Fatal measles encephalopathy with retinopathy during cytotoxic chemotherapy.

A 14-year-old boy receiving post-operative cytotoxic chemotherapy for a testicular rhabdomyosarcoma developed a fatal encephalopathy associated with retinal changes 2 months after an episode of acute measles. Post-mortem histological examination showed intranuclear inclusion bodies in the neurons and glial cells, but inflammatory cell infiltrations were absent. Electron-microscopic and immunofluorescent studies revealed intracellular masses of paramyxovirus nucleocapsid-like structures, which had the morphological and antigenic properties of measles virus. Recent reports have emphasized the possibility of occurrence of a similar encephalopathy in treated childhood leukemia. It is evident, however, that this potentially fatal complication must be borne in mind when measles is contracted during any form of cytotoxic treatment or immunosuppression. Retinal changes may be of value for the diagnosis during life. We propose the designation "measles encephalopathy during immunosuppression" (MEI) for this condition.

Measles retinopathy during immunosuppression.

A 14-year-old boy had an acute attack of measles while on cytotoxic chemotherapy for a testicular neoplasm. Two months later a fatal measles encephalopathy developed, verified by histological, ultrastructural, and immunofluorescent studies. Ophthalmoscopy showed progression of flat depigmented areas of the retina as well as prominent lesions mimicking central serous retinopathy or retinitis. Histopathological studies showed focal retinal necroses with invasion of pigment-laden macrophages into the retina. There were no inflammatory cell infiltrations in the choroid. The presence of structures with the morphological and antigenic properties of measles virus in the affected areas of the retina was shown by electron microsocpy and indirect immunofluorescence. With the increase of immunosuppressive therapy for various purposes the incidence of opportunistic measles virus infections is likely to rise. In the clinical management of such complications ophthalmological examination may prove very helpful.

A simple method for anterior segment photography of the eye with standard equipment.

A simple hand-held system for colour photography of the anterior eye structures using a standard camera and conventional incandescent slit lamp is presented for use by a general eye practitioner. No electronic flash is required. The anterior ocular pathology is well documented with the method.

A simple method for screening of children with strabismus, anisometropia or ametropia by simultaneous photography of the corneal and the fundus reflexes.

A simple screening method for detecting strabismus, anisometropia and ametropia in young children by simultaneous photography of the corneal and fundus reflexes with a conventional camera and flashlight is presented. The method is the photographic application of the von Brückner Durchleuchtung test and static skiascopy. The objective document from the external part of the eyes and the face is obtained at the same time. Model photographs with certain gaze deviation angles are presented with the method.

Photographic screening for strabismus and high refractive errors of children aged 1-4 years.

UNLABELLED: 182 children (age 1-4 years) were photographed by health sisters at the annual screening at the children's health care center as described by Kaakinen (1979). The photographs were examined by an ophthalmologist to diagnose squint and/or refractive error cases based on the typical changes in the corneal and fundus reflexes. The cases found in this way were controlled clinically. RESULTS: 7 pathological cases were detected: 2 esotropias, 1 microesotropia, 2 hyperopias of both eyes, 2 anisocorias. False positive were 6 cases, from which 4 were false positive microstrabismus suspects and 2 cases with asymmetrical fundus reflexes, which were normal. 14 cases failed (9 (4.9%) looked to the side, and 5 (2.7%) were technical failures). For the reliability of the method, a random sample of 20 children, who had normal corneal and fundus reflexes were examined clinically. No anisometropia of over 0.5 diopters appeared among these 20 control cases, and the highest hyperopic and astigmatic errors that appeared were +1.75 diopters. All the astigmatic cases were combined with a slight myopia of -0.5- -1.0 diopters in each case. No higher myopias occurred in this group, and all these 20 children had straight eyes with the cover test at near fixation.

A clinical study on the detection of strabismus, anisometropia or ametropia of children by simultaneous photography of the corneal and the fundus reflexes.

Twenty two strabismus and 106 straight eyed patients with anatomically normal eyes were first photographed with a conventional camera equipped with a weak 100 mm teleobjective and coaxial flashlight and then examined clinically. The possibility of detecting strabismus, anisometropias and ametropias in the photographs by noting the localisation of the corneal reflexes and examining the appearance and lightness of the fundus reflexes and their possible asymmetry were tested in a double blind study. Even small angled strabismus cases could be found because of the asymmetrical localisation of the corneal reflexes. In 18 of the 22 strabismus cases (82%) there was asymmetrical lightness of the fundus reflexes and the fundus reflex of the deviating eye was lighter than that of the fixating eye. All the straight eyed anisometropias of 3.0 diopters or more (five cases) were observed in the photographs because of the asymmetrical appearance of the fundus reflexes. In straight eyed anisometropias of under 3.0 diopters, the fundus reflexes were symmetrical in 90 cases and asymmetrical in 11 cases (11%). Only three out of eight hyperopias of fomr +4.5 to +6.0 diopters were found because of the light crescent in the low part of the pupil. All myopias of over -4.0 diopters (14 cases) were observed because of the light crescent appearance in the upper part of the pupil. No pupillary crescents appeared with refractions of less than -1.75 diopters myopia or less than +4.5 diopters hyperopia; 172 eyes came within this range. Even a technician can perform, without premedication, the method tested here for rapid and simple screening to detect strabismus and straight eyed anisometropias of 3.0 diopters or more in small children or other patients who do not co-operate well in normal clinical examination. Over -4.0 diopters myopias can also be found. The method was rather unreliable for finding hyperopias, presumably because no cycloplegic drops were used.

Screening of infants for strabismus and refractive errors with two-flash photorefraction with and without cycloplegia.

35 1/2-year-old and 31 1-year-old children were screened by two-flash photorefraction for strabismus and refractive errors with and without cycloplegia. The sensitivity of the method to detect refractive errors was tested with an optical demonstration eye. All the children were examined clinically to compare the sensitivity of the method. Every child co-operated with the photography, but 4 children did not co-operate in the clinical examination and were thus excluded from the refractive material, as were also two cases of esotropias which were found. There were no false positive or negative strabismus cases. The total refractive material consisted of 120 eyes. The method was clearly more sensitive for refractive errors with cycloplegia. Even one hyperopia of +5.25 D(OD) and +6.0 D(OS) was underestimated without cycloplegia. In the material there were no cases of anisometropia of over 1.0 D in spherical equivivalent that would cause a potential risk for amblyopia. A rather good correlation of refractive results existed with the method in cycloplegia. With partial overlapping of emmetropic and moderate hyperopic cases. The screening of children aged 1/2-1 year with two-flash photorefraction is simple to perform. The underestimation of symmetrical hyperopias should be accepted when cycloplegia is not used. Only one successful photograph of each child is necessary for the interpretation.

Two-flash photorefraction in screening of amblyogenic refractive errors.

A selection of amblyopic (n = 14) and nonamblyopic (n = 18) children with different ametropias, anisometropias, and astigmatisms was photorefracted without cycloplegia by two-flash photorefraction (T-FP) in which refractions in both horizontal and vertical meridians of both eyes are measured simultaneously. The results were compared to conventional cycloplegic retinoscopy in a blind study. Significant amblyogenic conditions, such as hyperopic anisometropias of more than 1.0 diopter (D), high ametropias, or astigmatism and strabismus cases of 2 degrees to 3 degrees or more are detectable. The technique provides a simple and useful tool for mass screening of infants. The sensitivity of the method for detecting amblyopia seems to be at least as high as in visual checking. Media opacities are recordable, and a permanent document is obtained.

Mass screening of children for strabismus or ametropia with two-flash photoskiascopy.

UNLABELLED: 169 non-selected 1-5 year-old children (338 eyes) were screened by two-flash photoskiascopy with an autofocus camera for strabismus, high anisometropia and high ametropias without cycloplegia. The photography was performed by nurses or technicians and the photographs were analyzed by an optician. The sensitivity of the method for the refractive errors was tested with an optical demonstration eye. FINDINGS: 5 esotropias, 1 exotropia, 1 straight-eyed hypermetropic anisometropia of 4 diopters; 1 false positive high hyperopia (of +2.5 diopters) of both eyes. The examination of the photographs showed slight refractive errors in 33 cases (66 eyes; 19.5%): two of them of symmetrical myopia of -1.0 and -1.75 diopters and 31 of symmetrical hyperopia of +0.25 to +4.25 diopters in retinoscopy. 128 cases (256 eyes; 76%) were normal on the photographs. Of these, 37 non-selected cases (74 eyes) were checked clinically and were symmetrical cases of -1.0 to +3.25 diopters on retinoscopy. No false negative cases appeared among these control cases. 2,4% of the photographs failed technically or because of noncooperation of the children. Two-flash photoskiascopy, performed by technicians or nurses provides a valuable tool for mass screening of infants for strabismus and/or ametropia causing amblyopia.