Primary Central Nervous System Vasculitis With Optic Nerve Involvement.

A 20-year-old woman presented with headache, decreased vision, eye pain, and urinary retention. During her clinical course, visual acuity declined to 20/800, right eye, and 20/50, left eye, associated with bilateral optic disc edema. Brain magnetic resonance imaging revealed enhancement of the leptomeninges, right optic nerve, and right side of the optic chiasm. Extensive evaluation of the central nervous system (CNS) for an infectious cause was negative. Brain biopsy showed a pattern consistent with vasculitis. The patient was treated with prednisone and cyclophosphamide, resulting in improvement of her vision and systemic symptoms. Primary CNS vasculitis is a rare condition that may affect the anterior visual pathways.

Patient Portals in Child and Adolescent Psychiatry.

Utilization of patient portals in the child and adolescent population presents an exciting and somewhat complex opportunity for providers and young patients. This article summarizes the limited information currently available in the literature about child and adolescent patient portals. The concept and implementation of patient portals are discussed in detail. Data referencing provider, parent, and young patient opinion regarding patient portals are discussed. Important considerations regarding confidentiality and adherence to federal, state, and local regulations, as well as potential institution level solutions are presented. Potential problems and benefits of utilizing patient portals for child and adolescent psychiatric populations are discussed.

The Degree of Anisocoria in Pediatric Patients With Horner Syndrome When Compared to Children Without Disease.

PURPOSE: To study the magnitude of anisocoria in pediatric patients using the plusoptiX A08 (plusoptiX GmbH, Nuremberg, Germany) photoscreener as compared to a literature review of pediatric patients with known Horner syndrome to determine if anisocoria alone should raise suspicion for the diagnosis. METHODS: The medical records of 592 consecutive patients, neonates to 9 years old, were collected and analyzed. All patients had complete ophthalmic examinations that included photoscreening with the plusoptiX A08. Data included age, pupil sizes, and anisocoria. A complete literature search of documented pupillary size in pediatric patients with the diagnosis of Horner syndrome was performed. This was then compared to the normative pediatric pupil data from the study. RESULTS: Of the 592 children without Horner syndrome, 372 had an anisocoria of 0.1 to 0.5 mm (62.84%), 167 had an anisocoria of 0.6 to 1.2 mm (28.16%), and 21 had an anisocoria of 1.3 mm or greater (3.70%). There was no correlation between increasing age and severity of anisocoria (P = .55). For pediatric patients with a diagnosis of Horner syndrome, the average level of anisocoria was 1.37 mm in room light and 2 mm in darkness. In room light, three children had anisocoria of 0.1 to 0.5 mm (9.4%), 14 had anisocoria of 0.6 to 1.2 mm (43.8%), and 15 had anisocoria of 1.3 mm or greater (46.9%). In darkness, the level of anisocoria increased in 19 patients, causing the first category, 0.1 to 0.5 mm, to include 1 patient (3.1%), the second group to include 5 patients (15.6%), and the last group to include 26 patients (81.3%). Other associated signs/symptoms included ptosis (100%), heterochromia (28.1%), anhidrosis (9.4%), straight hair on affected/curly on unaffected side (9.4%), and neck mass (6.3%). In 37.5% of cases, imaging results were negative and no specific etiology was determined. CONCLUSIONS: In a study of 592 children without Horner syndrome, the average pupillary size increased with age, but the degree of anisocoria remained stable with increasing age. Over half of the children studied had anisocoria up to 0.5 mm (62.84%), but rarely had anisocoria greater than 1.3 mm (3.70%). In children with a diagnosis of Horner syndrome, the majority had anisocoria greater than 1.3 mm, with the discrepancy in pupil size becoming more apparent in low levels of light intensity. Anisocoria greater than 1.3 mm is unlikely to be physiologic in a child; therefore, he or she should be carefully evaluated for other localizing signs, such as ptosis, anhidrosis, and neck mass. [J Pediatr Ophthalmol Strabismus. 2016;53(3):186-189.].

Bilateral papillitis and unilateral focal chorioretinitis as the presenting features of syphilis.

BACKGROUND: Syphilis is a multisystem bacterial infection caused by Treponema pallidum. The incidence of infection in the United States has risen by more than 75% since the year 2000, when it was at a low of 2.1 per 100,000 people. Ocular involvement may occur in any stage of infection and may present in a variety of ways, with posterior uveitis being the most common manifestation. We report a case of ocular syphilis infection with an unusual presentation of bilateral non-granulomatous panuveitis with papillitis and unilateral focal chorioretinitis. FINDINGS: This is a retrospective case report with literature review. A 39-year-old Caucasian female presented with a 2-week history of bilateral ocular flashes and left eye pain. Dilated fundus examination revealed mild optic disc edema in both eyes, the right eye more than the left. In the left eye, there was an area of retinal elevation and whitening involving the peripheral retina. Fluorescein angiography, B-scan ultrasonography, and ocular coherence tomography were performed, and laboratory tests were ordered based on the clinical presentation. After rapid plasma reagin (RPR) and fluorescent treponemal antibody absorption (FTA-Abs) were positive, syphilitic uveitis was confirmed, and the patient was admitted for a 14-day course of high-dose intravenous penicillin G. CONCLUSIONS: The first signs and symptoms of syphilis may be ocular, which can lead to a diagnostic challenge. A high index of suspicion is the key for early diagnosis of ocular syphilis. Prompt treatment with intravenous penicillin G is highly effective in resolving the infection.

Dual application versus single application of povidone-iodine in reducing surgical site contamination during strabismus surgery.

PURPOSE: To investigate the contamination rates in patients undergoing strabismus surgery who received a single versus a dual application of povidone-iodine. METHODS: Patients undergoing strabismus surgery were divided into two groups of approximately equal size. Prior to surgery, the surgical sites for both groups were prepared by applying 4 drops of povidone-iodine 5% directly into the conjunctival fornices, after which the eyelashes were cleaned with cotton tips soaked with povidone-iodine 5%. Sterile gauze pads soaked with povidone-iodine 5% were used to clean the periocular skin. After lid speculum placement, the patients in the dual application group received an additional 2 drops of povidone-iodine in the conjunctival fornices. Intraoperatively, the conjunctiva, sclera, needles/sutures, and lid speculum were cultured. Gram stain and cultures were obtained and quantified. Contamination was defined as any bacterial growth on blood agar plates at 2 days. RESULTS: A total of 104 patients (aged 7 months to 79 years) were included. The single application group had a 25% contamination rate of surgical site and sutures; the dual application group, a 10% contamination rate. This difference was statistically significant (P = 0.03). The rate of eyelid speculum contamination was unaffected by additional applications (12.5% contamination rate in both groups [P = 0.5]). The additional application of povidone-iodine affected the contamination rate of the conjunctival incision site the most, with a decrease from 20.5% to 5% (P = 0.02). CONCLUSIONS: In our study cohort a second application of povidone-iodine significantly decreased the rate of contamination of the surgical site and sutures. It did not affect contamination of the lid speculum.

Extending nurse practitioner care using the virtual reality world of second life.

The growth of Internet applications has substantially broadened the potential for its use in global telehealth. This pilot project used the virtual reality world of Second Life for diabetic patients to meet with their nurse practitioners for their maintenance visits. Using avatars and the online patient portal, these scheduled visits were designed to meet the needs of the patients as determined by the results from a questionnaire completed by patients prior to the visit. The virtual visits took place in the replicated building where patients typically receive their care, the Eskind Diabetes Clinic. Orientation sessions to Second Life were made available prior to the actual visit, and additional online resources were made available after the visit was over. Although only seven pilot patients have currently completed visits, data illustrate the positive potential use of this treatment modality for future study.

Unilateral congenital glaucoma in a child with optic nerve aplasia.

Unilateral optic nerve aplasia is a rare, nonhereditary defect associated with anterior chamber malformations and other ocular malformations. We report the case of an 8½-week-old boy with unilateral optic nerve aplasia who was diagnosed with glaucoma on presentation with corneal edema and an intraocular pressure of 36 mm Hg. The cornea edema cleared after a trabeculotomy, and subsequent fundus examination revealed optic nerve aplasia that was confirmed with magnetic resonance imaging. Intraocular pressure remained well-controlled with 7½ months of follow-up. To our knowledge, this is the first documented case of optic nerve aplasia associated with glaucoma at presentation.