David S. Friendly

Traumatic Retinoschisis in Battered Babies

Five infants who were victims of physical abuse had extensive bilateral retinal hemorrhages on initial evaluation and subsequently developed signs of permanent retinal damage. None showed external evidence of trauma to the eyes. Vitreous hemorrhage developed after a delay of several days or more in three cases that were followed closely from the time of the traumatic incident. In several eyes, apparent intraretinal blood-filled cavities were seen acutely in the macular region and elsewhere. Late scarring of the macula typically had a cystic or crater-like configuration. Electroretinography showed loss or reduction of the positive B-wave with preservation of the negative A-wave in every case. We propose that splitting of the retina resulting from the direct mechanical effects of violent shaking was responsible for all of these findings.

Bacterial periorbital and orbital cellulitis in childhood.

The clinical features, microbiologic data, complications, and treatment in 137 children with periorbital cellulitis and 21 children with orbital cellulitis is presented. Periorbital cellulitis was more frequent (87%) than orbital cellulitis (13%). Periorbital cellulitis is a heterogeneous disease that may complicate trauma of the eyelids, external ocular infection, and upper respiratory infection. Children with periorbital cellulitis related to trauma or external infection tended to be less than 5 years old with negative blood cultures (99%) and positive cultures of percutaneous aspirates (42%); while children with periorbital cellulitis related to upper respiratory infection also tended to be less than 5 years of age, but blood cultures were frequently positive (42%) and cultures of percutaneous aspirates were usually negative (92%). Three children in the latter group developed meningitis. Intravenous antibiotic alone was effective treatment in most patients (90%). Orbital cellulitis was more frequent in children older than 5 years and frequently associated with sinusitis (90%). Blood and skin cultures were usually negative. Intravenous antibiotics alone were effective management in many patients (62%), but a significant proportion required paranasal sinus or orbital surgery (38%).

Practical Management of Amblyopia

One hundred sixteen strabismus patients with amblyopia treated with initial full-time or part-time conventional occlusion of the preferred eye followed when necessary with maintenance occlusion up to a maximum of nine years were studied. Based on the need for maintenance occlusion, patients were divided into a primary occlusion group, composed of patients who did not require maintenance occlusion and a maintenance group occlusion group, composed of patients who did require maintenance occlusion. The main difference between the two groups of patients was the degree of amblyopia at the onset of occlusion therapy, being significantly greater in the maintenance occlusion group. The maintenance occlusion group showed a significantly higher incidence of visual acuity regression when evaluated at ages 12 and 13 years. Occlusion therapy administered to strabismus patients in the manner described in this study resulted in significant visual improvement with a regression in visual acuity of no more than an average of one line on the Snellen chart.

Retinoblastoma. Immunohistochemistry and cell differentiation.

Tumor from eight enucleated eyes was analyzed by immunohistochemistry, using a panel of specific antibodies including interphotoreceptor retinoid-binding protein (IRBP), S-antigen (S-Ag), opsin, neuron-specific enolase (NSE), glial fibrillary acidic protein (GFAP), laminin, and vimentin. In addition, immunoelectron microscopy and enzyme-linked immunosorbent assay (ELISA) for IRBP were performed. Immunohistochemical staining disclosed the most pronounced labeling of tumor cells with NSE and IRBP antibodies. A correlation was found between the degree of tumor differentiation and amount of IRBP, a protein specifically synthesized by photoreceptor cells. Moderate labeling of the better differentiated tumors was also observed with antibodies against S-Ag and focal labeling in a few tumors with opsin antibodies. Anti-GFAP labeling was limited to a smaller number of reactive glial cells and perivascular glial cells. These data indicate the essential neuronal nature of retinoblastoma tumor cells in situ as well as at least partial photoreceptor-like features, as shown by the presence of recognized photoreceptor cell markers (IRBP, S-Ag, opsin). Tissue culture studies using the human Y-79 retinoblastoma cell line also demonstrate that the tumor cells are primitive multipotential retinoblasts capable of at least partial differentiation along neuronal, glial, or pigment epithelial cell lines.

Pattern-Reversal Visual-Evoked Potentials in the Diagnosis of Amblyopia in Children

We assessed the potential clinical usefulness of pattern-reversal visual-evoked potentials in the diagnosis of amblyopia. Twenty-seven children with anisometropic amblyopia and four children without amblyopia participated. Estimates of visual acuity for each eye (Snellen visual acuity) were obtained by conventional psychometric methods. Visual-evoked potentials to reversing checks subtending 15 minutes of visual arc were also obtained. Visual-evoked potential testing and interpretation were done in a masked fashion. Ten of the 31 children were retested seven to 21 days after the first test to estimate reliability of the procedures. Of the 27 amblyopic children, 22 were correctly identified by the visual-evoked potential test alone. In four patients initial visual-evoked potential tests failed to identify the disparity in visual acuity between the eyes and retests in two of the four again had false-negative results. In one child initial visual-evoked potential testing incorrectly identified the amblyopic eye but repeat testing did identify it. Of the four children with symmetrically good vision, three were correctly identified as normal by the initial visual-evoked potential test. The other normal child was incorrectly identified by the visual-evoked potential test as having amblyopia.

An Automated Visual Acuity Testing Computer Program Using the Apple II System

We developed an automated visual acuity testing program that uses an E optotype with surrounding confusion bars. The computer software program runs on Apple II equipment and a black-and-white monitor with a five-inch screen. The program is available in response box and joystick versions. The test is suitable for children older than 31/2 to 4 years of age and for adults. A t-test on the same floppy disk as the visual acuity programs is used to test the probability that the differences in test results are greater than chance. Visual acuities of 20 normal subjects were reduced by means of plus lenses. Test-retest acuity correlation coefficients were similar for letter charts and computer-generated E optotypes, suggesting approximately equal reliability under the test conditions employed. Visual acuities of 12 amblyopic eyes were obtained by a Ferris-type letter chart and computer-generated E optotypes. The correlation coefficient was +0.93, suggesting similar test results by these two methods.

Results of Combined Surgery on the Superior Oblique and Horizontal Rectus Muscles for A-Pattern Horizontal Strabismus

Results obtained in 32 patients with A-pattern horizontal strabismus and overacting superior oblique muscles treated with combined bilateral superior oblique tenotomies and bilateral symmetric surgery on the horizontal rectus muscles were analyzed retrospectively. The magnitude of reduction of the A-pattern correlated positively (r = 0.69) with the size of the preoperative A-pattern. Overall, 27 of the 32 patients (84%) had a satisfactory reduction in their A-pattern. Esodeviated patients received less correction in the primary position than exodeviated patients. Postoperative complications were minimal if the superior oblique tendon was hooked under direct visualization, and minimal dissection was performed on the surrounding tissue prior to transecting it near the nasal side of the superior rectus muscle.

Hemangioendothelioma of Frontal Bone

Radiographic studies disclosed that a 5-year-old girl with proptosis and inferior displacement of her left globe had a lytic lesion in the superior orbital rim. Tissue removed at the time of the initial biopsy was not sufficiently distinctive for a definitive diagnosis, but microscopic examination of residual tumor clearly established the diagnosis of hemangioendothelioma of the frontal bone. Electron microscopic studies demonstrated that the vascular structures, which resembled endothelium, contained many thin microfilaments and mitochondria and scattered dense bodies. Each vessel was surrounded by a prominent mantle of pericytes.

Patient data storage and retrieval using dBASE III in a pediatric ophthalmology department

Ashton Tates dBASE III has been adapted to store patient data for both medical and administrative purposes by the Department of Ophthalmology of Childrens Hospital National Medical Center. The program is run on an IBM-PC microcomputer and stored on twin Iomega 10 megabyte cartridge disks. The advantages of this system include ready availability of both software and hardware, relative ease of customization, simplicity of use, and modest cost.

Pupillary Abnormalities: Light and Sight

Excerpt To the editor: A survey of major pediatrics and neonatology textbooks shows few recommendations concerning the need for immediate referral of infants, toddlers, and children with abnormal p...