Medical conditions of children and young people with Down syndrome.

BACKGROUND: The life expectancy of people with Down syndrome (DS) has significantly increased in the last decades. We describe the congenital malformations and main comorbidities of a cohort of children and young people with DS and analyse their differences according to age and gender groups. METHODS: This retrospective cross-sectional study was conducted at DS centre of Bambino Gesù Children's Hospital in Rome (Italy). The period for reviewing all electronic health records ran from July 2016 to September 2017. We collected data on clinical conditions and compared them with the general paediatric population. Moreover, we compared the main comorbidities, dental diseases and body mass index data between age groups. RESULTS: Seven hundred sixty-three children and young people with DS included in this study were aged 7.45 ± 5.49 years. Gender distribution included 58.19% male patients. The majority of our population (71.04%) came from central regions of Italy. Respiratory diseases (19%), congenital heart defects (72.23%), malocclusions (58.62%), astigmatism (20.31%), farsightedness (16.51%), near-sightedness (12.19%) and autoimmune hypothyroidism (3.28%) were more frequent in our population compared with the typical paediatric population. Upper respiratory tract infections and underweight were significantly more frequent in the youngest children, whereas dental diseases, refractive errors, obesity and autoimmune hypothyroidism increased over age. CONCLUSIONS: Children and young people with DS present a high prevalence of potentially treatable medical conditions making multidisciplinary teams a mandatory need for this population.

Visual perception skills: a comparison between patients with Noonan syndrome and 22q11.2 deletion syndrome.

Ventral and dorsal streams are visual pathways deputed to transmit information from the photoreceptors of the retina to the lateral geniculate nucleus and then to the primary visual cortex (V1). Several studies investigated whether one pathway is more vulnerable than the other during development, and whether these streams develop at different rates. The results are still discordant. The aim of the present study was to understand the functionality of the dorsal and the ventral streams in two populations affected by different genetic disorders, Noonan syndrome (NS) and 22q11.2 deletion syndrome (22q11.2DS), and explore the possible genotype-phenotype relationships. 'Form coherence' abilities for the ventral stream and 'motion coherence' abilities for the dorsal stream were evaluated in 19 participants with NS and 20 participants with 22q11.2DS. Collected data were compared with 55 age-matched controls. Participants with NS and 22q11.2DS did not differ in the form coherence task, and their performance was significantly lower than that of controls. However, in the motion coherence task, the group with NS and controls did not differ, and both obtained significantly higher scores than the group with 22q11.2DS. Our findings indicate that deficits in the dorsal stream are related to the specific genotype, and that in our syndromic groups the ventral stream is more vulnerable than the dorsal stream.

The association between retinal microvascular changes, metabolic risk factors, and liver histology in pediatric patients with non-alcoholic fatty liver disease (NAFLD).

BACKGROUND: The prevalence of childhood obesity is increasing worldwide. Studies in adult populations show that retinal microvascular changes are associated with obesity and components of the metabolic syndrome. In our study we have assessed the effect of body mass index (BMI), metabolic parameters, and adiposity on the retinal microvasculature in children. METHODS: Fifty-four consecutive children with biopsy-proven NAFLD were enrolled in this study. Anthropometric and laboratory parameters were obtained using standardized protocols. Retinal caliber was quantified from digital retinal images using well-known computer-based programs. Twenty-four-hour ambulatory blood pressure monitoring was measured using a standard protocol. RESULTS: In our population, the prevalence of retinopathy was of 53 % (13 males). The 29 patients with retinopathy (mean age 10.91 ± 3.10) showed significantly higher values of triglycerides (mg/day) (105.57 vs. 90.20, p = 0.04), basal insulin (mUI/ml) (17.20 vs. 12.97, p = 0.02), and HOMA-IR (3.37 vs. 2.76, p = 0.04). The patients with a HOMA-IR >2.5 (OR = 3.34, p = 0.02; 95 % IC, 1.07-10.39), and systolic non-dipping (OR 4.16, p = 0.028, 95 % IC, 1.11-13.67), have an increased risk of retinopathy. Moreover, the study of correlation between all stages of liver biopsy (CRN criteria) and the grade of retinopathy showed a positive correlation with fibrosis (r = 0.31) and an NAS score (r = 0.28). CONCLUSIONS: We found an association between metabolic parameters and nocturnal blood pressure on the retinal microvasculature among the obese children with NAFLD. Furthermore, for the first time, we report the positive relationship between hepatic fibrosis in pediatric NAFLD patients and the degree of retinopathy signs.

Transiently raised intraocular pressure reveals pattern electroretinogram losses in ocular hypertension.

PURPOSE: It is known that the pattern electroretinogram (PERG) of normal subjects is reduced temporarily after short-term elevation of intraocular pressure (IOP). The authors evaluated PERG changes in ocular hypertension during and after transient IOP elevation. METHODS: Steady state (8 Hz) PERGs to sinusoidal gratings (1.7 cyc/deg spatial frequency) were recorded in seven untreated patients with ocular hypertension at medium risk (maximum IOP, 22 to 25 mm Hg; cup-disk ratio, 0.6 to 0.7; normal Humphrey 30-2 visual field results; positive family history), as well as in six age-matched normal subjects. Recordings were obtained for the baseline condition during a short-term (6-minute) IOP elevation (to 30 mm Hg) by using a suction cup apparatus and during a 6-minute recovery period after removal of the apparatus. RESULTS: During IOP elevation, PERG amplitudes were reduced significantly from baseline values in normal subjects and patients. However, PERG losses were significantly greater in patients (average loss from baseline after 4 minutes of IOP elevation: 72% +/- 7.6%) compared to controls (average loss after 2 minutes of IOP elevation: 40% +/- 7.5%). In the recovery phase, mean PERG amplitude returned to baseline values in normal subjects but not in patients, whose recovery took longer. In normal subjects, PERG phase did not change either during or after IOP elevation. In patients, however, PERG phase showed a delay from baseline during and after IOP elevation (average delay after 6 minutes of recovery: -41.1 degrees +/- 13 degrees). CONCLUSIONS: Results indicate that increasing IOP with scleral suction produces greater PERG losses in eyes with ocular hypertension than in normal eyes. This suggests that the inner retina of eyes with ocular hypertension may have a heightened sensitivity to vascular or mechanical changes induced by transient IOP elevation.

Postreceptoral contribution to macular dysfunction in retinitis pigmentosa.

PURPOSE: To understand the sites of macular dysfunction in retinitis pigmentosa by evaluating focal electroretinogram (FERG) fundamental and second harmonic components, which are dominated by the activity of the outer and inner retina, respectively. METHODS: FERGs were recorded in response to a uniform field (9 degrees x 9 degrees) flickered sinusoidally at either 8 Hz or 32 Hz. The fundamental components of the responses to both the 8-Hz and 32-Hz stimuli and the second harmonic of the response to the 8-Hz stimulus were measured in their amplitudes and phases. Normal subjects (n = 17), as well as patients with typical retinitis pigmentosa (n = 22), cone dystrophy (CD, n = 7) and X-linked congenital retinoschisis (XLR, n = 5) served as subjects. The fundamental (32-Hz)-second harmonic (8 Hz) amplitude ratio was taken as an index of the relative function of outer-inner layers of the macula. RESULTS: Compared to controls, patients with retinitis pigmentosa showed losses of both FERG fundamental and second harmonic and an increase of the fundamental-second harmonic ratio. Patients with CD also showed losses of both fundamental and second harmonic, but the fundamental-second harmonic ratio was normal. Patients with XLR had a selective loss of the second harmonic, resulting in an increased fundamental-second harmonic ratio. On average, the fundamental-second harmonic ratio of patients with retinitis pigmentosa tended to increase with age. CONCLUSIONS: The results suggest that in retinitis pigmentosa, both receptoral and postreceptoral sites contribute to macular dysfunction. This differs from CD and XLR, where losses appear more selective for the outer and the inner retina. Postreceptoral losses in retinitis pigmentosa may become larger with increasing age.

Correlation of pattern electroretinogram with optic disc cup shape in ocular hypertension.

PURPOSE: To evaluate the correlation of pattern electroretinogram (PERG), an index of inner retinal function, with confocal scanning laser (CSLO) optic disc structural parameters in ocular hypertension (OHT). METHODS: Thirty-four patients with OHT, normal white-on-white (Humphrey 30-2) perimetry, and normal clinical optic discs were examined with PERG and CSLO disc analysis. Two groups of normal subjects (n = 38 and 18, for PERG and CSLO, respectively) and a group of 12 patients with early open-angle glaucoma (EOAG) were also tested. Pattern electroretinogram amplitudes were measured in response to sinusoidal gratings of variable spatial frequency (0.58-5.8 cycles/degree), modulated in counter-phase at 7.5 Hz. Morphometric optic disc parameters were obtained by the Heidelberg Retina Tomograph (HRT), either globally or from predefined disc sectors. In addition to standard parameters, the cup shape measure, an index of depth variation and steepness of the cup walls, was determined. RESULTS: In individual OHT patients, PERG amplitudes at 2.6 cycles/degree were negatively correlated with cup shape measures (r = -0.43, P < 0.01) obtained from analysis of the inferotemporal (IT) sector. No significant correlations were found for the other parameters. On average, the cup shape measures derived from IT sector or global analysis were significantly (P < 0.01) worse, and closer to the measures of EOAG patients, in OHT patients with abnormal PERG compared with those with normal PERGs. The cup shape measure displayed a low sensitivity (20%) and a high specificity (100%) in predicting PERG abnormalities in individual OHT patients. CONCLUSIONS: The results indicate that in OHT there is a significant although weak correlation between PERG amplitude and the shape of the optic disc cup, suggesting a parallel involvement of both function and morphology. Combined PERG and optic disc cup structural analysis is of potential diagnostic value to detect early damage to optic nerve head in individual OHT patients.

Macular flicker electroretinograms in Best vitelliform dystrophy.

PURPOSE: The aim of this study was to evaluate the function of the neurosensory retina in Best vitelliform macular dystrophy (BMD) by recording the focal electroretinogram (ERG) fundamental and 2nd harmonic components, which are known to be dominated by receptoral and postreceptoral activity, respectively. METHODS: FERGs were recorded in response to a uniform field (9 x 9 deg) flickered sinusoidally at either 8 Hz or 32 Hz (peak frequencies for the 2nd and fundamental harmonic, respectively). The fundamental component of the response to the 32-Hz stimulus and the 2nd harmonic of the response to the 8-Hz stimulus were measured in their amplitudes and phases. The fundamental-2nd harmonic amplitude ratio was taken as an index of the relative changes in the FERG components. Eleven patients with BMD and vitelliform stage macular lesions were evaluated. Results were compared with those obtained from 13 patients with Type 2 Stargardt macular dystrophy (STD) according to the Noble and Carr Classification, and 29 normal control subjects. Four BMD and four STD patients were also followed electrophysiologically over a 48 month period. RESULTS: Compared to controls, BMD patients showed losses of both FERG fundamental and 2nd harmonic amplitudes, and an increase in the fundamental and increase in the fundamental-2nd harmonic ratio. STD patients also showed losses of both fundamental and 2nd harmonic, but the fundamental-2nd harmonic ratio was normal. In BMD patients, but not in those with STD, the fundamental amplitude tended to decrease over the follow-up period. CONCLUSIONS: The results indicate that BMD involves neurosensory abnormalities early in the disease process. The increased fundamental-2nd harmonic ratio suggests that a postreceptoral dysfunction may be present in addition to that of photoreceptors. This differs from STD, where losses appear to affect primarily the receptoral retina. Receptoral losses in BMD may progress throughout the medium-term follow up.

Massive corneal edema treated with corneal cross-linking.

INTRODUCTION: Massive corneal edema disrupts the fine architecture of corneal stroma that guarantees its transparency, causing opacities that seriously impair clear vision and are usually solved by corneal transplant. Corneal cross-linking, a treatment developed to halt keratoconus progression, results in a loss of water and a compaction of corneal stroma. It might therefore be useful to improve the pathologic edematous condition of some corneas, ameliorating visual acuity and allowing more time for a surgical procedure of keratoplasty. PATIENTS AND METHODS: Six patients with visual impairing corneal edemas further to lens phacoemulsification, penetrating keratoplasty, or post-infective neovascularization were treated with corneal cross-linking alone, or in combination with amniotic membrane apposition with or without anti-angiogenic therapy. RESULTS: All patients partly resolved the edematous condition, improving both corneal transparency and visual acuity. CONCLUSIONS: Corneal cross-linking appears to be a useful method to treat massive corneal edemas, so that keratoplasty can be at least delayed, and need not to be an emergency treatment in these cases.

Pattern electroretinogram and optic nerve topography in ocular hypertension.

It is known that changes in pattern electroretinogram (PERG) and optic disk morphology may both precede the onset of visual field damage in glaucomatous disease. However, the relationship between PERG and optic disk morphometry in ocular hypertension (OHT) has not yet been evaluated in detail. This study of PERG amplitude in a group of OHT patients indicates its significant correlation with various optic disk morphometric parameters, in particular, those of optic disk sectors considered at risk for early glaucomatous damage. Analysis of individual data points to the possibility that, while functional abnormalities may often precede optic disk morphologic changes, in a much lower number of cases it seems to be the other way around.

Macular electroretinograms to flicker and pattern stimulation in lamellar macular holes.

Steady-state macular (9 degrees x 9 degrees) electroretinograms in response to either sinusoidal flicker (focal electroretinogram) or counterphased sinusoidal gratings (pattern electroretinogram) were recorded in 14 patients with inner lamellar macular holes, in 4 patients with full-thickness macular holes and in 14 age-matched controls. Fourier analysis of focal and pattern electroretinograms yielded three main components: a first and a second harmonic to flicker, and a second harmonic to pattern. Recent evidence indicates that the first harmonic to flicker is of receptoral origin, whereas the flicker and pattern second harmonics represent, at least in part, the activity of different generators in the inner retina. When compared to controls, patients with inner lamellar holes showed significant amplitude reduction and phase delay for both flicker and pattern second harmonics, but not for the flicker first harmonic. Patients with full-thickness holes showed significant amplitude reduction also for the flicker first harmonic. These results indicate a prevalent functional involvement of the inner retina in lamellar macular holes, which can be clinically detected by evaluating focal and pattern electroretinogram second harmonics.

Pattern electroretinogram in treated ocular hypertension: a cross-sectional study after timolol maleate therapy.

To investigate pattern electroretinogram changes in treated ocular hypertension, we evaluated pattern electroretinogram recordings of 48 hypertensive eyes following an 8-month timolol maleate therapy. During treatment, 27 of 48 eyes had normalized intraocular pressures (15-18 mm Hg), while 21 retained elevated values (21-25 mm Hg). Twenty-eight eyes with untreated hypertension (22-25 mm Hg) lasting at least 8 months, as well as 32 untreated, normotensive eyes served as controls. When compared to untreated normotensive controls, timolol-treated eyes with either elevated or normalized intraocular pressures showed reductions in the mean electroretinographic amplitudes. However, these amplitude reductions were substantially greater in treated eyes with elevated pressures as compared to those with normalized ones. Untreated hypertensive controls showed pattern electroretinogram reductions, with respect to normal values, that were comparable to those of treated hypertensive eyes, but larger than those of treated normotensive ones. These results indicate that, in treated ocular hypertension, pattern electroretinogram losses tend to be associated with moderately increased intraocular pressures in the range of 21-25 mm Hg. Electroretinographic abnormalities may be, at least in part, prevented only by lowering intraocular pressure into a normal range.