Heikki Erkkilä

REFRACTIVE ERRORS AND OTHER OCULAR FINDINGS IN SCHOOL CHILDREN

A series consisting of 411 non‐selected school children, 7 to 15 years of age, was examined. Decreased visual acuity (less than 0.8 in one or both eyes without correction) was found in 55 children (13.4%), the frequency increasing from 3.7% to 29.1% with age. The frequency of hyperopic eyes (+2.0 D. or more) decreased from 19.1% to 3.6% and the frequency of myopic eyes (‐0.5 D. or more) increased from 1.9% to 21.8% with age. Altogether, myopia, hyperopia, or astigmatism (1 D. or more) in one or both eyes was found in 93 children (22.6%).

Optic disc drusen in children.

Among 1076 schoolchildren aged about 7, four were found to have anomalous elevation of the optic disc attributable to buried drusen. No superficial optic disc drusen were found in any of the children examined. The optic disc anomaly due to buried drusen is peculiar to children. The frequency of the condition in the child population examined corresponds to previous estimates of the frequency of drusen of the optic disc among adults. In all those affected the eyes were subjectively symptom-free. All four children had normal visual acuity but a visual field defect of the nerve fiber bundle defect type was observed in one. Two had severe headaches. Neurological examination revealed abnormal findings in all four subjects, one had abnormal EEG. Since neurological symptoms and findings are common in individuals with optic disc drusen, neurological examination is indicated after the ophthalmological diagnosis has been made.

A FOLLOW‐UP STUDY ON SERPIGINOUS CHOROIDITIS

Fifteen patients suffering from serpiginous choroiditis were followed up for 1 to 10 years (mean 4.9 years). There were 7 women and 8 men with ages ranging from 20 to 65 years (mean 35 years). In 13 patients both eyes were involved. Ten of the 15 patients had both inactive scars and fresh lesions when first seen. The individual lesions resolved in a few weeks but, due to the gradual extension of the primary lesions centripetally in the shape of halos or pseudopods, signs of activity were observed for 1 to 9 months after the initial examination. After an interval of 3 months to 4 years, new recurrences were found in 8 patients; in some of them progression was noticed on serial fundus photographs only. Central vision was lost in 6 eyes, in 2 of them due to a subretinal neovascular membrane. Progression and recurrences could not be prevented by antituberculous medication or systemic corticosteroids. The cause of serpiginous choroiditis remains unknown but, on the basis of the fluorescein angiography, occlusion of the uveal vessels, possibly due to an immune vasculitis, is suggested. Immunological studies revealed no signs of diffuse vasculitis. Of the histocompatibility antigens, HLA‐A2 was found in five and HLA‐B7 in 4 of the 6 patients studied.

Clinical appearance of optic disc drusen in childhood

In a series of 50 individuals with optic disc drusen diagnosed before the age of 15, the anomaly occurred most often in the form of an elevation of the whole or one part of the optic disc without visible superficial drusen. Superficial drusen were seen only in 15 of the 92 eyes with the anomaly. In those 42 subjects in whom the anomaly was bilateral, it was seldom symmetrical. The reduced visual acuity found in a few cases could be attributed to causes other than the drusen. In 10 eyes the anomaly was observed to be associated with visual field defects. The age distributions of the subjects with visual field defects and with superficial drusen show that they were more common among older children. The superficial position of the drusen and the presence of visual field defects do not, however, have a close cause- and-effect relationship. A cilioretinal artery was observed to co-exist with optic disc drusen with a high frequency, i.e. in more than 40%. Other vascular aberrations were also noted in association with the optic disc anomaly. Neurological symptoms were the most common cause for consultation in the 50 children examined. In more than half of the present cases appearance of the optic disc had contributed to the suspicion of an intracranial expansive process. A fallacious similarity between the elevation of the optic disc caused by buried drusen and optic disc edema caused by increased intracranial pressure presents a problem of differential diagnosis, expressly in younger children.

The central vascular pattern of the eyeground in children with drusen of the optic disk

In a series of 50 children with optic disk drusen the anomaly was found to be associated with unusual properties. A cilioretinal artery was more frequent in the series with drusen than in a control series of the same age. The emergence and course of the central retinal vessels were studied in the right-sided fundi of 46 of the children and in two control series (the fundi of the “better” eyes of 46 strabismic children and the fundi of one of the eyes of 10 children or young adults with papilledema). Analysis of the measurements indicated that early branching of the central vessels and vascular tortuosity are so frequently associated with optic disk drusen that they can he considered features of the anomaly. On the other hand, the fundal vascular features in papilledema seem to he distinguishable by the method used from those associated with optic disk drusen. When the peripapillary choroidal vascular pattern was studied by fluorescein angiography, choriocapillaris filling was delayed in about the half of the angiograms. The aberrant vascular features found on and around optic disks with drusen can be explained by an embryonic affection of the developing vascular system at the optic nerve head. In this respect the anomaly seems to resemble congenital disorders of mesodermal origin. Der Augenhintergrund von 50 Kindern mit Drusenpapille wies bei der Mehrzahl ein abweichendes Gefäßmuster auf. Eine zilioretinale Arterie kam in der Gruppe mit Drusenpapille häufiger vor als in der Kontrollgruppe mit entsprechender Altersverteilung. Die zentralen Netzhautgefäße wurden nach Austritt und Verlauf untersucht und mit denen zweier Kontrollegruppen verglichen. Als Kontrolle diente in der ersten der Augenhintergrund von 46 „gesunden” Augen von Kindern mit Strabismus, in der zweiten der Augenhintergrund des rechten oder linken Auges von 10 Kindern oder jungen Erwachsenen mit Papillenödem. Hieraus ergab sich, daß die frühe Verzweigung und die Schlängelung der Gefäße zum Wesen der Anomalie gehören. Anderseits unterschied sich auch das Gefäßmuster bei Papillenödem von dem der Drusenpapille mit der angewandten Methode. In dem peripapillaren, chorioidalen Gefäßsystem, das mittels der Fluoreszein-Angiographie untersucht wurde, lag eine verlangsamte Füllung der Choriokapillaris hei etwa der Hälfte der Untersuchten vor. Das spezielle Gefäßmuster der Drusenpapille läßt sich mit früher Einwirkung der hereditären Anomalie auf die Entwicklung des vaskularen Systems erklären. In dieser Beziehung scheint die Drusenpapille kongenitalen Zuständen mesodermalen Ursprungs ähnlich.

OCULAR FINDINGS IN FOUR SIBLINGS WITH PSEUDOXANTHOMA ELASTICUM

In a family consisting of 8 surviving siblings, pseudoxanthoma elasticum was diagnosed in 4 sisters. One of them had a severe visual handicap, and another a slight decrease of the visual acuity because of the ocular lesions. The other 2 sisters also had fundal lesions, but they were visually symptom‐free. Great variation was also found in the appearance of the ocular lesions in the affected siblings. In addition to the angioid streaks, the fundal findings in the probands affected included changes of the retinal pigment epithelium, exudative maculopathy, optic disc drusen and ‘fire‐work’‐pattern of drusen of the Bruchs membrane. A similar variety of alterations was also found in the histopathology of the skin.

Characteristics of optic disc in healthy school children.

The ophthalmoscopic features of the optic discs were studied in a series of 411 non‐selected school children representing four age groups from 7 to 15 years. The distribution of the cup disc diameter ratios (C/D) showed that in the majority of the eyes (58.8%) the ratio was 0.2‐0.3, independently of the age group. The highest ratio recorded, 0.7, was found in two eyes of the series. An asymmetry of 0.2 or more in the C/D ratios of the eyes was found in 5.2% of the children studied. The correlation between C/D ratio and the age or refraction was not statistically significant although C/D ratio of 0.4 or more was significantly commoner in myopia of ‐2.0 D. or more than in the other eyes. A preponderance of large C/D ratio was also found in children with a birth weight of 2500 g or less but the difference from the distribution in the total series was not significant.

VISUAL SCREENING OF SCHOOL CHILDREN

A non‐selected group of 411 school children, 7 to 15 years of age, were screened by the school nurses. The screening program included (1) testing of visual acuity by the Snellen chart (with glasses if worn), (2) observing noticeable strabismus, and (3) recording subjective ocular symptoms related to reading. Later the whole series underwent a thorough eye examination performed by the authors including a hyperopia test and the Titmus stereo test.

CLINICAL AND FLUORESCEIN ANGIOGRAPHIC FINDINGS OF ACUTE MULTIFOCAL CENTRAL SUBRETINAL INFLAMMATION

Three female patients with acute multifocal subretinal central lesions and with almost complete recovery of macular function are presented. The findings and the course of the disease are very similar to acute posterior multifocal placoid pigment epitheliopathy described initially by Gass in 1968. Etiology of the disease could not be determined, but the history of solar exposition in two patients suggests the possibility of an exogenous factor.

Children referred for pleoptic treatment. A survey on aspects considering referral for examination, role of screening programmes, previous therapy and compliance.

Abstract The patient histories of 53 unselected children referred for pleoptic treatment were evaluated. The age of the patients ranged from 7 to 12 years, and the mean age was 8.8 years. Information concerning the history was obtained from a questionnaire answered by the parents. The data concerning the ocular conditions were available in the case records. In 83% of the children the diagnosis of functional amblyopia had already been made before school age. During the first 3 years of life altogether 38% were diagnosed outside of routine screening programmes. When the children caught by screening were added, the proportion of those diagnosed before the age of four was 45%. The practice of referring patients from the child health center to the ophthalmological examination was unsatisfactory in some children (19%). Poor compliance was noted still more often (at least in 58%). Occlusion therapy had been used by 92% of the children, and in 42% alternating complete occlusion had been prescribed.