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Ophthalmoscopic findings in occult child abuse.

Two previously healthy infants initially presented with vomiting and lethargy. There was a history of whiplash shaken infant syndrome in one infant, but neither child had external or skeletal survey evidence of abuse. However, ophthalmoscopy revealed bilateral retinal hemorrhages, papilledema and vitreous hemorrhage. Subdural aspirations revealed occult hematomas. Both children required ventricular peritoneal shunts to control intracranial pressure. Ophthalmologists, pediatricians, and primary physicians should be aware of the possibility of child abuse in the differential of diagnosis of Terson's syndrome, especially in infants since this may be the only physical finding.

Child Abuse↗

Altitude illness. The dangers of the heights and how to avoid them.

Altitude illness, caused by lack of oxygen, manifests itself in several forms, including acute mountain sickness, high-altitude pulmonary edema, and high-altitude cerebral edema. The first of these is usually minor, but the second and third can be fatal unless promptly diagnosed and treated (descent being the most effective management). Other, more specific, problems such as high-altitude retinal hemorrhage and thrombophlebitis can also occur in some individuals. Even so, there are only a few medical reasons to deprive an ambulatory, well-compensated patient of a visit to moderate altitude, and the conscientious physician will weigh carefully the risks against the benefits of a vacation in a beautiful and inspiring mountain setting.

Altitude Sickness↗

Ocular involvement in childhood leukemias.

Ocular involvement was detected in 36 of 84 children suffering from acute leukemia. The major manifestation of leukemic ophthalmology was retinal hemorrhage. Neither platelet counts nor hematocrit values correlated with the occurrence of hemorrhages. As the eye is a pharmacologic sanctuary, it is emphasized that full ophthalmologic evaluation of leukemic patients is a critical part of their follow-up and will guide the choice of therapeutic regimen.

Adolescent↗

Nonsurgical management of macular hemorrhage secondary to retinal artery macroaneurysms.

OBJECTIVE: To report visual acuity outcomes of nonsurgical management of macular hemorrhage secondary to retinal artery macroaneurysms. METHODS: Forty-one patients at multiple centers with macular hemorrhage secondary to retinal artery macroaneurysms managed with observation alone were reviewed. Time to clearance of macular hemorrhage, visual acuity at final follow-up, and presence or absence of macular pigmentary changes after absorption of the hemorrhage were recorded for each patient. RESULTS: On initial examination, visual acuity was 20/200 or worse in all except 4 patients (3 with 20/70, 1 with 20/80). At an average follow-up of 15. 7 months, a final visual acuity of 20/40 or better was achieved in 15 eyes (37%), between 20/50 and 20/100 in 12 (29%), and 20/200 or worse in 14 (34%). Macular pigmentary abnormalities were noted after clearance of the hemorrhage in 23 (56%) of 41 cases, and these eyes generally had worse visual acuity outcomes. CONCLUSIONS: In eyes with macular hemorrhage secondary to retinal artery macroaneurysms managed with observation alone, good visual acuity outcomes can often be achieved. Poorer visual acuity outcomes are associated with macular pigmentary changes after resorption of blood. Arch Ophthalmol. 2000;118:780-785

Adult↗

[Not-always-apparent abuse: the shaken baby syndrome].

The authors report 3 cases of infants presenting with cerebral lesions related to violent head shaking. They emphasize the diagnostic difficulties when the classical signs of the battered child (marks of blows, fractures) are lacking. The traumatism is rarely recognized: only the negativity of the usual medical causes of subdural hematoma, meningeal or retinal hemorrhage and a peculiar familial history lead to the possible diagnosis of shaken baby syndrome. The value of skull CT-scan is major, showing intracranial lesions which could not be found before. Because of the observed lesions, evolution is often severe.

Brain Injuries↗

Elevated blood histamine caused by vaccinations and Vitamin C deficiency may mimic the shaken baby syndrome.

The findings of subdural hematoma and retinal hemorrhages in infants, without any documented history of major trauma, do not always indicate child abuse. A combination of ascorbate depletion and the injection of foreign proteins can cause a very high blood histamine level, leading to capillary fragility and venular bleeding. This can be prevented by the administration of vitamin C.

Ascorbic Acid↗

Indocyanine green angiography in high myopia.

BACKGROUND AND OBJECTIVE: To evaluate indocyanine green imaging of choroidal changes in pathologic myopia and to compare it with fluorescein angiography. PATIENTS AND METHODS: The angiograms of all consecutive patients with pathologic myopia photographed with confocal indocyanine green angiography using a scanning infrared laser or ophthalmoscope from March 1997 to December 1999 were reviewed. RESULTS: Twenty-one patients (35 eyes) were included. Indocyanine green angiography was performed in 35 eyes and immediate sequential fluorescein angiography and indocyanine green angiography in 25 eyes. The lacquer cracks were demonstrated to radiate from the disc, at the papillomacular bundle, through the macula, and around the macula. Lacquer cracks were identified in 89% and 28% of the eyes, respectively. Choroidal neovascularization (CNV) was demonstrated in 57% of eyes by indocyanine green angiography and in 56% by fluorescein angiography. All of the CNVs were classic and were located within 300 microm of the foveal center. Seventy percent of the CNVs were delineated in lacquer cracks by indocyanine green angiography. Overall, 124 lacquer cracks were identified by indocyanine green angiography and only 14 by fluorescein angiography. Lipids or serous detachment were not observed. Retinal hemorrhages were noted in 22% and 28% of eyes with indocyanine green angiography and fluorescein angiography, respectively. CONCLUSION: Confocal indocyanine green angiography offers better delineation of lacquer cracks and the localization of the CNV in lacquer cracks than does fluorescein angiography.

Choroidal Neovascularization↗

[Biomicroscopy of an intraocular lens. Comparison of specular microscopy findings with the cytologic specimen].

Seventeen months after implanting an anterior chamber intraocular lens the lens had to be removed because of secondary glaucoma and retinal hemorrhage. The lens had been examined 5 days prior to surgery. It appeared that histiocytic giant cells and fibroblasts had settled on its surface. This was subsequently confirmed by cytological studies. It therefore appears possible to describe an in vivo differential cytology and to diagnose the type of inflammatory reaction in vivo.

Aged↗

Electroretinographic findings in infants with the shaken baby syndrome.

PURPOSE: To determine if electroretinography is helpful in the work-up of children with the shaken baby syndrome. METHODS: Six children with retinal hemorrhages and the shaken baby syndrome underwent electroretinography (ERG). The ERGs of these six children were compared with six age-matched controls using the sign-rank test. RESULTS: Neither the implicit time nor the amplitude of the white scotopic ERG response was significantly different between these patients and age-matched controls. Although the amplitude of the blue scotopic and 30 Hz flicker responses were attenuated (p < 0.05), the implicit times were not significantly different from controls. Three of the patients had serial ERGs recorded. The b-wave implicit time and amplitude improved in two of these patients. The ERG was helpful in distinguishing between a CNS and a retinal cause of visual loss in one child. CONCLUSIONS: The ERG can be helpful in assessing retinal function in children with the shaken baby syndrome who have persistent visual impairment. In most cases, the ERG is not helpful in the initial assessment of children with the shaken baby syndrome.

Battered Child Syndrome↗

Anterior ischemic optic neuropathy after a trans-Atlantic airplane journey.

PURPOSE: To report a case of anterior ischemic optic neuropathy after a trans-Atlantic airplane journey. DESIGN: An observational case report. METHODS: A 48-year-old healthy man presented with severe visual loss in his left eye within 12 hours after a 15-hour-long trans-Atlantic airplane flight. The patient underwent slit-lamp examination, funduscopy, fluorescein angiography, automated perimetry, and various blood examinations. RESULTS: Visual acuity was LE: 20/30, and a mild left eye relative afferent pupillary defect was noted. Funduscopic evaluation revealed an edematous optic disk in the left eye with a para-diskal retinal hemorrhage. Fluorescein angiography revealed a leaking optic disk, and perimetry showed an inferior hemi-field scotoma. Anterior ischemic optic neuropathy was diagnosed. CONCLUSION: Prolonged airplane travel may compromise vision either by a thromboembolic mechanism caused by prolonged immobilization or by a vasospasm mechanism induced by the low oxygen pressure during the flight.

Aerospace Medicine↗

Ocular hazards during birth.

In a study of over 2,000 consecutive live births, 243 newborns (12%) suffered birth trauma to the eye and its adnexa. Two hundred twenty-one cases (11%) had multiple retinal hemorrhages. Severe ocular accidents by forceps delivery were seen in the form of hyphema, Purtscher's retinopathy, corneal edema, facial palsy, and corneal abscess. Purtscher's retinopathy and corneal abscess are rare birth injuries that have not been reported so far in newborn babies.

Abscess↗

[Endogenous Aspergillus endophthalmitis in AIDS].

BACKGROUND: We present the course of an endogenous Aspergillus endophthalmitis in a 38-year-old HIV-positive man. HISTORY AND CLINICAL SIGNS: The first examination because of a sudden visual loss in the right eye showed a central subretinal infiltration, peripheral vascular sheeting and retinal hemorrhages. THERAPY AND OUTCOME: In spite of high-dose systemic antifungal therapy we could not prevent the penetration of the posterior wall of the eye and infiltration of adjacent orbital structures. Enucleation had to be performed. CONCLUSIONS: In case of scleral involvement in Aspergillus endophthalmitis the necessity of enucleation has to be considered.

AIDS-Related Opportunistic Infections↗

Retinal complications after bungee jumping.

Bungee jumping is becoming a popular sport in the Western world with some cases of ophthalmic complications being reported in recent literature. The authors reported a case of a 23-year-old healthy female who presented retinal complications following a bungee jumping. Her fundi showed superficial retinal hemorrhages in the right eye and a sub-internal limiting membrane hemorrhage affecting the left eye. A general examination, including a full neurological examination, was normal and laboratorial investigations were all within normal values. More studies are necessary to identify risk factors and the true incidence of related ocular lesions, but until then, we think this sport activity should be desencouraged, especially to those that are not psychological and physically fit.

Adult↗

Child abuse: radiographic findings at King Chulalongkorn Memorial Hospital.

OBJECTIVE: To describe radiographic findings in physically abused children. MATERIAL AND METHOD: The physically abused children diagnosed in King Chulalongkorn Memorial Hospital from 1998 to 2002 were retrospectively reviewed of medical records and radiographic imaging. RESULT: Eighteen of 30 physically abused children had positive radiographic findings and 15 of 18 were related to head injury. Subdural hematomas and skull fractures were the two most common findings found in 11 cases and 9 cases respectively. Seven of 11 cases of head injury had retinal hemorrhage. Fractures other than the skull were detected in 6 patients, located at the long bones, ribs and spines. The abused children with positive radiographic findings were more commonly found in younger infants and mucocutaneous lesions might be absent. CONCLUSION: Inflicted head injury was the most common radiographic findings in the present series. Shaking-impact mechanism was likely to play a significant role in this group of patients.

Child Abuse↗

Spontaneous retinal haemorrhages.

Five patients are described with spontaneous retinal haemorrhages. In two patients small retinal hemorrhages occurred at the posterior pole, in one of them after physical exertion. In three patients multiple small round haemorrhages occurred in the retina, in one of them after physical exertion, in two of them associated with large preretinal subhyaloidal haemorrhages. The haemorrhages developed at relatively young age and only in one eye, and cleared rapidly with good visual outcome. Physical exertion as pathogenic factor was only observed in two patients.

Adult↗

Measurements of fetal head compression pressure during bearing down and their relationship to the condition of the newborn.

Fetal head compression pressure (FHCP) and its clinical importance has been investigated in a group of 46 spontaneous births. Measurement of FHCP was facilitated using a compression transducer positioned between the fetal head and the wall of the birth canal. This method not only constitutes a means of quantitating the forces acting directly on the fetal head, but also provides information about the intracranial pressure generated during delivery. The latter extrapolation is based on the principle of applanation. The technique provides an objective and reliable estimate of intracranial strain and therefore a means of comparing the forces generated under different delivery modes. The condition of the same neonates at birth was assessed using umbilical artery pH, Apgar score, neurobehavioral testing and fundoscopic examination. The mean amplitude of FHCP in the different deliveries ranged from 38 to 390 mmHg (5-52 kPa) with an overall mean of 157.9 mmHg (21.1 kPa). The study indicated that the appearance of retinal hemorrhages in the newborn cannot be explained by exposure of the fetal head to abnormally high compression during birth. Other explanations must be sought for infants with a neurobehavioral deficit, reduced Apgar score, or umbilical artery acidosis at birth. It is concluded that a relatively short period of high FHCP has no obvious consequences for fetal well-being, at least within the limits described in the present report.

Apgar Score↗

Transient blindness after lumbar epidural steroid injection: a case report and literature review.

STUDY DESIGN: A case report of transient blindness after lumbar epidural steroids is presented. OBJECTIVE: To report the diagnosis and treatment of a case of blindness after administration of lumbar epidural steroids. SUMMARY OF BACKGROUND DATA: Nine previous cases of blindness after lumbar epidural injection for back pain were identified. Retinal hemorrhages were identified on ophthalmologic examination in all cases. METHODS: The 1-year follow up evaluation of a 39-year-old male who sustained transient blindness after administration of lumbar epidural steroids is reported. RESULTS: At 1 year, the patient had significant return of vision, but it did not improve back to baseline. CONCLUSIONS: Transient blindness is a rare complication of lumbar epidural injection. The pathophysiology and prevention of this rare entity is reviewed.

Adult↗

[The battered child syndrome: neurologic aspects in 7 cases].

Data on 7 cases of battered child syndrome with neurological complications are reviewed. First symptoms were convulsions and bulged fontanel of undetermined origin. At clinical examination the unexpected presence of retinal hemorrhage in 5/7 patients has been the main criteria to diagnostic definition. CT showed the presence of subdural collections in the majority of the patients. A normal CT, however, does not display the possibility of future problems. Successive CT studies have proved useful. In two cases they demonstrated the appearance of diffuse images of central nervous system destruction some weeks later, and probably related to ischaemic troubles in connection with the aggression mechanisms.

Battered Child Syndrome↗