Pediatric ophthalmology inpatient consults at a tertiary care children's hospital.

PURPOSE: To analyze the pattern of pediatric ophthalmology inpatient consults at a single children's hospital over 5 years. METHODS: The records of all pediatric ophthalmology consults over a 5-year period were reviewed retrospectively. RESULTS: A total of 1,805 new pediatric inpatient consultations were requested, most commonly for papilledema (14.18%), workup for unknown systemic disease (12.96%), and nonaccidental trauma (8.92%). In 50.86% of consults, an abnormal eye examination was found. When consulted for papilledema or nonaccidental trauma (NAT), we found a positivity rate of 26.56% and 27.95%, respectively. The most common ocular abnormalities noted were orbital/preseptal cellulitis (3.82%), optic disk edema (3.77%), and retinal hemorrhages (3.05%). Over the 5-year period, there was a significant increase in consults to rule out papilledema (P = 0.0001) and for trauma/nonaccidental trauma (P = 0.04) and a decrease in consults for workup of systemic disease (P = 0.03) and to rule out fungal endophthalmitis (P = 0.0007). CONCLUSIONS: We found an abnormal eye examination in half of our consults. When consulted for papilledema or nonaccidental trauma (NAT), we found a positivity rate of 26.56% and 27.95%, respectively.

Pediatric Eyelid and Canalicular Lacerations: Epidemiology and Outcomes.

PURPOSE: To characterize the epidemiology of eyelid lacerations, identify risk factors for canalicular involvement, and describe postoperative complications following laceration repair. METHODS: All patients undergoing eyelid laceration repair at a tertiary care, level I trauma center children's hospital from November 2010 to April 2021 were identified by a Current Procedural Terminology code search. Patient characteristics, surgical characteristics, and surgical outcomes were collected via chart review. Univariate analysis and multivariate logistic regression were performed to identify risk factors for canalicular involvement and postoperative complication. RESULTS: A total of 165 patients were identified, of whom 136 had at least 1 week of follow-up and were further assessed for postoperative complications. The most common mechanisms of injury were dog bites (62, 38%), falls (33, 20%), and being struck by an object (22, 13%). Eyelid margin involvement was present in 108 patients (65%) and canalicular involvement in 77 patients (47%). Risk factors for canalicular involvement were hook-related injury, eyelid margin involvement, and lower eyelid injury. Thirty-three patients (24%) had postoperative complications, most commonly ptosis (7, 5%), premature stent loss (7, 5%), and eyelid margin notching (6, 4%). There was no association between postoperative complication and antibiotic use, delayed repair, or wound class. CONCLUSIONS: Hook-related injury, eyelid margin involvement, and lower eyelid injury are risk factors for canalicular involvement. Postoperative complications of eyelid lacerations are generally minor and are not associated with perioperative factors. Close postoperative follow-up is needed to monitor for complication development. [J Pediatr Ophthalmol Strabismus. 2023;60(1):33-38.].

Ocular findings in pediatric turner syndrome.

OBJECTIVE: Turner syndrome (TS) is associated with abnormalities across several organ systems, including the visual system. There is a relative paucity of literature describing ophthalmic manifestations of TS. We sought to investigate eye manifestations in our cross-sectional population of pediatric TS patients. METHODS: All patients managed by the TS program of a tertiary children's hospital were identified. Patients with documentation of at least one eye exam were included for analysis. Chart review was retrospectively performed to identify all documented ocular abnormalities as well as patient demographics, including TS karyotype. Statistical analysis was performed to identify any association between karyotype and ocular abnormality. RESULTS: A total of 187 patients with TS were identified. The mean age of the cohort was 14.3 ± 7.2 years. Ametropia was the most common ocular abnormality, occurring in 79 patients (42%), followed by strabismus in 25 (13%). Of the patients with strabismus, 17 had exotropia and 8 had esotropia, with only 2 patients requiring surgical intervention. Posterior segment abnormalities were identified in five patients without accompanying visual deficits. Two patients had ocular tumors: one with retinoblastoma and one with retinal astrocytic hamartoma. There was no association between TS karyotype and occurrence of ocular abnormalities. CONCLUSION: Ophthalmic manifestations of TS were common, particularly ametropia and strabismus. Management of strabismus was conservative in the vast majority of patients. Ocular manifestations were not associated with TS karyotype. Early screening and routine ophthalmic evaluation of patients with TS is needed to prevent progression of potentially vision-threatening abnormalities.

The Long-term Visual Outcomes of Primary Congenital Glaucoma.

PURPOSE: To evaluate the long-term visual outcomes of ab externo trabeculotomy for primary congenital glaucoma (PCG) at a single pediatric ophthalmology center. METHODS: In this retrospective single-center case series, data from 63 eyes of 40 patients who underwent ab externo trabeculotomy between September 2006 and June 2018 were included. The data were analyzed for best corrected visual acuity (BCVA), stereopsis, and surgical success. Kaplan-Meier analysis was performed using the surgical success criteria defined as intraocular pressure (IOP) ≤ 21 mmHg and ≥ 20% below baseline without the need for additional glaucoma surgery. RESULTS: BCVA at the time of diagnosis was 0.37 ± 0.48 logMAR, which changed to 0.51 ± 0.56 logMAR at the final follow-up (P = 0.08). Twenty-five percent of patients had BCVA equal to or better than 20/40 at the final visit. The mean refraction at baseline was -4.78 ± 5.87 diopters, which changed to less myopic refraction of -2.90 ± 3.83 diopters at the final visit. Optical correction was prescribed in 66% of eyes at the final visit. The average final stereopsis was 395.33 sec of arc. The linear regression model showed a significant association between the surgery success rate and final BCVA as well as stereoacuity (P-values: 0.04 and 0.03, respectively). Intraocular pressure (IOP) decreased significantly from 29.79 ± 7.67 mmHg at baseline to 16.13 ± 3.41 mmHg at the final follow-up (P = 0.001). CONCLUSION: Patients with PCG can achieve an acceptable visual acuity and stereoacuity, particularly in cases of timely intervention and close follow-up.

Establishing a normative database for quantitative pupillometry in the pediatric population.

BACKGROUND: Pupillary evaluation is a crucial element of physical exams. Noting size, reactivity, and consensual response is critical in assessing for optic nerve dysfunction. We aim to establish normative data for scotopic pupillary size and function in the pediatric population in a clinical setting. METHODS: Pupillometry was obtained prospectively for consecutive, normal patients < 18 years old being evaluated by Lurie Children's Ophthalmology. Quantitative data included maximum (MAX) and minimum (MIN) diameters, constriction percentage (CON), latency (LAT), average (ACV) and maximum (MCV) constriction velocities, average dilation velocity (ADV), and 75% recovery time (T75). Iris color was noted as light, intermediate, or dark. RESULTS: 196 eyes of 101 participants (42.6% male, ages 1-17 years, average age 10.3 years) were analyzed. Mean MAX was 6.6 mm (5.1-8.1 mm 95% CI); MIN was 4.7 mm (3.1-6.1 mm 95% CI); CON was 30% (17-42 95% CI); LAT was 230 milliseconds (160-300 ms 95% CI); ACV was 3.70 mm/sec (2.21-5.18 mm/sec 95% CI); and ADV was 0.88 mm/sec (0.38-1.38 mm/sec 95% CI). Age had a positive correlation with MAX, MIN, and CON. 84.2 and 95.8% of participants showed resting pupil asymmetry of ≤0.5 mm and ≤ 1.0 mm, respectively. CONCLUSIONS: Quantitative pupillometry can be a useful tool for screening pediatric patients. We sought to establish normative data in this group. We found males to have significantly greater MCV and CON than females (p < 0.05). Also, age had a positive correlation with MAX, MIN, and CON.

A case of acquired Brown syndrome treated with adalimumab.

We present the case of a 4-year-old boy with acquired Brown syndrome of inflammatory origin. Without evidence of systemic inflammation, the disease typically resolves with oral steroids or nonsteroidal anti-inflammatory drugs. Refractory cases can be treated with local steroid injections or surgery. The present case of inflammatory Brown syndrome did not respond to conservative therapy, and parental concerns and wishes precluded more invasive treatments. Adalimumab was initiated and led to complete resolution of the disease.

Long-term surgical outcomes of ab externo trabeculotomy in the management of primary congenital glaucoma.

PURPOSE: To analyze the long-term results of ab externo trabeculotomy with a Harms trabeculotome at a single, tertiary care pediatric hospital. METHODS: The medical records of pediatric patients operated on between September 2006 and June 2018 were reviewed retrospectively. Kaplan-Meier analysis was performed, with success defined as postoperative intraocular pressure (IOP) of ≤21 mm Hg, >20% reduction from preoperative IOP, and no need for further glaucoma surgery. Risk factors for failure were identified using Cox proportional hazards ratio. RESULTS: A total of 63 eyes of 40 patients were included. The cumulative probability of success rate was 83% at 3 months, 76% at 6, 73% at 12, 72% at 18, and 65% at final visit. Presentation within 3 months of life was associated with a less favorable outcome. Thirty-five eyes (56%) underwent repeat trabeculotomy to treat a different area of the trabecular meshwork because of inadequately controlled IOP after the first session. Of those who needed another session of trabeculotomy, the final success rate was 60.2%. IOP significantly decreased from 29.79 ± 7.67 mm Hg at baseline to 16.13 ± 3.41 mm Hg by final follow-up (P = 0.001). Patients were followed for an average of 85.74 ± 32.95 months. IOP and success rates remained stable 18 months after surgery. CONCLUSIONS: In our patient cohort, ab externo trabeculotomy was associated with good long-term results. More extensive trabeculotomy (ie, more than one procedure) was associated with better long-term success rates.

Pediatric Nd:YAG laser capsulotomy in the operating room: review of 87 cases.

AIM: To report a large series of children having Nd:YAG laser capsulotomy in the operating room using the lateral decubitus position. METHODS: Medical records of children who underwent Nd:YAG laser capsulotomy in the operating room at Ann & Robert H. Lurie Children's Hospital of Chicago between September 2008 and April 2017 were reviewed. Induction of general anesthesia and intubation was performed in the supine position after which the patient was placed in lateral decubitus position. The Nd:YAG laser capsulotomy was performed using a standard protocol. At the completion of the procedure, the patient was turned back into the supine position and extubated. RESULTS: This study included 87 eyes of 60 patients. Patient's age ranged from 1 to 18y (mean 6.4±4.1y). In most cases (84/87, 97%), the procedure was performed under general anesthesia. In all cases, good focus on the membrane was achieved, and the procedure was performed successfully. There were no intraoperative ocular or anesthesia-related complications. CONCLUSION: When performing Nd:YAG laser capsulotomy in the operating room, the lateral decubitus position allows an easy and safe approach without the risk of potentially devastating complications that have been associated with the previously described sitting and prone positions.

Pupillary manifestations of Marfan syndrome: from the Marfan eye consortium of Chicago.

BACKGROUND: Marfan syndrome (MFS) is a genetic disorder that affects multiple organ systems, including the eye. The most common ocular manifestations include ectopia lentis and retinal detachment. The current literature qualitatively cites that MFS patients have miotic or "poorly dilating" pupils. This study was the first to quantitatively assess pupillary function in MFS patients. MATERIALS AND METHODS: 57 eyes from 29 MFS patients, 36 eyes from 18 pediatric age- and gender-matched controls, and 44 eyes from 22 adult age-matched controls were measured in a clinic-based cross sectional study. Pupillometry data were measured in scotopic conditions using the handheld NeurOptics PLR-200™ Pupillometer (NeurOptics, Irvine, CA, USA). Data obtained with the pupillometer were maximum and minimum diameter, constriction percentage, latency, average and maximum constriction velocities, average dilation velocity, and 75% recovery time (T75). RESULTS: Pediatric patients with MFS had significantly slower average constriction velocity measurements (ß = 0.65, p = 0.0003), maximum constriction velocity measurements (ß = 0.51, p = 0.0150) and average dilation velocity measurements (ß = -0.19, p = 0.0029) compared to control patients. In the adult cohort, results indicated significantly slower average dilation velocity measurements (ß = -0.13, p = 0.0077) compared to controls. CONCLUSIONS: Our data highlight pupillary parameters within a population of MFS patients under scotopic conditions. Constriction and dilation velocities were slower in the pediatric MFS patients compared to age- and gender-matched controls, and dilation velocities were slower in the adult MFS patients compared to age-matched controls. These findings, for the first time, quantitatively demonstrated differences in pupillary function in patients with MFS.

Ocular biometry and determinants of refractive error in a founder population of European ancestry.

BACKGROUND: The prevalence of myopia is increasing worldwide. Previous studies have found a positive association between myopia, education, and near activities, while others have noted a negative association with outdoor exposure. This study reports refractive error and biometry in a founder population of European ancestry, the Hutterites, and discusses risk factors contributing to myopia. METHODS: Cross-sectional study, including complete eye exams with retinoscopy and biometry. RESULTS: 939 study participants, ages 6 to 89, were examined. Females were significantly more myopic than males (SE -0.87 ± 2.07 and -0.40 ± 1.49 in females and males, respectively, p < 0.0001). Males had significantly longer axial lengths. Females had steeper corneas. This is the first epidemiological report of refractive error among the Hutterites. DISCUSSION: As a genetically isolated population with a communal lifestyle, the Hutterites present a unique opportunity to study risk factors for myopia. Hutterite females are more myopic than males, a finding which has only been reported in a few other populations. Hutterite children complete compulsory education through the 8th grade, after which women and men assume gender-specific occupational tasks. Men often work outside on the farm, while women engage in more domestic activities inside. These occupational differences likely contribute to the increased myopia comparing females to males, and their uniform lifestyle reduces the impact of potential confounding factors, such as education and income. CONCLUSIONS: The Hutterites are more myopic than most other North American and European populations. Greater time spent doing near work and less time spent outdoors likely explain the increased myopia comparing females to males.

Idiopathic bilateral central artery occlusion in a young woman.

Central retinal artery occlusion (CRAO) is uncommon among children and young adults. Bilateral CRAO before the age of 18 years are extremely rare. We present a case of an idiopathic bilateral CRAO in a young healthy female.

The Colorado-retinopathy of prematurity model (CO-ROP): postnatal weight gain screening algorithm.

PURPOSE: To describe a novel retinopathy of prematurity (ROP) screening model incorporating birth weight, gestational age, and postnatal weight gain that maintains sensitivity but improves specificity in detecting all grades of ROP compared to current 2013 screening guidelines. METHODS: The medical records of 499 neonates from a single tertiary referral center who met the 2013 screening guidelines for ROP were retrospectively reviewed. Weekly weights were analyzed using standard logistic regression to determine the age at which the weekly net weight gain best predicted the development of ROP, which was designated as the postnatal weight gain criterion. The 2013 birth weight and gestational age criteria were included in an "and" fashion to form the CO-ROP model. Sensitivities and specificities in detecting high grade (type 1 and 2) and all grades of ROP were calculated. RESULTS: The CO-ROP model screens infants with a gestational age at birth of ≤30 weeks and birth weight of ≤1500 g and net weight gain of ≤650 g between birth and 1 month of age. In our cohort, CO-ROP had a sensitivity of 100% (95% CI, 92.1%-100.0%) for high-grade (type 1 and 2) ROP and 96.4% (95% CI, 92.3%-98.7%) for all grades of ROP. It would reduce the number of infants screened by 23.7% compared to 2013 guidelines. Calibrating the model to detect only high-grade ROP would result in a 45.9% reduction in the total number of infants screened. CONCLUSIONS: CO-ROP is a simple model that maintains a statistically similar sensitivity in detecting all grades of ROP while significantly reducing the total number of required ROP screenings compared to 2013 guidelines. The study had a small sample size but shows promise for future research and clinical efforts.