Spontaneous dural cavernous fistula in infancy.

A 4-month-old boy presented with the sudden onset of proptosis and dilated episcleral veins. CT revealed an enlarged superior ophthalmic vein and diffusely thickened extraocular muscles. MRI and angiography confirmed a dural middle meningeal--cavernous sinus fistula. Embolization was performed leading to successful resolution of the patient's signs and symptoms. Spontaneous atraumatic arteriovenous cavernous fistulae in infancy are extremely rare, but should be included in the differential diagnosis of infants with orbital congestion. Appropriate treatment leads to prevention of amblyopia, glaucoma, and anisometropia.

Subepidermal calcified nodules of the eyelid.

Subepidermal calcified nodule uncommonly involves the eyelid, and the authors report their experience with 9 cases of this entity. Most lesions appeared as solitary, raised, tan, or white nodules on the upper eyelid or medial canthal skin of healthy, young patients. The diagnosis was not suspected in any of the patients. The most common preoperative diagnosis was a "cyst." Excisional biopsy was performed in all cases and was curative with the exception of one recurrence. Histopathologic evaluation showed basophilic deposits beneath acanthotic and papillomatous epidermis on hematoxylin and eosin-stained preparations. The deposits stained with von Kossa's stain for calcium and were surrounded by foreign body reaction. Ophthalmologists should be aware that subepidermal calcified nodule is a benign lesion that can occur in the eyelid skin.

Effect of written instructions on accuracy of self-reporting medication regimen in glaucoma patients.

PURPOSE: Our purpose was to evaluate the accuracy of self-reporting of the prescribed medication regimen in a glaucoma population, identify contributing factors, and assess the effect of written instructions. METHODS AND MATERIALS: All patients at an urban resident glaucoma clinic were offered participation in this prospective, case-controlled study. Two trained interviewers administered a confidential questionnaire consisting of six questions regarding the name and dosage of ophthalmic medications, education level, ability to read, and age. A verbatim response for each question was recorded on the questionnaire. At the end of the visit, patients were given a written chart describing their ophthalmic medications, frequency, and dosage. At their next scheduled visit, the same questionnaire was repeated. The patients' responses from both visits were compared with the regimen they were prescribed and with each other. This information was used to determine the accuracy of reporting medications. RESULTS: A total of 193 patients were enrolled in the study over a 10-month period; 164 patients completed both phases (85% completion rate). The study population consisted of 85 women and 79 men with a mean age of 68.40+/-11.6 years. Eighty-four patients had attained less than 12th grade education and 80 had completed high school. At the first visit, 66 patients (40%) showed less than 100% accuracy. Forty-nine of 84 (58%) patients who had not completed high school education showed less than 100% accuracy with a mean score of 65% (P=0.001), whereas 17 of 80 (21%) of patients who had completed high school showed less than 100% accuracy with a mean score of 87% (P=0.001). After written instruction, the accuracy of reporting improved by 23.36+/-30.8 percentile points in patients without completion of high school education and improved by 8.46+/-21.7 percentile points in patients who had completed high school (P<0.001). The mean number of ophthalmic medications prescribed was 2.10+/-0.93 (range 1 to 4). Patients on one medication had 100% accuracy in reporting 82% of the time, whereas those with four medications had 100% accuracy 21% of the time. Gender, age, and race of the patient were not correlated with the accuracy of self-reporting (P>0.05). CONCLUSION: The education level of the patient and the number of medications showed direct correlation with patients' ability to report medications accurately. Patients showed improvement in accuracy of reporting medications when given written instructions about their regimen, regardless of their level of education or number of medications.

Toxic clonidine ingestion in children.

OBJECTIVES: We performed a prospective case series to seek dosage or clinical parameters to better identify patients who need direct medical evaluation. STUDY DESIGN: All clonidine ingestions in children younger than 12 years of age reported to 6 poison centers were followed for a minimum of 24 hours. Exclusion criterion was polydrug ingestion. RESULTS: The study included 113 patients, of whom 63 were male. Mean age was 3.8 years (+/-2.4 SD). Clinical effects were common, but severe adverse effects occurred in <10% of patients. The dose ingested was reported for 90 patients (80%); 61 (68%) children ingested <0.3 mg and none had coma, respiratory depression, or hypotension. The lowest dose ingested by history with coma and respiratory depression was 0.3 mg (0.015 mg/kg). Prior clonidine therapy did not affect outcome. Onset of full clinical effects in all cases was complete within 4 hours of ingestion. CONCLUSIONS: We recommend direct medical evaluation for (1) all children 4 years of age and younger with unintentional clonidine ingestion of >or=0.1 mg, (2) ingestion of >0.2 mg in children 5 to 8 years of age, and (3) ingestion of >or=0.4 mg in children older than 8 years of age. Observation for 4 hours may be sufficient to detect patients who will develop severe effects.

Treatment of Spasticity in Spinal Cord Injury with Dronabinol, a Tetrahydrocannabinol Derivative.

Spinal-cord-injured patients and the medical literature have increasingly reported anecdotes regarding tetrahydrocannabinol (THC)-induced spasmolysis. These reports motivated this trial of dronabinol, a THC derivative, for the treatment of spasticity in the spinal-cord-injured population. Five made quadriplegic patients were given oral dronabinol in escalating doses from 5 mg BID to 20 mg TID in addition to their current, but ineffective, spasmolytic regime. The pendulum drop test was used to quantify spasticity (stiffness) in the knees. The Weschler Memory Scale (WMS), Profile of Mood States (POMS), and personal interviews were administered by the clinical psychologist to evaluate any changes in the subjects' cognition and/or emotional states. Spasticity was markedly improved in two of the five subjects, unchanged in a third, fluctuated in a fourth and made progressively worse in a fifth. The WMS revealed improvement in memory skills of two subjects and no change in the other. Psychological interviews and the POMS indicated decreased vigor in all subject, but otherwise demonstrated highly individualized emotional changes as indicated by increases and/or decreases in the dysphoric mood scales.