Periocular ecthyma gangrenosum with Pseudomonas septicemia in an infant: A case report.

Ecthyma gangrenosum is a skin manifestation of fatal septicemia. We report a case of periocular ecthyma gangrenosum, which is an uncommonly infected area and rarely reported in infants. A 1-month-old female infant with periocular ecthyma gangrenosum presented with a high-grade fever and acute left medial canthus of the eyelid swelling and erythema. Hemoculture at 6 h confirmed Pseudomonas aeruginosa infection. Intravenous and topical antibiotics were administered. Daily dressing of the wound and noninvasive bedside escharectomy were performed. Cosmetically acceptable scar was achieved without additional surgery. The patient was considered to have congenital neutropenia due to persistent neutropenia and severe skin and mucosal infections in her first year of life. Noninvasive debridement of the wound reduces the risk of exposure keratitis, lacrimal drainage pathway damage, and the need for further surgical reconstruction. The cause of compromised immunity in infants with ecthyma gangrenosum should be investigated, and intensive follow-up is recommended.

Correlation between clinical presentations, radiological findings and high risk histopathological features of primary enucleated eyes with advanced retinoblastoma at Queen Sirikit National Institute of Child Health: 5 years result.

PURPOSE: To evaluate the correlation between clinical presentations, radiological findings and high risk histopathological features of primary enucleated eyes in patients with advanced retinoblastoma at a tertiary child hospital in Thailand. MATERIALS AND METHODS: We retrospectively reviewed the medical records of patients who were treated with primary enucleation of tumor eyes between 2015-2020. Demographic data, radiological assessment, and histopathological findings were collected. The association between clinical presentations and high-risk histopathological features in the primary enucleated eyes were evaluated. The radiological findings, which showed characteristic of high risk features, were compared with the histopathological findings. RESULTS: Thirty-three enucleated eyes were enrolled in this study. The mean age at diagnosis was 23.12 months. Most patients had unilateral group E retinoblastoma, with no difference in sex and laterality of the eye. Leukocoria was the most common presentation, followed by proptosis and uveitis. Older age at presentation were statistically associated with post laminar cribrosa optic nerve invasion (P-value 0.0027) and high-risk histopathological features in enucleated eyes (P-value 0.0032). Clinical presentations with proptosis were statistically associated with post laminar cribrosa optic nerve invasion, while leukocoria and uveitis were statistically associated with anterior segment invasion. Unifocal intraocular mass with necrosis was the most common histopathological finding. High-risk features were found in 45% of primary enucleated eye. The sensitivity and specificity of magnetic resonance imaging (MRI) for detected optic nerve invasion in retinoblastoma patients were 75% and 54%, respectively. CONCLUSION: Patients with unilateral retinoblastoma who presented with older age related to high-risk features after enucleation. Ophthalmic examination with slitlamp is the best way for detection of anterior segment invasion. Choroidal invasion was unable to predict with clinical presentation. MRI was the better imaging for detection of post laminar cribrosa optic nerve invasion.

Outcomes of Surgical Interventions in Primary Congenital Glaucoma Patients.

PURPOSE: The aim was to report long-term surgical success of primary congenital glaucoma (PCG) patients in Thailand. MATERIALS AND METHODS: PCG patients who underwent one of the following primary operations: trabeculotomy, goniotomy, trabeculectomy, combined trabeculotrabeculectomy (CTT) and diode transscleral cyclophotocoagulation (TSCPC) between January 1992 and January 2018 were reviewed. Surgical success was defined as intraocular pressure (IOP) between 5 and 21 mm Hg with or without antiglaucoma medications. Failure was defined as IOP ≤5 or ≥21 mm Hg for 2 consecutive visits, or when an additional glaucoma surgery was required to control IOP. Survival curves were analyzed using multilevel mixed-effect Weibull model. RESULTS: A total of 81 eyes from 55 PCG patients were included. Surgical procedures involved 20 goniotomies, 15 trabeculotomies, 16 trabeculectomies, 15 CTT, and 15 TSCPC. Median follow-up time was 24 months (interquartile range: 9 to 60 mo). Overall success rates were 68.8% at 1 year, 63.8% at 3 years, and 53.7% at 5 years. All types of surgery except TSCPC had comparable cumulative 1 year success rates ranging from 78.5% to 83.3%. Cumulative success rates of trabeculotomy (80.05%) and CTT (79.4%) were maintained at 3 and 5 years and were the highest among all procedures at 5 years. TSCPC had a significantly lower success rate compared with other types of surgery (hazard ratio: 7.4 to 13.1, all P=0.01). All patients receiving primary TSCPC showed no success at 48 months. CONCLUSION: Primary trabeculotomy and primary CTT demonstrated the highest long-term success rates in PCG patients.

Prevalence of Prescription Glasses in the First-Grade Thai Students (7-8 Years Old).

PURPOSE: To study the prevalence of the prescription glasses given to first-grade students due to the "Good Sight for Thai Children" (GSTC) policy. METHODS: This was a cross-sectional study that examined all prescription glasses given to first-grade students throughout Thailand, after visual screening due to the GSTC policy between 2016 and 2017. Trained class teachers screened their students' visual acuity and referred children who had less than 20/40 visual acuity in either eye to a hospital for an eye examination and prescription glasses. RESULTS: A total of 786,729 students were screened. Of these, 20,401 (2.59%) students were referred to hospital. However, only 9867 (48.37%) students presented to a hospital. Glasses were prescribed for 5324 (53.96%) students following cycloplegic refraction by ophthalmologists or trained refractionists. The mean spherical equivalent was -1.08 (-19.00 to +10.00, SD 2.32) diopters. There were 1626 (30.54%) children at amblyopic risk without glasses. A 5.49% had high myopia (< -6 diopters), 5.22% had high hyperopia (> +5 diopters) and 27.82% had high astigmatism (>2 diopters). A cylindrical lens analysis showed that 81.53% had with-the-rule astigmatism, 4.07% had against-the-rule astigmatism, and 14.40% had oblique astigmatism. CONCLUSION: Although the reliable prevalence of refractive error cannot be estimated, the prevalence of visual impairment may be estimated. There were a number of students who required glasses. The astigmatism was the most common refractive error on prescription glasses for first-grade children. With-the-rule astigmatism was the most prevalent. The visual screening program of school children proved to be valuable and should be continued and developed.

Outcomes of pediatric accommodative esotropia with botulinum toxin A treatment in Thailand.

Accommodative esotropia is a condition commonly encountered by pediatric ophthalmologists. Patient with accommodative esotropia wear hyperopic glasses to decrease accommodation which occasionally provide them with good vision without glasses. Children are known to have limited compliance with glasses and patching. Their limited cooperation can also lead to variability in angle measurement across visits and defer surgery. To cope with these challenges, our team offered botulinum toxin injection to the medial rectus as an optional treatment while waiting for compliance and deferring the surgery. This is retrospective study including data from 114 accommodative esotropia patients who were injected with botulinum toxin into the medial rectus between 2010 and 2017. Of these, 102 patients met the inclusion criteria. Almost half of the patients were boys (47.06%). The average angle deviation before injection was 40 prism diopters (PD). The post-injection angle averaged at 11 PD at 2 weeks, 19 PD at 3 months, and 25 PD at 6 months. At 6 months, 51 patients (50.00%) had satisfactory results, 17 (16.67%) had excellent results (ortho to esotropia < 10 PD) and 34 (33.33%) had small angle esotropia (esotropia 11-20 PD). All complications including ptosis (37.25%), exotropia (11.76%), and hypertropia (4.9%) were reversible. Botulinum toxin injection into the medial rectus for pediatric esotropia showed satisfactory outcomes in 50% of patients with minimal complications. The study showed no significant association of good outcomes with age at onset, age during injection, status of development, status of amblyopia, refractive error, and angle of deviation as analyzed by the statistical package for social sciences.

Characteristics and long-term outcomes of childhood glaucoma: a retrospective-cohort study.

Purpose: To evaluate the clinical characteristics and treatment outcomes of patients with childhood glaucoma. Methods: We retrospectively reviewed the data of patients with childhood glaucoma who visited the glaucoma clinics at the Queen Sirikit National Institute of Child Health and the King Chulalongkorn Memorial Hospital between January 2008 and January 2018. The diagnosis was based on the Childhood Glaucoma Research Network classification. We recorded their clinical characteristics and requirement of any glaucoma interventions. Results: A total of 691 eyes from 423 patients were included in this study. The patients predominantly comprised boys. The average follow-up duration was 71.3±63.8 months. The mean age at presentation was 3.9±4.4 years. Most patients presented with a high initial intraocular pressure (IOP). The average intial IOP of all patients was 28.5±11.2 mmHg. Glaucoma associated with non-acquired ocular anomalies (22.9%) was the most common subtype, followed by primary congenital glaucoma (20.8%). We recorded a family history of glaucoma in 6.4% of patients of the 234 patients with an available family history. Most patients had bilateral glaucoma (63.4%) and required at least one intervention (51.5%). The average IOP at the latest follow-up visit was 19.1±10.8 mmHg. All glaucoma types had significantly lower IOP, compared to that at their baselines (all p<0.001). Moreover, most patients had an unfavourable visual acuity (49.5%) at their latest visit. Conclusions: Secondary glaucoma associated with non-acquired ocular anomalies is the most common subtype of glaucoma. The majority of patients had unfavourable visual outcomes. These real-world findings are fundamental to acquire a better understanding of childhood glaucoma.

Hypertensive phase and its association with surgical outcomes in Baerveldt implantation.

PURPOSE: To evaluate the rate of the hypertensive phase (HP) post-Baerveldt implantation and association between HP and surgical outcomes. METHODS: This is a retrospective observational study of glaucoma patients who had Baerveldt implantation in 2004 and completed 18 months of follow-up. At 18 months of follow-up, medical records for HP and its associated factors, and surgical outcomes such as rate of failures, intraocular pressure (IOP), numbers of medications administered, and complications were reviewed and identified. RESULTS: Thirty-seven patients were eligible. Mean (SD) preoperative IOP was 30.5 (7.9) mmHg which significantly lowered to 13.1 (7.0) mmHg post-operation. Mean numbers of medications (SD) significantly decreased from 3.6 (0.7) to 1.3 (1.3). Failure rate at 18 months was 10.8% (4/37 patients). HP was noted in 18/37 patients (48.6%) with the onset between 1 and 3 months post-surgery. Preoperative IOP and one previous glaucoma surgery were associated with presence of HP (p = 0.010, OR 0.82, 95% CI 0.71-0.96 and p = 0.003, OR 26.12, 95% CI 2.95-231.41, respectively). The presence of HP was predictive of postoperative numbers of medications administered (p = 0.001). None of those with HP were from the failure group. CONCLUSION: Baerveldt implantation is an effective procedure with high success rate. HP was common after Baerveldt implantation. Preoperative IOP and numbers of previous glaucoma surgery are risk factors for developing HP. Presence of HP can predict whether long-term anti-glaucoma medication(s) are needed or not.