Retinal Findings in Young Children With Increased Intracranial Pressure From Nontraumatic Causes.

OBJECTIVES: Increased intracranial pressure (ICP) has been suggested in legal settings as an alternative cause of retinal hemorrhages (RHs) in young children who may have sustained abusive head trauma. We assessed the prevalence and characteristics of RHs in children with increased ICP. METHODS: We conducted a prospective, multicenter study of children <4 years old with newly diagnosed increased ICP as determined by using direct measurement and/or clinical criteria. Infants who were premature, neonates, and suspected survivors of abusive head trauma were excluded on the basis of nonocular findings. Fundus examinations were performed; extent, number, and type of RH in each of 4 distinct retinal zones were recorded. RESULTS: Fifty-six children (27 boys) were studied (mean age 15.4 months; range 1-43 months). All of the children had elevated ICP that required intervention. One child had papilledema. No child (0%; 95% confidence interval: 0%-6.4%) or eye (0%; 95% confidence interval: 0%-3.3%) was found to have an RH. Causes of increased ICP included hydrocephalus, intraventricular hemorrhage, congenital malformations, malfunctioning shunts, and the presence of intracranial space-occupying lesions. CONCLUSIONS: Although acute increased ICP can present in children with a pattern of peripapillary superficial RHs in the presence of papilledema, our study supports the conclusion that RHs rarely occur in the absence of optic disc swelling and do not present beyond the peripapillary area in the entities we have studied.

Primary treatment of nasolacrimal duct obstruction with probing in children younger than 4 years.

OBJECTIVE: To report the outcome of nasolacrimal duct probing as the primary treatment of congenital nasolacrimal duct obstruction (NLDO) in children younger than 4 years. DESIGN: Prospective nonrandomized observational multicenter study (44 sites). PARTICIPANTS: Nine hundred fifty-five eyes of 718 children 6 to <48 months old at the time of surgery with no prior nasolacrimal surgical procedure and with at least one of the following clinical signs of NLDO present: epiphora, mucous discharge, and increased tear lake. INTERVENTION: Probing of the nasolacrimal system of the affected eye. MAIN OUTCOME MEASURE: Treatment success was defined as no epiphora, mucous discharge, or increased tear lake present at the outcome visit 1 month after surgery. RESULTS: Proportions of eyes treated successfully were 78% (95% confidence interval [CI], 75%-81%) overall, 78% for the 421 eyes in children 6 to <12 months old, 79% for the 421 eyes in children 12 to <24 months, 79% for the 37 eyes in children 24 to <36 months, and 56% for the 11 eyes in children 36 to <48 months. The probability of treatment success was lower in eyes operated in an office setting than in eyes operated in a surgical facility (adjusted relative risk, 0.88 [95% CI, 0.80-0.96]), with success reported in 72% (95% CI, 66%-78%) of probings performed in an office and 80% (95% CI, 77%-84%) of probings performed in a facility. The probability of treatment success was also lower in eyes of patients with bilateral disease (adjusted relative risk, 0.88 [95% CI, 0.81-0.95]). CONCLUSIONS: In children 6 to <36 months old, probing is a successful primary treatment of NLDO in about three fourths of cases, with no decline in treatment success with increasing age. The study enrolled too few children ages 36 to <48 months to allow a conclusion regarding the probability of treatment success in this age group.

Office probing for treatment of nasolacrimal duct obstruction in infants.

PURPOSE: To determine whether demographic or clinical factors are associated with the outcome of office-based nasolacrimal duct probing for the treatment of congenital nasolacrimal duct obstruction (NLDO). METHODS: In two multicenter prospective studies, 384 eyes of 304 children aged 6 to <15 months with NLDO underwent a nasolacrimal duct probing performed in the office using topical anesthesia. Treatment success, defined as no clinical signs of NLDO (epiphora, increased tear lake, or mucous discharge) and no reoperation, was assessed 1 month after probing in one study and 6 months after probing in the other study. Data from both studies were pooled to evaluate associations between baseline characteristics and treatment success. RESULTS: Office probing was successful in 75% of eyes overall (95% CI, 70%-80%). The procedure was less successful in eyes of children with bilateral NLDO compared with unilateral NLDO (63% vs 80%; relative risk = 0.78 [95% CI, 0.66-0.92]) and in eyes that had 2 or 3 clinical signs of NLDO compared with one (71% vs 83%; relative risk = 0.88 [95% CI, 0.81-0.96]). Treatment success did not appear to be related to age, specific clinical signs of NLDO, prior treatment, or research study. CONCLUSIONS: Performing nasolacrimal duct probing in the office successfully treats NLDO in the majority of cases in children aged 6 to <15 months. The success rate is lower with bilateral disease or when more than one clinical sign of NLDO is present.

Intraobserver reliability of contact pachymetry in children.

BACKGROUND: Central corneal thickness (CCT) is an important measurement in the treatment and management of pediatric glaucoma and potentially of refractive error, but data regarding reliability of CCT measurement in children are limited. The purpose of this study was to evaluate the reliability of CCT measurement with the use of handheld contact pachymetry in children. METHODS: We conducted a multicenter intraobserver test-retest reliability study of more than 3,400 healthy eyes in children aged from newborn to 17 years by using a handheld contact pachymeter (Pachmate DGH55; DGH Technology Inc, Exton, PA) in 2 clinical settings--with the use of topical anesthesia in the office and with the patient under general anesthesia in a surgical facility. RESULTS: The overall standard error of measurement, including only measurements with standard deviation ≤5 µm, was 8 µm; the corresponding coefficient of repeatability, or limits within which 95% of test-retest differences fell, was ±22.3 µm. However, standard error of measurement increased as CCT increased, from 6.8 µm for CCT less than 525 µm, to 12.9 µm for CCT 625 µm and greater. The standard error of measurement including measurements with standard deviation >5 µm was 10.5 µm. Age, sex, race/ethnicity group, and examination setting did not influence the magnitude of test-retest differences. CONCLUSIONS: CCT measurement reliability in children via the Pachmate DGH55 handheld contact pachymeter is similar to that reported for adults. Because thicker CCT measurements are less reliable than thinner measurements, a second measure may be helpful when the first exceeds 575 µm. Reliability is also improved by disregarding measurements with instrument-reported standard deviations >5 µm.

Comparison of Tono-Pen and Goldmann applanation tonometers for measurement of intraocular pressure in healthy children.

PURPOSE: To assess the agreement of intraocular pressure (IOP) measured with the Tono-Pen and the Goldmann applanation tonometer (GAT) in normal children and adolescents. METHODS: A total of 439 subjects from birth to <18 years of age without anterior segment anomalies or glaucoma had their IOP measured with the two instruments by separate, masked examiners in the office or under general anesthesia. RESULTS: On average, the Tono-Pen measured values slightly lower than the GAT for IOP <11 mm Hg and slightly higher than the GAT for IOP >11 mm Hg in the office setting. Using the average of GAT and Tono-Pen IOPs to estimate the true IOP, the average difference (GAT - Tono-Pen) was 0.4 mm Hg at IOP of 10 mm Hg and -3.0 mm Hg at IOP of 20 mm Hg. The 95% limits of agreement on the average difference between instruments were ± 6.4 mm Hg in the office setting and ± 6.8 mm Hg under general anesthesia. Larger differences between instruments were found with younger age. Standard error of measurement with the Tono-Pen was 1.44 mm Hg and 1.82 mm Hg for the office and anesthesia settings, respectively. Thicker corneas were associated with higher IOP with both the GAT and the Tono-Pen. CONCLUSIONS: In normal children, average differences between IOP measured by Tono-Pen and GAT were small, although there was substantial test-retest variability. Younger age was associated with larger average differences, as was higher IOP in the office setting.

Central corneal thickness in children.

OBJECTIVES: To determine the central corneal thickness (CCT) in healthy white, African American, and Hispanic children from birth to 17 years of age and to determine whether CCT varies by age, race, or ethnicity. DESIGN: Prospective observational multicenter study. Central corneal thickness was measured with a handheld contact pachymeter. RESULTS: A total of 2079 children were included in the study, with ages ranging from birth to 17 years. Included were 807 whites, 494 Hispanics, and 474 African Americans, in addition to Asian, unknown race, and mixed-race individuals. African American children had thinner corneas on average than that of both white and Hispanic children (P < .001 for both) by approximately 20 µm. Thicker median CCT was observed with each successive year of age from age 1 to 11 years, with year-to-year differences steadily decreasing and reaching a plateau after age 11 at 573 µm in white and Hispanic children and 551 µm in African American children. For every 100 µm of thicker CCT measured, the intraocular pressure was 1.5 mm Hg higher on average (P < .001). For every diopter of increased myopic refractive error, CCT was 1 µm thinner on average (P < .001). CONCLUSIONS: Median CCT increases with age from 1 to 11 years, with the greatest increase present in the youngest age groups. African American children on average have thinner central corneas than white and Hispanic children, whereas white and Hispanic children demonstrate similar CCT.

Triangular congenital cataract morphology associated with prenatal methamphetamine exposure.

Bilateral congenital cataracts are often characterized by morphology, etiology, and related conditions. We report a case of unique congenital cataracts with triangular morphology and associated prenatal methamphetamine exposure. Although this association is likely coincidental, the cataract's morphology in light of the specific timing of prenatal drug use deserves reporting.

Balloon catheter dilation and nasolacrimal duct intubation for treatment of nasolacrimal duct obstruction after failed probing.

OBJECTIVE: To compare the outcomes of balloon catheter dilation and nasolacrimal intubation as treatment for congenital nasolacrimal duct obstruction after failed probing in children younger than 4 years. METHODS: We conducted a prospective, nonrandomized, multicenter study that enrolled 159 children aged 6 months to younger than 48 months who had a history of a single failed nasolacrimal duct probing and at least 1 of the following clinical signs of nasolacrimal duct obstruction: epiphora, mucous discharge, or increased tear lake. One hundred ninety-nine eyes underwent either balloon catheter nasolacrimal duct dilation or nasolacrimal duct intubation. Treatment success was defined as absence of epiphora, mucous discharge, or increased tear lake at the outcome visit 6 months after surgery. RESULTS: Treatment success was reported in 65 of 84 eyes (77%; 95% confidence interval, 65%-85%) in the balloon catheter dilation group compared with 72 of 88 eyes (84% after adjustment for intereye correlation; 74%-91%) in the nasolacrimal intubation group (risk ratio for success for intubation vs balloon dilation, 1.08; 0.95-1.22). CONCLUSION: Both balloon catheter dilation and nasolacrimal duct intubation alleviate the clinical signs of persistent nasolacrimal duct obstruction in a similar percentage of patients.

Retinal findings in children with intracranial hemorrhage.

PURPOSE: To identify the incidence of Terson's syndrome in children. DESIGN: Prospective, observational case series. PARTICIPANTS: Fifty-seven consecutive children with known intracranial hemorrhage from nonabuse causes. METHODS: Dilated fundus examination to detect intraretinal hemorrhages or other abnormalities. MAIN OUTCOME MEASURES: Presence or absence of intraretinal hemorrhages or other abnormalities. RESULTS: Fifty-five patients (96%) had no evidence of intraretinal or vitreous hemorrhage. Two patients had abnormal retinal examinations. One patient had a single dot hemorrhage associated with presumed infectious white retinal lesions. The second patient had three flame and two deeper dot intraretinal hemorrhages after a motor vehicle accident (1.5% incidence of retinal hemorrhage). CONCLUSIONS: Retinal hemorrhage is uncommon in children with intracranial hemorrhage not resulting from shaken baby syndrome. The maximal incidence of intraretinal hemorrhage in children with nonabuse intracranial hemorrhage is 8%.