Sarah P. Read

RETINAL DETACHMENT SURGERY IN A PEDIATRIC POPULATION: Visual and Anatomic Outcomes

Purpose: Pediatric retinal detachments (RDs) are unique in etiology, anatomy, and prognosis compared with the adult population. The mechanisms of pediatric RD include tractional (TRD), rhegmatogenous retinal detachment, traumatic, and other types, such as exudative or hemorrhagic. This study examined visual and anatomical outcomes of pediatric RD undergoing surgical repair at a single university referral center. Methods: A retrospective consecutive case series of patients clinically diagnosed and undergoing surgery for RD between birth and 15 years of age from 2002 to 2013 at a single academic institution. Results: A total of 206 patients (231 eyes) were included in this study, of which 25 (12%) had bilateral RD. Of those patients, 67 (29%) had TRD (retinopathy of prematurity, persistent fetal vasculature, or familial exudative vitreoretinopathy), 51 (22%) had rhegmatogenous retinal detachment (myopia, X-linked retinoschisis, or Stickler syndrome), 60 (26%) had traumatic RD, and 53 (23%) were due to other types of RD, such as Coats disease or coloboma. Presenting best-corrected visual acuity better than 20/200 correlated with better final best-corrected visual acuity (P < 0.0001). Anatomical success was strongly correlated with visual acuity outcome (P < 0.00001) and was significantly more likely in rhegmatogenous retinal detachment versus TRD (78% vs. 39%, P < 0.05). The rates of obtaining a final best-corrected visual acuity > 20/200 were poorer in TRD (10%) compared with rhegmatogenous retinal detachment (39%, P < 0.01) or traumatic RD (28%, P < 0.05). Conclusion: Visual and anatomical outcomes varied among categories of RD. Rhegmatogenous retinal detachments were associated with the best outcomes (anatomical success and globe conservation), whereas TRDs generally had poorer visual and anatomical outcomes.

Visualization of the retina and vitreous during vitreoretinal surgery: new technologies

PURPOSE OF REVIEW Visualization remains a critical factor in successful ocular surgery.Here we review new technology that has the potential to allow for safer and more efficient retinal surgery. RECENT FINDINGS Vitreoretinal surgery poses unique visualization challenges such as the need for specialized optical systems and the delicate and microscopic features of retinal structures. Better retinal visualization allows for new approaches to increasingly complex retinal cases. Wide-angle viewing has allowed stereopic visualization of the peripheral retina. Improved lighting systems have shown better safety profiles and can facilitate bimanual techniques. The potential to improve surgical decision making has been shown with intraoperative imaging such as optical coherence tomography. SUMMARY Although some of the benefits of these developments have yet to be proven, improved technology for visualization during retinal surgery will hopefully allow for safer and more efficient surgeries.

Retinal detachment associated with atopic dermatitis

Ocular manifestations related to atopic dermatitis include keratoconus, keratoconjunctivitis, cataract, and retinal detachment. The authors report three cases of retinal detachment associated with atopic dermatitis. Although the pathogenesis is poorly understood, chronic blunt trauma may play a role in the development of retinal detachment. In addition, retinal detachments associated with atopic dermatitis may have lower rates of successful retinal detachment repair. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:513-517.].

Treatment of Refractory Filamentary Keratitis With Autologous Serum Tears

Purpose: To report a case of filamentary keratitis (FK) successfully treated with autologous serum tears and to review the pathogenesis and management of FK. Methods: Case report including high-resolution anterior segment optical coherence tomography and filament histopathology. Case Report: A 61-year-old Hispanic man presented with pain and photophobia of the right eye. He was found to have a corneal epithelial defect and a small peripheral infiltrate 4 months after Laser Assisted in situ Keratomileusis. After resolution of the epithelial defect, he developed FK. Over a 4-month period, conservative management with aggressive lubrication, lid hygiene, topical corticosteroids, topical cyclosporine, bandage contact lenses, and oral doxycycline failed to resolve the corneal filaments. Notably, treatment with 20% autologous serum tears, four times daily, led to a sustained resolution of the FK within 1 week. Conclusions: This case demonstrates the complexity of FK management and introduces autologous serum tears as a viable management option when conservative approaches to this condition fail.

Optical Coherence Tomography Imaging After Surgical Closure of Pediatric Traumatic Macular Holes

Purpose: To date, little attention has been directed to retinal photoreceptor migration after traumatic macular hole surgical repair in the pediatric population. The purpose of this study was to evaluate optical coherence tomography (OCT) findings in the foveae of pediatric patients with history of traumatic macular hole surgical repair. Methods: Retrospective case series of 3 eyes in 3 pediatric patients with traumatic macular hole surgical repair. Spectral domain OCT images were obtained pre- and postoperatively. Results: We report 3 cases of restoration of the ellipsoid zone with good visual acuity outcomes following macular hole closure. Conclusion: Optical coherence tomography findings of an intact ellipsoid zone may be a predictor of visual acuity and explain better surgical outcomes in the pediatric population.

Two infants with presumed Zika congenital syndrome presenting for exam under general anesthesia

appropriate legal supervision. The child occupied a tertiary PICU bed for 8 days, requiring input from multiple specialties. Concomitantly, some national referrals were delayed. Some might contend that socially funded hospital beds should be primarily reserved for domestic citizens. However, as a signatory to the 1951 UN Convention Relating to the Status of Refugees, Ireland espouses the right to health care for all refugees (4). The ethical care of this significantly compromised child focused on distributive justice, and the right of all humans to access medical care. He subsequently required percutaneous gastrostomy feeding tube insertion with general anesthesia, once his multiorgan failure had resolved. The potential challenges in the perioperative period, especially the complexities surrounding his consent process and resuscitation status, were ameliorated considerably by incorporating many of the aspects detailed above (5).

Retinal detachment in a combined case of stickler syndrome and X-linked retinoschisis

A 12-year-old boy presented with a total rhegmatogenous retinal detachment and a giant retinal tear in the right eye. Clinical examination, optical coherence tomography, and fundus images showed an optically empty vitreous, lattice degeneration, and retinoschisis of the macula. Genetic testing revealed mutations in the COL2A1 and RS1 genes, confirming a dual diagnosis of Stickler syndrome and X-linked retinoschisis, respectively. This represents the first published account of a patient with both Stickler syndrome and X-linked retinoschisis. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:83-86.].

The Use of Fluorescein Angiography to Evaluate Pediatric Abusive Head Trauma: An Observational Case Series

Background or Purpose: The evaluation of retinal hemorrhages in the setting of suspected abusive head trauma (AHT) has important medical, social, and legal implications. Challenges include late presentation after retinal hemorrhages have resolved and differentiating AHT-related retinal changes from mimicking pathologies. To date, angiographic evidence of peripheral retinal injury in AHT has been reported in small series, but further study is needed to determine the prevalence and long-term sequelae of these findings. The purpose of this study was to describe fluorescein angiography (FA) findings in pediatric patients with a history of definite AHT and demonstrate the potential utility of FA in evaluating cases of suspected abuse with late presentation. Methods: Retrospective case series of 10 eyes in 5 pediatric patients with a history of definite AHT. RetCam fundus photography images and digital FA were performed. Results: Peripheral retinal nonperfusion affected 10 of 10 eyes in patients with a history of definite AHT. These changes persisted after acute retinal hemorrhages had resolved. Conclusions: “Retinal surveys” using FA provide angiographic evidence of peripheral retinal nonperfusion that may be a sign of AHT. This series adds to the growing body of cases reporting similar AHT-related findings and additionally demonstrates the longevity of these pathologic changes after trauma, which has not been previously described. Fluorescein angiography may offer a distinct advantage in evaluating cases of suspected abuse with late presentation to medical care when pathognomonic retinal hemorrhages may no longer be present. Further study is needed to determine the prevalence and long-term sequelae of these findings.

Outcomes in bullous retinal detachment

Purpose To report two patients with giant retinal tear (GRT) associated retinal detachment in the setting of baseball trauma. Observations Two patients presented with retinal detachment associated with GRT following blunt trauma with a baseball. The first was a superotemporal GRT detachment treated with scleral buckling, pars plana vitrectomy, endolaser, and silicone oil injection. He subsequently underwent cataract surgery with silicone oil removal and at two year follow up the retina with attached with best-corrected visual acuity of 20/20. The second case was an inferotemporal GRT detachment treated initially with laser demarcation, however the tear progressed to a retinal detachment that was then treated with pars plana vitrectomy and lensectomy, endolaser, perfluoro-octane (PFO), and silicone oil injection. At the one year follow up, the retina was attached and the best-corrected visual acuity was 20/30. Conclusions and importance GRTs are an uncommon cause of retinal detachment. While pars plana vitrectomy with tamponade is standard in GRT management, there is variability in the use of scleral buckling and PFO in these cases. This is in contrast to retinal dialysis where scleral buckle alone can yield favorable results. Though a baseball ocular trauma is common, retinal involvement is rare compared to other sports injuries such as those occurring with tennis, soccer and golf. Sports trauma remains an important cause of retinal injury and patients should be counseled on the need for eye protection.

Antiphosphospholipid syndrome presenting with amaurosis fugax and cotton wool spots

Purpose To describe the importance of considering vaso-occlusive disease on the differential diagnosis of a patient presenting with amaurosis fugax (AF) and unilateral cotton wool spots (CWS). Observations A 69-year-old female with history of obesity, hyperlipidemia and recent orthopedic surgery, presented with 3 days of worsening monocular AF and CWS in the right eye. She was diagnosed with antiphosphospholipid syndrome based on positive serologic testing for antiphosphatidylserine IgM, anticardiolipin IgM. The patient was treated with lipid lowering medication, long-term aspirin, and has followed a weightloss and physical therapy program under medical supervision. The CWS resolved and AF symptoms have not recurred. Conclusions and importance Antiphospholipid syndrome can be considered in the differential diagnosis of patients presenting with AF, assymetric CWS, and/or rapid progression of symptoms.