Epidemiology, risk factors, clinical presentation and complications of late-onset neonatal sepsis among preterm neonates in Cyprus: a prospective case-control study.

BACKGROUND: Late-onset neonatal sepsis (LOS) is common in preterm neonates, with increasing incidence in recent years. In the present study, we examined the epidemiology, clinical presentation, and complications of LOS in Cyprus and quantified possible risk factors for the development of this condition. METHODS: The study subjects were preterm neonates admitted in the Neonatal Intensive Care Unit (NICU) of Archbishop Makarios III Hospital, the only neonatal tertiary centre in Cyprus. A prospective, case-control study was designed, and carried out between April 2017-October 2018. Depending on blood culture results, preterm neonates were classified as "Confirmed LOS": positive blood culture - microorganism isolated and LOS symptoms, "Unconfirmed LOS": negative blood culture and LOS symptoms, and "Controls" group: negative blood culture and absence of LOS symptoms. Comparisons between the 3 groups were performed and the associations between demographic, clinical and treatment characteristics with the likelihood of LOS were assessed using univariate and multivariate logistic regression. RESULTS: A total of 350 preterm neonates were included in the study and the incidence of LOS was 41.1%. 79 (22.6%) and 65 (18.6%) neonates were classified as "Confirmed LOS", and "unconfirmed LOS" cases respectively while 206 (58.9%) served as controls. The rate of confirmed LOS ranged from 12.2% in moderate to late preterm neonates to 78.6% in extremely preterm neonates. In the multivariate model, we demonstrated an independent association between LOS and duration of hospitalization (OR: 1.06, 95%CI: 1.01-1.10), duration of ventilation (OR: 1.23, 95%CI: 1.07-1.43) and necrotising enterocolitis (OR: 3.41, 95%CI: 1.13-10.25). CONCLUSIONS: The present study highlights the epidemiology of LOS in preterm neonates in Cyprus and its association with the duration of ventilation and hospitalization as well as with necrotizing enterocolitis. Establishment of protocols for the prevention of nosocomial infections during hospitalization in the NICUs and mechanical ventilation of preterm neonates is recommended.

Maternal and neonatal risk factors for neonatal respiratory distress syndrome in term neonates in Cyprus: a prospective case-control study.

BACKGROUND: Neonatal respiratory distress syndrome (NRDS) is strongly associated with premature birth, but it can also affect term neonates. Unlike the extent of research in preterm neonates, risk factors associated with incidence and severity of NRDS in term neonates are not well studied. In this study, we examined the association of maternal and neonatal risk factors with the incidence and severity of NRDS in term neonates admitted to Neonatal Intensive Care Unit (NICU) in Cyprus. METHODS: In a prospective, case-control design we recruited term neonates with NRDS and non-NRDS admitted to the NICU of Archbishop Makarios III hospital, the only neonatal tertiary centre in Cyprus, between April 2017-October 2018. Clinical data were obtained from patients' files. We used univariate and multivariate logistic and linear regression models to analyse binary and continuous outcomes respectively. RESULTS: During the 18-month study period, 134 term neonates admitted to NICU were recruited, 55 (41%) with NRDS diagnosis and 79 with non-NRDS as controls. In multivariate adjusted analysis, male gender (OR: 4.35, 95% CI: 1.03-18.39, p = 0.045) and elective caesarean section (OR: 11.92, 95% CI: 1.80-78.95, p = 0.01) were identified as independent predictors of NRDS. Among neonates with NRDS, early-onset infection tended to be associated with increased administration of surfactant (ß:0.75, 95% CI: - 0.02-1.52, p = 0.055). Incidence of pulmonary hypertension or systemic hypotension were associated with longer duration of parenteral nutrition (pulmonary hypertension: 11Vs 5 days, p < 0.001, systemic hypotension: 7 Vs 4 days, p = 0.01) and higher rate of blood transfusion (pulmonary hypertension: 100% Vs 67%, p = 0.045, systemic hypotension: 85% Vs 55%, p = 0.013). CONCLUSIONS: This study highlights the role of elective caesarean section and male gender as independent risk factors for NRDS in term neonates. Certain therapeutic interventions are associated with complications during the course of disease. These findings can inform the development of evidence-based recommendations for improved perinatal care.

OCT Angiography Study of the Macula in Patients with Diabetic Macular Edema Treated with Intravitreal Aflibercept.

Purpose: To compare foveal avascular zone density (FAZ) in the superficial (SCP) and deep (DCP) capillary plexus and vessel density (VD) in the macula in eyes with diabetic macular edema (DME) treated with intravitreal aflibercept.Methods: Patients with DME were imaged at baseline, and 30 days after the 1st, 2nd and 3rd intravitreal aflibercept injection. Images were analyzed for the FAZ area in the SCP and DCP in each visit and VD.Results: Twenty eyes were enrolled. FAZ was 0.304 ± 0.131 mm2 in the SCP and 0.738 ± 0.5836 mm2 in the DCP at baseline. SCP FAZ was not significantly different whereas, FAZ in the DCP decreased (p = .035) after treatment. VD in the center was 20.62 ± 4.31 at baseline and decreased by 8% (p = .002). Parafoveal VD remained unchanged with treatment.Conclusion: DCP ischemia may improve after aflibercept treatment. Central macular vessel density was found to decrease post-treatment, but the clinical relevance needs further investigation.

Prevalence of hydroxychloroquine retinopathy using 2018 Royal College of Ophthalmologists diagnostic criteria.

INTRODUCTION: To measure the prevalence of hydroxychloroquine retinopathy in patients attending a hydroxychloroquine monitoring service using 2018 Royal College of Ophthalmologists diagnostic criteria. METHODS: A service evaluation audit of a hydroxychloroquine retinopathy monitoring service was undertaken. Results of Humphrey 10-2 field tests, spectral-domain optical coherence tomography and fundus autofluorescence were collected with data on dose, weight, duration of treatment, estimated glomerular filtration rate, and concurrent tamoxifen therapy. Visual field tests were assessed as reliable or unreliable, and classified as normal, hydroxychloroquine-like, poor test or related to other pathology. Cases of definite and possible retinopathy were identified using the 2018 RCOphth criteria. RESULTS: There were 1976 attendances over two years of 1597 patients. Seven hundred and twenty-eight patients had taken hydroxychloroquine for less than 5 years and 869 had taken hydroxychloroquine for 5 years or more. Fourteen patients were identified with definite hydroxychloroquine retinopathy (1.6%), and 41 patients with possible retinopathy (4.7%). Sixty-seven per cent of 861 visual fields were performed reliably, with 66.9% classified as normal, 24.9% as poor test, 5.2% hydroxychloroquine-like and 3.0% abnormal due to other pathology. CONCLUSIONS: The 1.6% prevalence of hydroxychloroquine retinopathy is lower than the previously reported prevalence of 7.5% as reported by Melles and Marmor JAMA Ophthalmol 132: 1453-60 (2014). This is because of a difference in the diagnostic criteria. Both definite and possible retinopathy would meet the diagnostic criteria of the Melles and Marmor study; 6.3% in our data, compared with 7.5%, a much smaller difference and likely to be explained by differences in the risk characteristics of the two groups.

Onodi Cell Mucocele-Associated Optic Neuropathy: A Rare Case Report and Review of the Literature.

PURPOSE: To present a rare case report of Onodi cell-associated optic neuropathy, conducting a review of the literature. METHODS: A 36-year-old male presented with an 18-h history of acute deterioration of vision in his left eye (LE). Ophthalmic examination and Magnetic Resonance Imaging (MRI) were consistent with an Onodi cell-associated compressive optic neuropathy. RESULTS: Despite immediate, successful surgical decompression, severe optic nerve atrophy and permanent visual loss occurred during early postoperative period. The reported case gives rise to different hypotheses regarding pathophysiology that may lead to irreversible blindness. A systematic review of the respective literature is provided attempting to compare different approaches in the management of Onodi cell-associated compressive optic neuropathy and assess their efficacy in the final visual outcome. Poor initial visual acuity (VA) may represent a bad prognostic factor. Moreover, age and gender do not seem to significantly influence the outcome. CONCLUSION: This report and associated literature review highlight the importance of the radiologic characteristics and early diagnosis in the final visual outcome of the Onodi cell-associated optic neuropathy. High level of suspicion is crucial for early diagnosis of mucoceles, which must be treated promptly by surgical and medical means to enhance visual recovery.

Unilateral Retinal Pigment Epithelium Dysgenesis: Long-Term Natural Evolution and Multimodal Imaging.

PURPOSE: To present the natural course and describe the characteristic findings of a case of unilateral retinal pigment epithelium dysgenesis (URPED) and highlight the optical coherence tomography angiography characteristics of this rare fundus pattern. METHODS: Case report. RESULTS: A 52-year-old male was referred 8 years ago to our clinic due to a distinctive unilateral lesion in his left fundus, of which he was aware from early adulthood. Clinical evaluation revealed an irregularly shaped patch of retinal pigment epithelium atrophy surrounding his left optic nerve, with a characteristic scalloped border and with severe distortion of the overlying retinal and vascular tissue. Retinal pigment epithelial hyperplasia was noted in the margin as well as in distinct lacunae clustered around the periphery of the lesion. Right fundus examination was normal. The patient was diagnosed with URPED and was followed annually with multimodal imaging ever since. No choroidal neovascularization or other complication was noted. However, the lesion appeared to slowly but steadily grow to eventually affect the foveal region causing severe visual loss. Best corrected visual acuity was 20/40 at baseline and 20/200 at last follow-up 8 years after the original diagnosis. CONCLUSION: URPED is a rare retinal disease with unique clinical characteristics that can progress relentlessly even in the absence of secondary complications.

Use of log-scaled crowded visual acuity charts in clinical studies regarding amblyopia.

PURPOSE: Log-scaled crowded charts using standardized testing protocol are essential for precise and reproducible visual acuity (VA) testing regarding amblyopia. Despite common acceptance of these standards, current VA testing clinical practice shows considerable diversity. The purpose of this retrospective literature review was to investigate the methodology of VA measurement and reporting in pediatric ophthalmology literature regarding amblyopia. METHODS: We searched PubMed for clinical trials regarding amblyopia, published from January 1994 to July 2016. Primary outcomes included VA measurement methodology, namely use of (a) log-scaled chart, (b) crowded chart, and (c) specified testing protocol. The study design, publication year, and the journal's impact factor were analyzed in relation to the primary outcomes. RESULTS: Out of the 165 initial reports, 150 were included. VA was measured with a log-scaled chart in 65%, with a crowded chart in 57%, and with a specified protocol in 51% of studies. All three criteria were met in 43% of studies and in multivariable logistic model, they were associated with more recent publication year (odds ratio [OR] = 1.11, 95% confidence interval [95%CI] = 1.03-1.20) and were more likely to be present in higher impact factor journals (OR = 1.42, 95%CI = 1.17-1.72) or randomized controlled trials (OR = 3.09, 95%CI = 1.44-6.59). CONCLUSIONS: In the last two decades, more than half of clinical trials addressing amblyopia have not followed the recommended methodology for optimal visual acuity assessment. Thus, their measurements may have been contaminated with noise, and their respective results and conclusions may include errors. Adhering to optimal, standardized methodology is key to progress in both clinical and research grounds.

Maternal socioeconomic factors and the risk of premature birth and low birth weight in Cyprus: a case-control study.

BACKGROUND: Prematurity and low birth weight are significant predictors of perinatal morbidity and mortality and are influenced by the overall health and socioeconomic status of the pregnant mother. Although Cyprus is characterized by the highest prematurity rate in Europe (13.1% in 2014), the relationship between maternal health and socioeconomic characteristics with prematurity and low birth weight has never been investigated. We aimed to investigate the association of maternal demographic, clinical and socioeconomic characteristics with premature delivery and low neonatal birth weight in Cyprus. METHODS: In a case-control design, questionnaire data were collected from 348 women who gave birth prematurely (cases) and 349 women who gave birth at term (controls). Information was obtained on gestation duration and birth weight as well as maternal demographic, socioeconomic and clinical profiles, including parameters such as smoking, body mass index, alcohol consumption, presence of gestational diabetes and mental health factors. RESULTS: Premature delivery was associated with greater maternal age (OR: 1.12, 95% CI: 1.06-1.18), absence of gestational diabetes (OR: 0.53, 95% CI: 0.30-0.97), long working hours (OR: 3.77, 95% CI: 2.08-6.84) and emotional stress (OR: 8.5, 95% CI: 3.03-23.89). Within the cases group, emotional stress was also associated with lower birth-weight (ß: -323.68 (95% CI: -570.36, - 77.00). CONCLUSIONS: The findings of this study demonstrate the positive association of maternal psychological factors, working conditions as well as maternal age with prematurity and low birth weight in Cyprus. Additional, prospective, studies are needed in the country to further investigate these associations and inform public health intervention measures.

Safety and efficacy of chloral hydrate for procedural sedation in paediatric ophthalmology: a systematic review and meta-analysis.

PURPOSE: Although chloral hydrate (CH) has been used as a sedative for decades, it is not widely accepted as a valid choice for ophthalmic examinations in uncooperative children. This study aimed to systematically review the literature on the drug's safety and efficacy. METHODS: We searched PubMed, EMBASE, ISI Web of Science, Scopus, CENTRAL, Google Scholar and Trip database to 1 October 2015, using the keywords 'chloral hydrate', 'paediatric' and 'procedural sedation OR diagnostic sedation'. A meta-analysis of randomised controlled trials (RCTs) was performed. RESULTS: A total of 6961 articles were screened and 104 were included in the review. Thirteen of these concerned paediatric ophthalmic examination, while 13 others were RCTs and were meta-analysed. CH was reported to have been administered in a total of 24 265 sedation episodes in children aged from <1 month to 18 years. The meta-analysis showed CH had a higher OR (2.95, 95% CI 1.09 to 7.99) for successful sedation compared to other sedatives, but significant limitations apply. The commonest reported adverse events (AE) were not serious (eg, paradoxical reaction or transient vomiting) and required no intervention. Severe AE, including two deaths, were related to comorbidity, overdose or aspiration. CONCLUSIONS: Despite the paucity of high quality evidence, the existing literature suggests that the use of CH for procedural sedation in children appears to be an effective alternative to general anaesthesia, and it can be safe when administered in the hospital setting with appropriate monitoring and vigilance for intervention.

Pendular eyelid flap: a novel technique for the management of extensive congenital upper lid colobomas.

We present a novel technique for the surgical management of sizeable medial upper eyelid colobomas that entails advancement of an ipsilateral upper lid flap sustained by a levator aponeurosis-Müller-conjunctiva pedicle and combined with a lateral semicircular flap from the affected lid. The technique was used in 4 consecutive pediatric patients of mean age 21.2 months and mean coloboma size 12.3 mm and resulted in sufficient cornea protection, rapid rehabilitation, and satisfying cosmesis.

Bilateral intermediate uveitis with appearance of frosted branch angiitis and association with Mycoplasma pneumoniae infection: case report and review of the literature.

A 12-year-old girl presented with acute bilateral visual loss following a mild upper respiratory tract infection. Clinical examination revealed bilateral severe peripheral retinal vasculitis with an appearance of frosted branch angiitis and cystoid macular edema. All tests for etiological diagnosis were negative, apart from positive IgM and IgG antibodies for Mycoplasma pneumoniae. She was treated with broad-spectrum antibiotics and intravenous corticosteroids. She responded to treatment, with dramatic improvement of her visual acuity, remission of angiitis, and a residual macular star formation. This is the first reported case of bilateral intermediate uveitis possibly associated with Mycoplasma pneumoniae infection.