Anterior Ischemic Optic Neuropathy in a Child Receiving Chronic Hemodialysis.

Anterior ischemic optic neuropathy (AION) occurs due to hypoperfusion of the optic nerve and is a rare complication in patients receiving maintenance dialysis. To date, AION has only been reported in 22 children, all of whom were receiving peritoneal dialysis. We report the first case of AION in a 2-year 11-month-old child receiving chronic hemodialysis secondary to polycystic kidney disease from a phosphomannomutase 2 gene mutation. This case highlights the consideration for frequent blood pressure monitoring and ophthalmic screening in a certain cohort of children receiving chronic dialysis.

Ophthalmology referral as part of a multidisciplinary approach to suspected abusive head trauma.

OBJECTIVE: To determine the use of ophthalmology consultation as part of investigation of children with suspected abusive head trauma (AHT). METHODS: Retrospective chart review of children under age 3 years evaluated at McMaster Children's Hospital for suspected AHT from January 2011 to December 2017. RESULTS: Fifty-seven children were investigated, and 29 (50.9%) of these were determined to have likely AHT. Eleven (19.3%) had other nonaccidental injuries. A mean of 3.6 consulting services were involved. Neuroimaging was performed for 52 patients (91.2%), including all patients in the AHT group. Intracranial hemorrhage (ICH) was present in 21 of the 29 AHT children (72.4%). All 57 patients had a dilated fundus examination, and retinal hemorrhages (RH) were seen in 23 patients (40.4%), including 16 (55.2%) in the AHT group. All patients with RH in AHT also had ICH. In the AHT group, there were more cases of hemorrhages too numerous to count (68.8% vs 28.6%), multilayered hemorrhages (75.0% vs 57.1%), and hemorrhages in the posterior pole and periphery (87.5% vs 42.9%) when compared with patients with RH from other etiologies. Retinoschisis was seen in the AHT group only in 3 patients (18.8%). CONCLUSIONS: A multidisciplinary approach is important when investigating suspected AHT. Not every child with RH had suffered AHT; however, children with AHT showed more widespread and more multilayered RH. The only finding specific to AHT was retinoschisis.

Increased incidence of retinopathy of prematurity and evolving treatment modalities at a Canadian tertiary centre.

OBJECTIVE: To determine the incidence of retinopathy of prematurity and severity of disease at a large Canadian tertiary care centre, as well as to determine risk factors for disease and current treatment practices. METHODS: This was a retrospective cohort study of infants admitted to the neonatal intensive care unit (NICU) at McMaster Children's Hospital, who underwent screening for retinopathy of prematurity between August 2010 and August 2016. RESULTS: The overall incidence of retinopathy of prematurity was 67.1% (418/623 infants); severe retinopathy of prematurity was seen in 14.3% (89/623). This signified an increase compared to our previous study at the same institution, where the incidence of retinopathy of prematurity was 40.4% and severe retinopathy of prematurity was 9.2% between 2006 and 2010. Stage 1 disease showed the greatest increase, from 9.0% (38/423) to 21.0% (131/623). Our cohort had a higher proportion of infants born at 24 weeks GA or less (15.7% vs 8.7%). Predictors of retinopathy of prematurity in a multivariate regression model were gestational age (OR = 0.829, p = 0.002), birth weight (OR = 0.712, p = 0.003) and length of NICU stay (OR = 0.844, p = 0.00). Treatment was performed in 10.5% (44/418) of infants with retinopathy of prematurity, with infants earlier in the study period mainly receiving laser photocoagulation and infants born in more recent years receiving intravitreal bevacizumab. CONCLUSIONS: There has been an increase in retinopathy of prematurity incidence, both in early (stage 1) disease and in severe retinopathy of prematurity. This is partially explained by the almost doubling of the proportion of infants born at 24 weeks gestational age or less. Since mid-2013, intravitreal anti-VEGF therapy has replaced laser photocoagulation as the preferred treatment modality. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Accuracy of a Popular Online Symptom Checker for Ophthalmic Diagnoses.

Importance: Because more patients are presenting with self-guided research of symptoms, it is important to assess the capabilities and limitations of these available health information tools. Objective: To determine the accuracy of the most popular online symptom checker for ophthalmic diagnoses. Design, Setting, and Participants: In a cross-sectional study, 42 validated clinical vignettes of ophthalmic symptoms were generated and distilled to their core presenting symptoms. Cases were entered into WebMD symptom checker by both medically trained and nonmedically trained personnel blinded to the diagnosis. Output from the symptom checker, including the number of symptoms, ranking and list of diagnoses, and triage urgency were recorded. The study was conducted on October 13, 2017. Analysis was performed between October 15, 2017, and April 30, 2018. Main Outcomes and Measures: Accuracy of the top 3 diagnoses generated by the online symptom checker. Results: The mean (SD) number of symptoms entered was 3.6 (1.6) (range, 1-8). The median (SD) number of diagnoses generated by the symptom checker was 26.8 (21.8) (range, 1-99). The primary diagnosis by the symptom checker was correct in 11 of 42 (26%; 95% CI, 12%-40%) cases. The correct diagnosis was included in the online symptom checker's top 3 diagnoses in 16 of 42 (38%; 95% CI, 25%-56%) cases. The correct diagnosis was not included in the symptom checker's list in 18 of 42 (43%; 95% CI, 32%-63%) cases. Triage urgency based on the top diagnosis was appropriate in 7 of 18 (39%; 95% CI, 14%-64%) emergent cases and 21 of 24 (88%; 95% CI, 73%-100%) nonemergent cases. Interuser variability for the correct diagnosis being in the top 3 listed was at least moderate (Cohen κ = 0.74; 95% CI, 0.54-0.95). Conclusions and Relevance: The most popular online symptom checker may arrive at the correct clinical diagnosis for ophthalmic conditions, but a substantial proportion of diagnoses may not be captured. These findings suggest that further research to reflect the real-life application of internet diagnostic resources is required.

Determinación cualitativa de algunos metabolitos de seis glucocorticoides en orina a través de cromatografía líquida de alta eficiencia acoplada a masas-masas. / Qualitative determination of metabolites in urine of six glucocorticoids by high performance liquid chromatography coupled to mass-sprectrometry

El uso de glucocorticoides está prohibido en el campo deportivo durante las competencias si son administrados por vías sistémicas, para lo cual, WADA definió un nivel de reporte de 30ng/mL para los compuestos padre y sus metabolitos. En este trabajo ha sido desarrollada una metodología analítica para la determinación cualitativa de los principales metabolitos de algunos glucocorticoides sintéticos: Betametasona, Budesonida, Dexametasona, Metilprednisolona, Prednisolona, y Triamcinolona Acetónido, presentes en muestras de orina conservadas por el Laboratorio de Control al Dopaje de COLDEPORTES. La metodología incluyó una comparación entre la extracción de los analitos libres y conjugados con glucurónido (para determinar cuál de las dos fracciones era más útil en el análisis de estas sustancias), su separación por cromatografía liquida de alta eficiencia con ionización positiva y la detección por medio de trampa iónica (HPLC-MS-MS). Se seleccionaron los metabolitos mayoritarios a través de sus tiempos de retención, posteriormente se fragmentaron para obtener sus espectros y a través de la abundancia se determinó la cantidad presente en cada fracción (libre y conjugada). Se identificaron los seis glucocorticoides y un total de doce metabolitos, que permitirán hacer un rastreo más prolongado del consumo de las sustancias. Además se confirmó que las cantidades para la mayoría de los compuestos de interés, fueron más altas en la fracción libre de las muestras de orina, pero que no es posible eliminar el proceso de hidrolisis porque algunos metabolitos se excretan conjugados.

Glucocorticoids use is prohibited on the sport during competitions when they are administered by systemic routes for which WADA defined a reporting level of 30ng/ml for parent compounds and their metabolites. In this paper has been developed an analytical methodology for the qualitative determination of the main metabolites of some synthetic glucocorticoids: Betamethasone, Budesonide, Dexamethasone, Methylprednisolone, Prednisolone and Triamcinolone Acetonide, present in urine samples preserved by the Laboratory of Doping Control of COLDEPORTES. The methodology included a comparison between the extraction of free and conjugated with glucuronide analytes (to determine which of the two fractions was more useful in the analysis of these substances), their separation by high performance liquid chromatography with positive ionization and detection using ion trap (HPLC -MS- MS). Major metabolites were selected by their retention times, later fragmented to obtain its spectra and through their abundance determine the amount present in each fraction (free and conjugated). There were identified the six glucocorticoids and twelve metabolites, that will allow to make a more extended screening of the consumption of these substances. Also it was confirmed that the amounts for most of the compounds of interest, were higher in the free fraction of the urine samples, but it is not possible to eliminate the hydrolysis process because some metabolites are excreted as conjugates.

Probing without irrigation in children with congenital nasolacrimal duct obstruction.

PURPOSE: The purpose of this study was to evaluate the results of probing, without fluorescein irrigation, as a primary treatment for epiphora and/or mucous discharge, secondary to congenital nasolacrimal duct obstruction (CNLDO) METHODS: The medical records of nine-two children (127 eyes) with CNLDO who underwent a single probing without the use of fluorescein irrigation between January 2006 and December 2011 were reviewed retrospectively. Inclusion criteria were no prior nasolacrimal surgical procedure, history of epiphora and/or discharge since birth or shortly after birth in one or both eyes and at least one of the following clinical signs: epiphora, muco-purulent discharge and increased tear meniscus height. Children were investigated in two sub-groups based on age at time of probing; group 1 (51 eyes/40 children) included children who underwent probing at age ≤ 2 years and group 2 (76 eyes/52 children) included children who underwent probing at age > 2years. The primary outcome was the complete disappearance of symptoms and signs in the affected eye(s), assessed at 3 months after surgery. RESULTS: The success rate for the overall sample was 83.5 % (106/127 eyes), in group 1 was 90.2% (46/51) and in group 2 was 78.9% (60/76). There was no significant difference in success rate between groups (p=0.094). Gender (p=0.292), affected eye (p=0.647) and bilateral cases (p=0.739) were not associated with successful elimination of symptoms. CONCLUSION: Probing without fluorescein irrigation for CNLDO beyond 1 year of age is highly successful and comparable to the published efficacy rates of the traditional probing with fluorescein irrigation.

Incidence of retinopathy of prematurity and risk factors among premature infants at a neonatal intensive care unit in Canada.

PURPOSE: To study the incidence of retinopathy of prematurity (ROP) in a neonatal intensive care unit and obtain information on risk factors associated with ROP. METHODS: Four hundred twenty-three infants were screened for ROP between July 2006 and July 2010. Demographic information, clinical data, and risk factors were reviewed. RESULTS: The incidence was 40.4% (171 infants) for ROP, 9.2% (39 infants) for severe ROP, and 5.67% (24 infants) for laser treatment. Mean gestational age and birth weight were significantly lower among infants with ROP versus those without ROP (26 ± 0.13 vs 28.55 ± 0.12 weeks, P < .0001 and 840.5 ±17.49 vs 1,190.24 ± 20.20 g, P < .0001, respectively). Birth weight (P < .001), gestational age (P < .001), mechanical ventilation therapy (P = .039), and necrotizing enterocolitis (P = .019) were independent risk factors for ROP. CONCLUSION: Gestational age and birth weight were the most significant risk factors for developing ROP. The study population had an elevated percentage of infants with birth weight less than 1,000 g (extremely low birth weight), yet there was no corresponding increase in severe ROP incidence and treatment when compared to other studies.

Incidence and severity of retinopathy of prematurity in extremely premature infants.

OBJECTIVE: To analyze incidence and severity of retinopathy of prematurity (ROP) among extremely premature infants. DESIGN: Retrospective, longitudinal study. PARTICIPANTS: We studied the data concerning 207 infants whose gestational ages (GAs) were equal to 27 weeks or fewer and who were admitted to a neonatal intensive care unit between July 2006 and July 2010. METHODS: Data were extracted from the Canadian Neonatal Network, which maintains clinical information about neonates, and were confirmed by reviewing medical charts. Infants were classified into 2 groups: the GAs of the infants in group 1 were ≤ 25 weeks; those in group 2 had GAs between 26 and 27 weeks. The incidence and severity of ROP were assessed in the total screened population and between groups. RESULTS: The overall incidence of any ROP was 64.7%; 88% of infants in group 1 had any ROP compared to 48% infants in group 2. The overall incidence of type 1 ROP was 11.6%; in group 1 it was 24.4%, compared to 2.5% in group 2. Type 1 ROP was significantly associated with birth weight in grams (p < 0.001; OR = 8.20) and GA (p < 0.001; OR = 2.46). There was no difference in mean postmenstrual age at first ROP onset between group 1 and group 2 (33.5 vs 33.9 weeks, respectively). PMA at time of ROP diagnosis was not associated with development of type 1 ROP (p = 0.75; OR = 0.94; CI 0.62-1.41). CONCLUSIONS: Extremely premature infants with lower GA had a higher incidence of type 1 ROP. Earlier presentation of ROP did not predict development of type 1 ROP. No infant with a GA > 26 weeks at birth or birth weight > 1000 g had type 1 ROP.

Traumatic aniridia in a pseudophakic patient 6 years following surgery.

PURPOSE: To report a case of aniridia in a pseudophakic patient following blunt trauma to the eye. CASE REPORT: The traumatized eye had cataract surgery through a 3.0 mm clear corneal incision 6 years prior to the incident. While there have been previous cases of traumatic aniridia in pseudophakic eyes, previous reports have all occurred closer to the time of the cataract surgery. We believe that the most likely mechanism of loss of iris tissue is through wound dehiscence, which would suggest the relative instability of clear corneal incisions several years postoperatively. The patient's visual acuity returned to 20/20 4 weeks post-trauma, with symptoms of glare which were managed by the use of a colored contact lens. CONCLUSION: The possibility of wound dehiscence should be recognized as an important clinical entity in the immediate postoperative period, but also several years following cataract surgery.

Paediatric pseudophakia: analysis of intraocular lens power and myopic shift.

BACKGROUND: At the Alberta Children's Hospital, the authors have been performing paediatric cataract extraction with intraocular lens (IOL) implant for over 10 years. The authors examined the amount of myopic shift that occurs in various age groups and cataract types, in order to evaluate the success of predicting the appropriate power of IOL to implant. METHODS: This study is a retrospective review children undergoing small incision posterior chamber foldable IOL implantation between age 1 month and 18 years, from 1995 to 2005. 163 eyes of 126 patients underwent surgery. All patients were followed for a minimum of 6 months postoperatively. The children were divided into four groups at time of surgery: Group A: 1-24 months, Group B: 25-48 months, Group C: 49-84 months, Group D: 85 months-18 years. RESULTS: The mean target refraction for the groups were: Group A: +6.37 D, Group B: +4.66 D, Group C: +1.95 D, and Group D: +0.97 D. Children under 4 years experienced the most myopic shift and the largest mean rate of refractive change per year. Mean change Group A: -5.43 D, Group B: -4.16 D, Group C: -1.58 D, Group D: -0.71 D. Eighty-nine per cent of patients with unilateral cataracts had a postoperative refraction within 3.00 D of the fellow eye at last follow-up visit (mean=3.16 years). CONCLUSIONS: The rate of myopic shift is high in children under age 4 years at time of surgery, shifting as much as -12.00 D. The mean postoperative target refraction should probably be increased from previous literature recommendations. The patient's age at time of cataract surgery and the refractive power of fellow eye are all factors to consider when deciding what power IOL to surgically implant in a paediatric patient.