Intraocular foreign bodies in children: A retrospective case series.

INTRODUCTION: Open globe injuries are a major cause of visual impairment in children, related to the severity of the trauma or secondary to induced amblyopia. Intraocular foreign bodies (IOFB) have been reported in approximately one third of cases of open globe injuries. As clinical presentation and management may differ between adults and children, data is lacking about IOFBs in children under 18years of age. The purpose of this study was to assess the clinical characteristics and visual prognosis of ocular trauma associated with intraocular foreign bodies in children. MATERIALS AND METHODS: This single-center retrospective study included patients under 18years of age treated for ocular trauma with IOFB. Demographic characteristics, complete initial and final ophthalmological examination, imaging data and details of medical and surgical management were collected. RESULTS: Fourteen patients were included (78.6% boys), with a mean age of 10.3years (min 7months-max 17years). In 92.9% of cases, patients were found to have a single IOFB, mostly metallic (71.4%). Posterior segment IOFBs were found in 50% of cases, anterior segment IOFBs in 28.6% and orbital IOFBs in 21.4%. The clinical examination permitted detection of the IOFBs in 50% of cases, while they were visible on CT scan in all cases. The mean initial visual acuity was 20/320, and the mean final visual acuity was 20/125. Endophthalmitis occurred in 2 cases (14%). DISCUSSION: Open globe injuries associated with IOFB are severe and sight-threatening. Localization of the IOFB in the posterior segment has a worse prognosis. CT scan is mandatory, especially in children, as the trauma history is often missing. Retinal detachment and endophthalmitis appear to be the main prognostic factors requiring urgent specialized pediatric ophthalmology management.

[Vision screening for children: Recommended practices from AFSOP]. / Le dépistage visuel chez l'enfant : les recommandations de l'Association Francophone de Strabologie et d'Ophtalmologie Pédiatrique (AFSOP).

In light of the international literature, a workgroup of experts from the AFSOP met in February 2019 to formulate updated recommendations for visual screening in children. An ophthalmologic examination during the first month of life is recommended for children at risk of developing infantile organic amblyopia. An ophthalmologic examination including cycloplegic refraction between 12 and 15 months of age is recommended for children at risk of developing functional amblyopia. At any age, a prompt ophthalmologic examination is recommended for a child suspected of functional or organic ocular pathology. In children without risk factors or warning signs, a systematic orthoptic screening examination is recommended during the third year of life, including a monocular visual acuity test, a cover-test and a refraction by photoscreener. The child is referred to the ophthalmologist only in the case of an abnormal screening result, according to the following criteria: visual acuity <5/10, or >1 difference between eyes, abnormal cover test, photodetection refraction values <-3D or>+2.5D for the sphere,>1.5D for astigmatism and>1D for anisometropia. Finally, we review normal childhood refractive errors as a function of age as well as the correct use of photo screening devices.

[Examination and clinical signs in infancy]. / Examen et sémiologie générale du nourrisson.

The first 2 years of life are essential to visual development. The ophthalmological examination of a baby is different from that of an adult, in terms of both methodology and clinical signs. The specifics of examination at this age require a rigorous history taking as a first step: personal and family medical history, first sign of the disease and its progression. Cycloplegic refraction and fundus exam are both critical regardless of the reason for consultation. In addition, fundus exam must be performed at the first visit in cases of strabismus, nystagmus, or abnormal visual function, in order to rule out underlying retinoblastoma. Gross inspection of the patient can offer much information: malformations, visual behavior, oculomotor abnormalities. Quantification of vision and refraction is age-specific. It cannot be based solely on visual behavior, it cannot be just an approximation, and it often needs to be repeated. Lastly, examination of the anterior and posterior segments may require specialized equipment, special techniques, and may reveal pathology specific to the infant. Throughout the examination, patience and gentleness help greatly to insure a reliable diagnosis.

Intubating conditions and adverse events during sevoflurane induction in infants.

BACKGROUND: The aim of this study was to compare intubating conditions and adverse events after sevoflurane induction in infants, with or without the use of rocuronium or alfentanil. METHODS: Seventy-five infants, aged 1-24 months, undergoing elective surgery under general anaesthesia were randomly assigned to receive 8% sevoflurane with either placebo (i.v. saline 0.5 ml kg⁻¹), rocuronium (0.3 mg kg⁻¹), or alfentanil (20 µg kg⁻¹). The primary outcome measure was intubating conditions evaluated 90 s after test drug injection by an anaesthetist unaware of the patient's group. The secondary outcome criteria were respiratory (Sp(O2) <90%, laryngospasm, closed vocal cords preventing intubation, bronchospasm) and haemodynamic adverse events (heart rate and mean arterial pressure variations ≥30% control value). RESULTS: Intubating conditions were significantly better in the rocuronium group, with clinically acceptable intubating conditions in 92%, vs 70% in the alfentanil group and 63% in the placebo group (P=0.044). Adverse respiratory events were significantly less frequent in the rocuronium group: 0% vs 33% in the placebo group and 30% in the alfentanil group (P=0.006). Haemodynamic adverse events were more frequent in the alfentanil group: 48% vs 7% in the placebo group and 16% in the rocuronium group (P=0.0019). CONCLUSIONS: In 1- to 24-month-old infants, the addition of 0.3 mg kg⁻¹ rocuronium to 8% sevoflurane improved intubating conditions and decreased the frequency of respiratory adverse events. Alfentanil provided no additional benefit in this study.

[Diagnosis and treatment of tearing in infancy]. / Larmoiement du nourrisson : conduite à tenir et thérapeutique.

Tearing in infancy is a very frequent symptom, particularly during the first year of life. A definite diagnosis can be made easily, only by questioning the parents about the characteristics and the evolution of the tearing since the birth and with a simple examination. The main causes are congenital nasolacrimal duct obstruction account of his high frequency in infant and congenital glaucoma account of his seriousness.

[Iris mammillations: three case reports]. / Mamelonnements de l'iris. A propos de trois cas.

INTRODUCTION: Iris mammillations are congenital abnormalities characterized by vitiliform protuberances regularly spaced on the surface of a velvety iris. They can be either isolated or associated with melanocytosis involving iris, sclera or periocular tissues, resulting in a risk for uveal melanoma. They can be complicated by ocular hypertension. We report three cases of iris mammillations in three children. CASES REPORT: For each patient, age, circumstances of revelation, anterior and posterior segment examination, intraocular pressure, associated anomalies, and progression were noted. Patient no. 1: In a 13-month-old boy examined for a squint, bilateral iris mammillations were fortuitously discovered. Intraocular pressure remained normal over 22 months of follow-up. Patient no. 2: In an eight-year-old boy, bilateral iris mammillations with papillary excavation were fortuitously discovered. Intraocular pressure was normal and the excavation did not change over 20 months of follow-up. Patient no. 3: A five-year-old boy was examined for a scleral pigmentation in the right eye. The examination found unilateral iris mammillations and ipsilateral ocular melanocytosis. Intraocular pressure and fundus were normal and remained normal over 13 months of follow-up. DISCUSSION: and conclusion: Iris mammillations are congenital abnormalities, generally unilateral, sometimes hereditary. The differential diagnosis includes Lisch nodules of neurofibromatosis and iris melanoma. The etiology of iris mammillations is unknown; these lesions can be complicated by ocular hypertony and, in case of associated melanocytosis of the iris, sclera or periocular tissues, by uveal melanoma. These potential complications warrant a regular clinical follow-up.

[Congenital glaucoma and trabeculodysgenesis. Clinical and genetic aspects]. / Glaucomes congénitaux et trabéculodysgénésies: aspects cliniques et génétiques.

Congenital glaucoma is generally related to an iridocorneal angle malformation, with an obstacle to aqueous humor outflow. This spectrum of diseases can involve the angle, the iris and the cornea. The diagnosis relies on characteristic signs and is confirmed by an examination under general anaesthesia and paraclinical examinations (especially echography). An early diagnosis is essential for beginning surgical treatment. Several filtering surgery techniques with equivalent intraocular pressure results are available, but visual function must be protected in all cases. In many cases, genetic counseling relies on a careful clinical analysis and sometimes on a molecular analysis. A number of ocular and/or general abnormalities can be accompanied by glaucoma in infants and children. They must be screened in case of associated signs, but the existence of these abnormalities leads to suspicion of associated glaucoma.

[Computer-assisted diagnosis and therapy for glaucoma]. / Diagnostic et traitement des glaucomes.

Boolean algebra, or combinatory analysis and their related computer routines, can provide invaluable help in resolving classic diagnostic problems. However complex each case may be, the diagnosis is always made from a finite set of data, and the fundamental problem is thus how to exploit this data. Invention no longer has a place in ascertaining a diagnosis. Traditional ways of reasoning are numerous, personal, and fragile, but fortunately redundant. They may give rise to four types of error: omission or mistake (an error of judgment), either during the semiotic or the dialectic stages. Whereas the physiological capacity of the human brain and memory only enables it to make a limited number of hypotheses concerning certain aspects of glaucoma, computer programs can take the total number of hypotheses into account, i.e., 3000. For every input the program explores each of the 3,000 items, thus eliminating the four types of error. The probabilistic nature of data, which compromises the confidence one can have in conclusions resulting from such complex reasoning, is treated by the adjusted probabilities. The use of such diagnostic aids, whose thesaurus is updated regularly, is reserved for ophthalmologists, the only authority capable of assessing the pertinence of the computer responses. Consequently, the specialist can rest assured that the patient has benefited from the most comprehensive and updated knowledge in medical science.

Sevoflurane effects on retrobulbar arteries blood flow in children.

BACKGROUND: Measure of blood flow velocity in retrobulbar vessels is performed to determine the severity of ophthalmic pathologies as glaucoma. In children, this measure is usually performed under general anaesthesia. Sevoflurane is known to not modify cerebral blow flow velocities. However, its effect on retrobulbar circulation is not known. This study was designed to evaluate the effect of sevoflurane on retrobulbar circulation flow velocity in children undergoing examination for ocular disorders under general anaesthesia. METHODS: Thirteen mechanically ventilated children (Fi(O2))=1) were included. Blood flow velocities of central retinal artery, ophthalmic artery, and middle cerebral artery were measured by Doppler ultrasound during 1 and 2 age-adjusted minimal alveolar concentration (MAC) sevoflurane anaesthesia. Intra-ocular pressure and non-invasive haemodynamic parameters were also measured. End-tidal carbon dioxide tension was controlled during all the study period. RESULTS: Mean arterial pressure decreased from 1 to 2 age-adjusted MAC sevoflurane (58 [12] vs 54 [12] mm Hg, P=0.01). In the ophthalmic artery, end diastolic velocity (EDV) decreased significantly at 2 MAC (1 MAC: 4.4 [4] cm s(-1) vs 2 MAC: 1.4 [2.4] cm s(-1); P=0.04) and resistivity index (RI) increased significantly (1 MAC: 0.83 [0.11] vs 2 MAC: 0.93 [0.09]; P=0.007). Systolic velocity, EDV, and RI remained constant in the central retinal artery and in the middle cerebral artery. CONCLUSION: High alveolar concentration of sevoflurane decreased blood flow velocity in the ophthalmic artery, but not in the central retinal and the middle cerebral arteries in children ventilated in hyperoxic condition. This effect was related to a decrease in mean arterial pressure. This vessel-dependent effect may be explained by the different autoregulatory mechanisms of these arteries. In the present hyperoxic conditions, the vascular effect of sevoflurane may have been limited in the central retinal artery and not in the ophthalmic artery.

[Ocular injuries and childbirth]. / Traumatismes oculaires et accouchement.

INTRODUCTION: Severe ocular traumatisms related to childbirth are rare and often subordinate to maneuvers with instruments. The aim of this study was to report on the different severe ocular injuries that might occur during childbirth and their possible consequences. There can be several of these ocular injuries. PATIENTS AND METHODS: Since 1984, we have examined 11 cases of this type of traumatism. For each case, the childbirth circumstances, the affected side, the different injuries observed such as ocular, orbital, cranial and even cerebral lesions, and the results of the ophthalmological follow-up examinations were recorded. RESULTS: In most cases, lesions resulted from forceps traumatisms, and the injuries were corneal (vertical tears in the Descemet's membrane), retinal (hemorrhages), and orbital (e.g., the optical nerve and oculomotor nerve). CONCLUSION: These injuries, sometimes severe, must benefit from early and complete examination, possibly with general anesthesia, and long-term follow-up. Furthermore, a radiographic and clinical neurological examination is recommended to prevent any cerebral complication.

Early prognostic factors for intellectual outcome in CHARGE syndrome.

CHARGE syndrome (coloboma, heart disease, atresia of the choanae, retarded growth and mental development, genital anomalies, and ear malformations and hearing loss) is a heterogeneous condition for which early prediction of intellectual outcome is important but difficult. The psychomotor milestones and intellectual outcome of a consecutive series of children with CHARGE syndrome who were observed by the same team from the neonatal period to the time of study were analyzed retrospectively. Twenty-one children (11 males and 10 females, aged from 5 to 12 years, mean 8 years 7 months, SD 2 years 5 months) were included. The influence of 19 early identifiable parameters that could be considered as deleterious for intellectual outcome was recorded. Generally, the main psychomotor milestones (0 to 4 years) were severely delayed, although intellectual outcome (at primary-school age) was satisfactory for half the children in this series. We show that extensive bilateral coloboma resulting in low vision, microcephaly, and brain malformation were the only three parameters that were predictive of poor intellectual outcome. Conversely, severe neonatal medical conditions, such as tracheotomy, conditions requiring long stays in hospital, or cardiac surgery were not predictive of poor intellectual outcome. Severe hearing loss was not found to be negatively correlated with intellectual outcome once coloboma had been taken into account.

Use of denaturing HPLC and automated sequencing to screen the VMD2 gene for mutations associated with Best's vitelliform macular dystrophy.

We identified three novel VMD2 mutations in patients with Best's macular dystrophy. DHPLC analysis of the 11 VMD2 exons revealed abnormal profiles in exon 8. Direct sequencing showed that these abnormal profiles were due to monoallelic transitions and transversions. We also found three polymorphic sequence changes that have been reported previously and annotated to an online database (http://www.uni-wuerzburg.de/humangenetics/vmd2.html).