Diffuse unilateral hemorrhagic retinopathy associated with accidental perinatal strangulation. A clinicopathologic report.

OBJECTIVE: To report an unusual case of diffuse retinal hemorrhage associated with strangulation in a neonate with a tightly wrapped nuchal cord around his neck at birth who was noted to have eyelid and subconjunctival petechial hemorrhages upon delivery. METHODS: Clinical diagnostic examination as well as postmortem gross and histopathologic examination of ocular and central nervous system structures was performed. RESULTS: Funduscopic and gross pathologic examination of the eyes revealed extensive unilateral retinal hemorrhage of the right eye only. This was corroborated by histopathologic studies, which revealed unilateral diffuse hemorrhage throughout all nuclear layers of the retina with a particularly dense nerve fiber layer and sub-internal limiting membrane hemorrhage in the macula along with extraocular muscle and episcleral hemorrhage. Clinical, gross, and microscopic examination also revealed multiple areas of hemorrhage involving the right side of the brain and throughout the cerebellum. CONCLUSION: Although retinal findings in nonaccidental trauma are common, accidental strangulation retinopathy in neonates is a rare occurrence. To the authors' knowledge, this case is the only documented histopathologic study of hemorrhagic retinopathy associated with strangulation in the literature.

Supplemental oxygen may decrease progression of prethreshold disease to threshold retinopathy of prematurity.

The optimum level of oxygen saturation for infants with prethreshold retinopathy of prematurity (ROP) is unknown. We reviewed our conversion rate from prethreshold to threshold ROP between 1985 and 1993 during which time target levels of oxygen saturation rose in a stepwise fashion. A retrospective study of 153 infants with prethreshold ROP was performed at Stanford University between 1985 and 1993 that showed that target minimum oxygen saturation rose from 92% (1985-1987) to 95% (1988) to 96% (1989) to 99% (1990-1993). In addition, we looked at 26 infants between 1994 and 1996 who were excluded from the STOP-ROP study and who were not receiving supplemental oxygen in an effort to maintain equipoise for that study. Infant characteristics were tabulated, and rates of progression from prethreshold to threshold ROP were calculated. Rates of progression to threshold varied little between 1985 and 1989 (average 37%), but dropped to 7% for the period between 1990 and 1993. From 1994 through 1996 the rate of progression to threshold disease rose again, to 38%. Moderate supplemental oxygen (target saturation 99% with PO2 no higher than 100 mm Hg) was associated with regression of prethreshold ROP, without appearing to arrest retinal vascular maturation.

Bacteroides fragilis endophthalmitis: a case report.

Bacteroides fragilis is an infrequent anaerobic ocular pathogen. Nevertheless, this organism is of particular significance because it may be resistant to many antibiotics that are typically effective against anaerobes. We present what is to the best of our knowledge the first reported case of B. fragilis endophthalmitis. The endophthalmitis presented in a 95-year-old man following extracapsular cataract extraction with posterior chamber intraocular lens implantation.

Retinopathy of prematurity.

Retinopathy of prematurity has reappeared in the neonatal nursery after largely disappearing 35 years ago. The major factor in its reemergence is the progressive improvement in neonatal care, resulting in salvage of infants who formerly would have been lost. Oxygen is now recognized to be but one of many interacting factors in the development of retinopathy of prematurity, with extreme immaturity being the primary factor. Methods of examination, classification and treatment of retinopathy of prematurity are discussed.

Retinal folds in the shaken baby syndrome.

We examined two children with presumed shaken baby syndrome. Both children suffered severe, indirect closed head trauma with intracranial hemorrhage, sharply increased intracranial pressure, and extensive neurologic damage. In addition to extensive retinal and preretinal hemorrhages, bilateral symmetric white ring-shaped retinal folds were seen encircling the macula outside the vascular arcades. These retinal folds may be a hallmark of shaking injuries in child abuse victims.

Visual electrical evoked potentials: evaluation of ocular injuries.

Clinical neurophysiologists may be asked to participate in the evaluation of patients with injured eyes. We describe a method for eliciting evoked potentials of cerebral origin using electrical pulse stimuli delivered to the globe of the eye through a contact lens electrode mounted on the cornea. These visual electrical evoked potentials (VEEPs) are contrasted with conventional flash visual evoked potentials in normal subjects and in 19 eyes of 17 patients with severe ocular damage, mostly recent trauma. The findings suggest that the site of transcorneal electrical excitation is not the photoreceptors, but more likely one of the nerve cell layers of the retina. VEEP recordings offer a way to circumvent the opacification of the ocular media by blood, which may otherwise hamper the evaluation of retinal function in the injured eye. Preserved VEEP response does not necessarily predict the capacity to recover visual function. Absent VEEP response is an unfavorable prognostic sign, which may be considered in arriving at a decision about enucleation.

Four-port bimanual vitrectomy.

A further subdivision of functions during vitrectomy surgery has been enabled. By means of a separate, suture-secured fiberoptic endoilluminator and a modified infusion cannula located in the inferior quadrants, two superior sclerotomies are kept free for the use of a variety of simple and complex instruments, alone or in combination. Included among these are vitreous scissors, forceps, picks, spatulas, diathermy probes, and endophotocoagulators.

Retinal neovascularization and ocular toxoplasmosis.

Retinal neovascularization, a rare complication of ocular toxoplasmosis, is a source of vitreous hemorrhage. We examined three patients (all women, 70, 36, and 19 years old) with inactive toxoplasmosis scars associated with occlusion of a retinal arteriole or venule passing through the scar, capillary nonperfusion, and adjacent retinal neovascularization. In two patients photocoagulation of the ischemic areas produced a cessation of hemorrhage and the disappearance of neovascularization. In the third case, the neovascular frond was avulsed from its supplying retinal arteriole without treatment.

Integrated projection of fundus photographs during macular photocoagulation.

Macular photocoagulation requires precise localization of abnormalities to be treated, in order to accomplish the aims of therapy without unnecessarily damaging adjacent tissue. A method is described by which a color fundus photo or a fluorescein image can be projected through a beam splitter into the ocular of a laser slit lamp, thus affording an image congruent with the surgeon's view of the patient's macula.

Alpha-interferon administration in cytomegalovirus retinitis.

Four patients, including three with the acquired immunodeficiency syndrome (AIDS), were treated with high-dose, buffy coat-derived alpha-interferon for progressive cytomegalovirus retinitis. Two of these patients had decreased viruria during therapy and the other two had increased viruria. There was evidence of progression of disease despite therapy in all patients, although the retinitis eventually became quiescent in the patient without AIDS. The severe immunosuppression encountered in AIDS patients complicates the management of cytomegalovirus and other opportunistic infections.

Linear array multiple transducer ultrasonic examination of the eye.

Dynamic ultrasonic imaging adds a time dimension to the clinical diagnosis of ocular pathology. A recent development in this area of ophthalmic sonography has been the introduction of an electronically scanned, multiple transducer system that provides improved real-time imaging of ocular tissue motion. This paper discusses clinical observations made in a variety of ophthalmic conditions with a high speed, linear array ultrasound system and discusses briefly the apparatus and special examination techniques needed to make these observations. Clinical subjects include vitreo-retinal adhesions: the clear cortical vitreous network; vitreous hemorrhage, opacities and membranes; shallow, fixed, and mobile retinal detachments; blood vessels within ocular tumors and the evaluation of intraocular foreign bodies.

Trauma-induced endophthalmitis caused by Acinetobacter anitratus.

A 56-year-old man sustained an intraocular injury by a piece of steel followed by endophthalmitis, which resolved after lensectomy, vitrectomy, and intravitreal injections of gentamicin. Acinetobacter anitratus was the organism responsible for the endophthalmitis. It is a Gram-negative polymorphic organism that can resemble several other pathogens and possesses unpredictable antibiotic susceptibility. A. anitratus is an important cause of nosocomial infection but has not previously been reported as a cause of endophthalmitis following trauma.

Down's syndrome: a ten-year group study.

Thirty individuals with the clinical diagnosis of Down's syndrome received ophthalmologic examination periodically over 10 years at a state school for exceptional children. External examination, retinoscopy, anterior segment evaluation, ophthalmoscopy, and tonometry were usually done. The ages at present range from 10 to 50 years. The sex ratio was 80% male and 20% female. Three subjects died during the course of the study. The most frequent ocular anomalies were oblique fissures, refractive error, blepharoconjunctivitis, epicanthus, and Brushfield's spots. All of these occurred in 50% or more of the subjects.