Gaurav Bhardwaj

A systematic review of the diagnostic accuracy of ocular signs in pediatric abusive head trauma

TOPIC To review systematically the diagnostic accuracy of various ocular signs for pediatric abusive head trauma (AHT). CLINICAL RELEVANCE Intraocular hemorrhages (IOH), perimacular retinal folds, traumatic retinoschisis and optic nerve sheath hemorrhages have been reported as cardinal signs of AHT. The evidence base supporting the accuracy of this interpretation, however, has not been systematically reviewed. METHODS A systematic keyword search of MEDLINE, EMBASE, and Evidence-Based Medicine Reviews was conducted for original studies reporting ocular findings in AHT. Articles were graded using a checklist for systematic reviews of diagnostic accuracy. RESULTS The initial search yielded 971 articles, of which 55 relevant studies were graded, and 20 studies met inclusion criteria and were included in the review. The overall sensitivity of IOH for AHT was 75% and their specificity was 94%. Intraretinal hemorrhage at the posterior pole was the most common finding, although extensive, bilateral, and multilayered IOH were the most specific for AHT. Optic nerve sheath hemorrhages had a sensitivity and specificity for AHT of 72% and 71%, respectively. Traumatic retinoschisis and perimacular retinal folds were reported in 8% and 14% of AHT, respectively, but were not reported in other conditions. CONCLUSIONS Prospective, consecutive studies confirm that IOH in infants-particularly bilateral, extensive, and multilayered-are highly specific for AHT. Optic nerve sheath hemorrhages are significantly more common in AHT than in other conditions, in autopsy studies. Traumatic retinoschisis and perimacular folds are present in a minority of AHT, but rarely seen in other conditions.

Endophthalmitis following cataract surgery: The sucking corneal wound

We were quite surprised, and also concerned, to note that a patient given the proposed Northern European panacea for prevention of endophthalmitis following cataract surgery (that is, intracameral cefuroxime) developed bilateral postoperative endophthalmitis. This occurred 4 days after bilateral cataract surgery performed at the same sitting. A recent editorial stated that the major risk factors for the development of postoperative endophthalmitis included corneal incisions, age (especially older than 80 years), and loss of posterior capsule integrity, which would allow direct access of bacteria into the vitreous. Further, it was recognized that there are essentially 2 opportunities for bacteria to enter the eye during cataract surgery: at the time of surgery and in the early postoperative period before epithelialization of an unsutured wound. This leads to the notion that sutured corneal incisions may reduce the risk for developing endophthalmitis in the postoperative period. In a laboratory model using India ink, Taban et al. demonstrated that aqueous aspirates from 3 eyes with sutureless clear corneal incisions had increased spectrophotometric readings (P!.01). This was in contrast to the readings from aspirates in eyeswith sutured corneal incisions, which showed no increase in absorbance level from baseline. This demonstrates that ingress of India ink occurs through sutureless clear corneal incisions, representing the potential passage of microorganisms into the eye. In sutureless cataract surgery, wound sealing is generally achieved by stromal hydration at the completion of the case. However, some evidence suggests that the wound is compromised when closure is not reinforced with suturing. Vasavada et al. demonstrated in routine cataract surgery that wounds sealed by stromal hydration allowed ingress of trypan blue into the anterior chamber. Notably, trypan blue was detected in the anterior chamber within 2 minutes of stromal hydration. A recent study by Praveen et al. confirmed this finding in 3 phacoemulsification techniques; the ingress was worst with bimanual phacoemulsification. Herretes et al. reported ingress of blood-tinged fluid into the anterior chamber after the incisions were sealed by stromal hydration. These results have led to the conclusion that clear corneal incisions may not always be self-sealing.

Terson syndrome with ipsilateral severe hemorrhagic retinopathy in a 7-month-old child.

In infants with intracranial hemorrhage, the most common cause of intraocular hemorrhages is abusive head trauma. Terson syndrome is rare in infants, and the retinal findings, although not well reported in the literature, are generally limited to the posterior pole. We report a case of a 7-month-old boy who developed ipsilateral, extensive preretinal and intraretinal hemorrhage after subarachnoid hemorrhage from a ruptured intracranial aneurysm.

Factors Influencing the Incidence of Postoperative Endophthalmitis

EDITOR: HAVING READ THE ARTICLE BY WYKOFF AND ASSOCIATES, we were impressed to read that the endophthalmitis rate at the Bascom Palmer Eye Institute (BPEI) was 2.8 per 10 000 for cataract surgery. 1 Although there is a range in the endophthalmitis rate reported in the literature, the currently accepted rate around the developed world is approximately 1 per 1000, or 1 per 2000 after intracameral antibiotics. 2,3 This suggests that BPEI may have an endophthalmitis rate of one quarter of rest of the developed world. Unfortunately, in New South Wales, Australia, the rate recently was shown to be more than 8 per 1000. 4 Perhaps in Australia something is very different from the sunny, healthy clime of Florida. Herein we raise some questions in relation to the study by Wykoff and associates. The authors stated that it is unlikely that any cases were missed in their 6-week follow-up in the light of the requirements of their Quality Assurance Committee. However, this assertion may not be able to be validated. Moreover, the patients in whom endophthalmitis developed may not have returned to BPEI for treatment. It was stated that the cataract surgery was being converted from subconjunctival or scleral incisions to unsutured clear corneal incisions during the period of the study. However, there was no documentation of the incision types, wound sizes, the frequency of wound suturing, or the level of experience of the surgeon, all of which are known to affect the incidence rate of endophthalmitis. Some studies have collected cases of endophthalmitis based on self-reporting of the complication by surgeons. 5 This type of reporting is known to be unreliable. Furthermore, a recent British study documented definitively that studies with positive results are more likely to be reported and published than those with negative results. 6

Negative dysphotopsia with spherical intraocular lenses

Neuroadaptation seems illustrated by a different patient of mine who saw a 360-degree ring shadow on the first day after surgery. At her next visit, she commented that it had become a temporal crescent shadow. At that point, she described a typical negative dysphotopsia. I cannot comment as to whether her symptoms were transient or permanent because she has been lost to follow-up. Neuroadaptation could explain why her symptoms improved. Might inconsistent neuroadaptation also explain why some negative dysphotopsia are transient and some are permanent? I agree with Gosala that further research into these phenomena would be beneficial.dDavid L. Cooke, MD

Bilateral retinoschisis in a 2-year-old following a three-storey fall

References 1 Chantranuwat C. Systemic form of juvenile xanthogranuloma: report of a case with liver and bone marrow involvement. Pediatr Dev Pathol 2004; 7(6): 646–648. 2 Shields CL, Shields JA, Buchanon HW. Solitary orbital involvement with juvenile xanthogranuloma. Arch Ophthalmol 1990; 108(11): 1587–1589. 3 Kaur H, Cameron JD, Mohney BG. Severe astigmatic amblyopia secondary to subcutaneous juvenile xanthogranuloma of the eyelid. JAAPOS 2006; 10(3): 277–278. 4 Chaudhry IA, Al-Jishi Z, Shamsi FA, Riley F. Juvenile xanthogranuloma of the corneoscleral limbus: case report and review of the literature. Surv Ophthalmol 2004; 49(6): 608–614.

Grading system for retinal hemorrhages in abusive head trauma: Clinical description and reliability study

PURPOSE There is currently no universally accepted grading system for describing retinal hemorrhages (RH) in abusive head trauma (AHT). The purpose of this study was to devise and evaluate a novel grading system and descriptive nomenclature for RH in AHT for clinical and research purposes. METHODS A traumatic hemorrhagic retinopathy (THR) grading system was developed for assessing and quantitatively analyzing retinal findings in abusive head trauma. The criteria for the THR grade included the extent, spread, and morphology of RH. Extent was classified as region 1 (posterior pole) or region 2 (peripheral). Spread, based on number of retinal hemorrhages, was classified as mild (10 or fewer RH), moderate (more than 10 RH) and severe (more than half of involved regions covered by RH). Morphology was classified by its intraretinal or extraretinal involvement. Two independent graders calculated the THR grade from RetCam images of 38 eyes of 19 patients <3 years of age with retinal hemorrhages associated with head injury. Grading was performed on two separate occasions. Intra- and interobserver reliability was assessed with Spearman correlation coefficient (r) and intraclass correlation coefficient (ICC). RESULTS There was a high level of intraobserver agreement across both assessments (97% agreement [Spearman r = 0.997; P < 0.0001] and 100% agreement [Spearman r = 1.0; P < 0.0000]). Intraclass correlation (ICC, 0.995; 95% CI, 0.991-0.997; P < 0.0001) confirmed a very high level of agreement overall. CONCLUSIONS The traumatic hemorrhagic retinopathy grading system demonstrated excellent intraobserver and interobserver reliability. The nomenclature is easily understood and may be useful in medical records and medicolegal reports.

Tunnel vision and night blindness in a 52-year-old man.

The Medical Journal of Australia ISSN: 0025729X 5 September 2011 195 5 287-288 ©The Medical Journal of Australia 2011 www.mja.com.au Lessons from Practice Vitamin A deficiency is a systemi an individual’s risk of blindness, s ity.1 It is rare in developed countri deficiency and xerophthalmia in reported in patients with malabs disease, in those who have had m in people with alcoholism, and in and other psychiatric disorders.3-6 c illness which can increase evere infections and mortales like Australia.2 Vitamin A developed countries are orption syndromes or liver ajor gastrointestinal surgery, those with anorexia nervosa This case is unique because our patient did not have any of these risk factors. This case also highlights the importance of clinicians regularly taking a thorough dietary history, especially in the context of other indications of nutritional insufficiencies, such as osteoporosis and previous vitamin B12 deficiency. Vitamin A is a fat-soluble vitamin found as retinol in dairy products and as provitamin A carotenoids in some fruits and green leafy vegetables.1,7-9 The first clinical evidence of vitamin A deficiency often occurs in the visual system and produces xerophthalmia. The ocular changes of Clinical record

Assessment of adequate removal of ophthalmic viscoelastic device with irrigation/aspiration by quantifying intraocular lens ‘Judders’

To assess the efficacy of ‘Judders’ as a technique reflecting adequacy of removal of ophthalmic viscoelastic device in cataract surgery.

Scalp necrosis in temporal arteritis: abrupt termination of the superficial temporal artery as a possible precursor

We were pleased to read the case report by Gkalpakiotis et al. [1] describing the rare manifestation of bilateral scalp necrosis as an early manifestation of temporal arteritis (TA). While the etiology of scalp necrosis in TA remains unclear, its presence has been attributed to the presence of severe disease leading to the rapid and complete occlusion of branches of the superfi cial temporal arteries. While the association between disease severity and scalp necrosis provides the most likely etiology of this rare manifestation of TA, we identifi ed a unique case of superfi cial temporal artery anatomy on routine biopsy in a case of biopsyproven TA. This may represent a possible precursor to and pathogenetic mechanism for scalp necrosis. An 85-year-old lady presented with intermittent horizontal diplopia, jaw claudication and temporal headache. There were no other symptoms suggestive of TA [2]. Examination revealed prominent, thickened, pulseless but tender superfi cial temporal and occipital arteries. The right superfi cial temporal artery was biopsied. This mediumsized artery was identifi ed easily, as it was large, irregular in caliber, rigid and non-pulsatile. As it was traced posterosuperiorly, it ceased abruptly in mid-tissue plane, coming to a taper. It therefore represented a medium-sized, true end-artery (Figure 1a). The 32 mm biopsied arterial segment demonstrated prominent lymphohistiocytic pan-infl ammatory infi ltrate, giant cells, intimal and medial thickening, internal elastic lamina obliteration, and marked luminal narrowing (Figure 1b). Intravenous corticosteroids and heparin therapy rapidly improved her symptoms [3], and normalized her elevated ESR and CRP. To our knowledge, the observation of an abrupt termination of the superfi cial temporal artery associated with TA is a unique fi nding. We have been unable to fi nd similar reports with a comprehensive literature search including MEDLINE, EMBASE, and the Cochrane Database. Temporal arteritis remains the commonest systemic vasculitis affecting elderly patients which results in lifeand sightthreatening complications. Although scalp necrosis is a rare phenomenon, its presence is associated with an older population [4], tongue gangrene, vision loss [5], a more severe disease course and a poorer prognosis [5−8] compared with patients without this manifestation. Patients with TA have a low mortality rate and their disease can generally be controlled [9]. Clinical Letter