therapy can be effective in managing and leading to resolution of MFC, retinal vasculitis, and optic disc leak in young patients.

Streptococcus agalactiae Endophthalmitis in Boston Keratoprosthesis in a Patient with Steven-Johnson Syndrome.

A 25-year-old Syrian male with a previous episode of Stevens-Johnson syndrome with bilateral corneal cicatrization previously underwent surgery for Type 1 Boston Keratoprosthesis (K-Pro). Sixteen months after the K-Pro surgery, the patient presented with decreased vision to hand motion and microbial keratitis of the graft around the K-Pro with purulent discharge. Corneal scrapings were nonrevealing. B-scan in 3 days showed increased debris in the vitreous cavity and thickened retinochoroidal layer. Intravitreal tap and injections of vancomycin and ceftazidime were performed. The vitreous culture revealed ß-hemolytic Streptococcus agalactiae; fungal cultures were negative. Repeat B-scan 3 days later demonstrated decreased vitreous opacity, and the patient felt more comfortable and was without pain. His visual acuity improved to 20/70, ocular findings have been stable for 9 months, and the patient continues to be monitored.

Clinical risk factors for central line-associated venous thrombosis in children.

BACKGROUND: Identifying risk factors related to central venous line (CVL) placement could potentially minimize central line-associated venous thrombosis (CLAVT). We sought to identify the clinical factors associated with CLAVT in children. METHODS: Over a 3-year period, 3733 CVLs were placed at a tertiary-care children's hospital. Data were extracted from the electronic medical records of patients with clinical signs and symptoms of venous thromboembolism, diagnosed using Doppler ultrasonography and/or echocardiography. Statistical analyses examined differences in CLAVT occurrence between groups based on patient and CVL characteristics (type, brand, placement site, and hospital unit). RESULTS: Femoral CVL placement was associated with greater risk for developing CLAVT (OR 11.1, 95% CI 3.9-31.6, p < 0.0001). CVLs placed in the NICU were also associated with increased CLAVT occurrence (OR 5.3, 95% CI 2.1-13.2, p = 0.0003). CVL brand was also significantly associated with risk of CLAVT events. CONCLUSION: Retrospective analyses identified femoral CVL placement and catheter type as independent risk factors for CLAVT, suggesting increased risks due to mechanical reasons. Placement of CVLs in the NICU also led to an increased risk of CLAVT, suggesting that small infants are at increased risk of thrombotic events. Alternative strategies for CVL placement, thromboprophylaxis, and earlier diagnosis may be important for reducing CLAVT events.

Sutured clear corneal incision: wound apposition and permeability to bacterial-sized particles.

PURPOSE: To determine the effects of single radial or horizontal suture placement in 2-step clear corneal incision (CCI) wound apposition and permeability to particles of India ink. METHODS: Five fresh human globes were included. Two 25-gauge needles connected to a saline solution bag and to a digital manometer were inserted through the limbus, 120 degrees apart from each other. Four 2-step CCIs (2.75 mm wide and 3 mm length) were constructed in each cornea. Incisions were divided into 3 groups: single radial suture (SRS), single horizontal suture (SHS), and unsutured group. Optical coherence tomography (OCT) was performed before and after suture placement. With a preset 10 mm Hg intraocular pressure (IOP), India ink was applied to the incision site and a standardized sudden IOP fluctuation was induced. OCT and superficial images were recorded before and after suture placement. India ink inflow and internal and external CCI gapping were outlined and measured by planimeter. RESULTS: The area and linear distance of India ink inflow after pressure challenge in all study groups were higher when compared with pre-pressure measurements; however, this increase was significant in the SRS and SHS groups (P < 0.05). Additionally, SRS placement significantly increased inner wound gapping (P = 0.018), and SHS significantly widened outer wound gape (P = 0.02). CONCLUSIONS: Well-constructed unsutured 2-step CCI seems to be more efficient at preventing bacterial-sized particles inflow during sudden changes in IOP, and it seems to offer better wound apposition as assessed by OCT.

Bacterial-sized particle inflow through sutured clear corneal incisions in a laboratory human model.

PURPOSE: To determine the effectiveness of a single radial suture placement in 2 clear corneal incision (CCI) configurations in preventing inflow of bacterial-sized particles. SETTING: Wilmer Eye Institute, Baltimore, Maryland, USA. DESIGN: Experimental study. METHODS: Ten human globes were used. Two 25-gauge needles connected to a saline solution bag and to a digital manometer were inserted through the limbus 120 degrees apart. Four incision-suture combinations were evaluated sequentially in each cornea. All incisions had the same dimensions (2.75 mm width, 3.00 mm length). Two incisions were single plane, and 2 were biplane. One incision from each configuration was left unsutured, and the other was sutured (10-0 nylon). With a preset 10 mm Hg intraocular pressure (IOP), India ink was applied to the incision site and a sudden IOP fluctuation was induced. Inflow was outlined and measured by planimetry. RESULTS: There was a significant increase in area and linear distance of India-ink inflow after pressure challenge in all groups (P < .05), but with important differences among them. When the sutured and unsutured groups from each CCI were compared, there was a significantly smaller area of inflow in the 2-step unsutured group (P < .05). The linear inflow was higher in both sutured groups; however, the difference was significant for the 2-step incision configuration only (P < .05). CONCLUSIONS: A single radial suture reduced the area of inflow of bacterial-sized particles but increased the linear distance of inflow in single-plane 3.0 mm incisions. Suture placement in a stepped incision increased inflow of bacterial-sized particles. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Standardized Seidel test to evaluate different sutureless cataract incision configurations.

PURPOSE: To compare aqueous outflow and India ink inflow to evaluate clear corneal incisions (CCIs). SETTING: Wilmer Eye Institute, Baltimore, Maryland, USA. METHODS: Two 25-gauge needles connected to a salt solution bag and to a digital manometer were inserted through the limbus of human donor corneas 120 degrees apart from each other. Three 2.75 mm wide incisions were created in a different third of each cornea as follows: single-plane 1.50 mm tunnel length, single-plane 3.00 mm tunnel length, and 2-step 3.00 mm tunnel length. The Seidel test was evaluated at 5 intraocular pressures (IOPs) in the physiologic range. A masked observer evaluated the recorded tests. With a preset 10 mm Hg IOP, India ink was applied to the incision site and a sudden IOP fluctuation induced. India ink influx was outlined and measured by planimetry. RESULTS: With the 1.5 mm single-plain incisions, all 6 globes showed inflow and outflow. With the 3.0 mm single-plain incisions, all 6 globes showed inflow and 2 showed outflow by the Seidel test. With the 3.0 mm 2-step incisions, 2 globes showed inflow and 3 had positive Seidel test results. Area and length of inflow were statistically significantly greater with the 2 single-planed incisions than with the 2-step incisions. CONCLUSION: This human ex vivo model showed that wound deformation produced during Seidel testing might not be an accurate way to predict the risk for bacterial invasion in the early postoperative period.