New Palpometer with Implications for Assessment of Deep Pain Sensitivity

The aims of this study were to compare test-retest variability and accuracy measures between (1) manual palpation and a novel palpometer and (2) different force levels. Sixteen clinicians were instructed to target 0.5, 1.0, and 2.0 kg on a force meter using manual palpation and the new palpometer (adjustable spring-coil with a small pin touching the examiner’s hand when the correct pressure is reached). In all experiments, 10 consecutive measures of the force levels were recorded. The coefficient of variation (CV), actual force levels, and relative differences between target level and actual force level were compared between experiments and target levels. All outcome parameters had significantly lower values for the new palpometer than for manual palpation in a force-dependent manner (p < 0.004). CVs and actual force levels were significantly different between all target levels (p < 0.004). The new palpometer had low test-retest variability and provides a more accurate pressure stimulus than manual palpation.

Unilateral situs inversus of optic disc associated with reduced binocularity and stereoacuity resembling monofixation syndrome

Situs inversus of the optic disc is a rare, usually bilateral, congenital embryological abnormality associated with high myopia, optic disc coloboma or tilted optic disc. It is characterized by emergence of the retinal vessels in an anomalous direction with dysversion of the optic disc. In this report we present a 13-year-old boy diagnosed with isolated, unilateral situs inversus of the optic disc associated with reduced binocularity and stereoacuity resembling a monofixation syndrome. The clinicians should be aware of this association and assess the binocularity in patients with unilateral optic disc or macular anomalies. Conversely, patients with reduced binocularity and stereoacuity should be carefully evaluated for macular or optic nerve anomalies, if not associated with strabismus, anisometropia and eccentric fixation. Typical fundus picture, optical coherence tomography and multifocal electro retinogram of the patient would be instructive to a clinician.

Bilateral Staphylococcus aureus sub-Tenon's abscess following strabismus surgery in a child

Infection after strabismus surgery is rare. Here we describe a 5-year-old girl who developed bilateral staphylococcal sub-Tenon's abscess resistant to fourth-generation fluoroquinolones that resolved completely after surgical drainage and irrigation with povidone iodine followed by administration of oral amoxicillin and clavulanic acid. A lost muscle required exploration and reattachment to the sclera.

Intravitreal anti-vascular endothelial growth factor agents as an adjunct in the management of Coats' disease in children

We describe the role of intravitreal anti-vascular endothelial growth factor (VEGF) agents in Coats' disease in children. In a prospective, interventional, non-randomized case series, three patients (three eyes) aged 16, seven and two years were diagnosed to have Coats' disease. In Case 1 (16 yr/ male) with macular edema, previous laser photocoagulation being unsuccessful, intravitreal pegaptanib sodium (Macugen™) was tried. Case 2 (seven yr/ male) and Case 3 (two yr/ female) were diagnosed to have Stage 4 Coats' and underwent external needle drainage, laser photocoagulation, SF6 gas injection and intravitreal injection of bevacizumab (Avastin™). Reduction of exudation and attached posterior pole (Cases 2 and 3) was seen at a follow-up of six months and two months respectively. Intravitreal anti-VEGF agents may be successfully used as adjunct treatment in select cases of Coats' disease in childhood.

Comparison of psychosocial and emotional consequences of childhood strabismus on the families from rural and urban India

Purpose:

To compare the psychosocial consequences of horizontal comitant strabismus in children between the families of urban and rural India.

Materials and Methods:

In this cohort study, an eight-question quality-of-life instrument was administered by trained staff to the guardians of strabismic children from rural and urban areas by a live interview.

Results:

This study included 93 strabismic-children aged 4-16 years of which 52 were females. Forty-one had esodeviation and 52 had exodeviation. Seventy per cent parents were extremely distressed due to squint, 65% were extremely distressed due to people's remarks, 65% were extremely worried, 55% children were extremely distressed due to people's remarks, 57% children were severely ostracized, 38% had severe difficulty in communication and 50% had difficulty to cope; 64% parents were not advised a corrective surgery. The difference between families from rural and urban areas, or whether a male child was affected or a female child or for an esodeviation or an exodeviation was statistically not significant. The questionnaire had a good internal consistency (Cronbach's Alpha = 0.71).

Conclusions:

There was a significant negative psychosocial and emotional impact of childhood strabismus that was not affected by the rural or urban location of the family or the gender of the strabismic child or type of the deviation. The quality-of-life instrument can be used as part of the clinical examination for strabismic children.

Evaluation of central, steady, maintained fixation grading for predicting inter-eye visual acuity difference to diagnose and treat amblyopia in strabismic patients

Background:

Diagnosis of amblyopia in preverbal strabismic patients is frequently made by binocular fixation preference (BFP) testing. The reports on reliability of BFP are equivocal. This study evaluated the reliability of BFP testing in patients with horizontal strabismus.

Materials and Methods:

This prospective observational study included patients with manifest, horizontal, comitant deviation >10 prism diopter (PD). Inter-eye acuity difference (IEAD) was calculated by converting Snellen visual acuity to logMAR and was compared with BFP testing. The fixation behavior of the non-preferred eye was evaluated by a single investigator as central or uncentral, steady or unsteady and maintained or unmaintained. Amblyopia was defined as the IEAD of >0.2 logMAR.

Results:

Of total 61 patients 36 were females and 36 had convergent squint, mean age 9.8 years. The correlation of BFP testing with IEAD was good for esotropia and exotropia. The sensitivity, specificity, positive and negative predictive value of central, steady, maintained (CSM) grading was 93%, 78%, 79%, and 93% respectively. Sensitivity and negative predictive values were higher in children aged four to nine years and anisometropia >1 diopter. The correlation between IEAD and lower grades of BFP testing was poor.

Conclusions:

CSM grading for BFP testing is useful for the detection of strabismic amblyopia but not useful to differentiate the depth of the amblyopia.

A novel method for management of conjunctival inclusion cysts following strabismus surgery using isopropyl alcohol with paired injection technique

Conjunctival inclusion cysts following strabismus surgery are typically treated by surgical excision in a hospital setting. Cysts may be aspirated in the office setting with the aid of a slit lamp, but this approach is associated with recurrence. Thermal cautery and intracyst injection of doxycycline may also be performed in the office. We present 2 cases of conjunctival inclusion cysts treated with isopropyl alcohol injection in an office setting. There was no recurrence at 9 months follow-up.

Resolution of recurrent conjunctival papilloma after topical and intralesional interferon alpha2b with partial excision in a child

The human papilloma virus (HPV) is a double-stranded DNA virus that infects the epithelium of skin and mucosa. Simple treatment of conjunctival papilloma is associated with recurrences, and while most medical therapy has met with limited success, interferon alpha 2b (IFN alpha2b) may be effective. In this report, we describe a 7-year-old child with severe, recurrent conjunctival papilloma who had complete regression of the papilloma after topical and intralesional IFN alpha2b with partial excision of the lesion.

Paralysis of the near-vision triad in a child

The near-vision triad, or complex, consists of convergence, miosis, and accommodation. Neuronal pathways that control each of these components are distinct but interrelated. Abnormalities affecting 1 or more components of the complex may present as eye pain, headache, blurred vision, or diplopia at near fixation. Although isolated abnormalities in any one of the components are common, a severe and concurrent defect in all three is rare.(1,2) We describe an 11-year-old child who presented with complete paralysis of the near triad without identifiable neurological defect. The child benefited from prism and plus lenses. To our knowledge, only three previous reports have described patients with idiopathic paralysis of convergence and accommodation in healthy children.(2-4) The methods we used to objectively confirm defects in the near-vision complex and rule out a psychogenic etiology may be instructive to other clinicians.

Anterior dislocation of a sulcus fixated posterior chamber intraocular lens in a high myope

A 31-year-old man with high axial myopia and strabismus fixus convergens underwent bilateral refractive lens exchange followed by a squint surgery (bilateral superior partial Jensen′s procedure and medial rectus recession). After one year he presented with traumatic anterior dislocation of the sulcus fixated posterior chamber polymethyl methacrylate lens. The lens was dialed back into the ciliary sulcus without any complications. This case highlights the importance of implanting an intraocular lens (IOL) in-the-bag. If the IOL needs to be implanted in the sulcus, a larger diameter of the IOL with larger optic size and overall length is desirable, especially in highly myopic eyes.

Nitrous oxide induced sub-acute combined degeneration of spinal cord: a case report

We report a patient who developed signs and symptoms of a myelopathy after exposure to nitrous oxide. Magnetic Resonance Imaging of the cervical spinal cord disclosed hyperintensities of the dorsal columns on T2 weighted images suggesting sub-acute combined degeneration.

Clinical characteristics of spontaneous late-onset comitant acute nonaccommodative esotropia in children

PURPOSE

To describe the clinical characteristics of spontaneous, late-onset comitant acute, nonaccommodative esotropia (ANAET) in children.

MATERIALS AND METHODS

Clinical characteristics of a cohort of patients under 16 years of age with ANAET were studied retrospectively.

RESULTS

Of 15 patients eight were females. Mean age was 7.15 years (range 2.5-13, SD 3.34). Mean age of the onset of deviation was 3.2 years (range 1.5-9, SD 2.26). Mean duration of strabismus was 36 months (range 3-132, SD 43). History of a precipitating event was present in five patients (33.3%). Mean cycloplegic refraction was 1.84 diopter sphere (range -5.75 to +7.25, SD 3.55). Mean esodeviation for near and distance fixation was 40 prism diopter (range 15-90, SD 23.9). None had near/distance disparity of more than 5 prism diopter. Amblyopia was present in 13 cases (87%). Strabismus surgery was performed for eight patients. Five patients had orthophoria and three were aligned within 8 prisms esodeviation.

CONCLUSION

ANAET is more common than previously reported, has a variable time of onset and high incidence of amblyopia. Timely management would avert emergence of amblyopia and vertical incomitance thereby promising better binocular outcome.

Longitudinal study of magnetic resonance imaging and standard X-rays to assess disease progression in osteoarthritis

OBJECTIVE

To investigate, over 1-year, the relationship between X-ray and magnetic resonance imaging (MRI) findings in patients with knee osteoarthritis (OA).

METHODS

Sixty-two osteoarthritic patients (46 women) were followed for 1 year. At baseline and after 1 year, volume and thickness of cartilage of the medial tibia, the lateral tibia and the femur were assessed by MRI. A global score from the multi-feature whole-organ MRI scoring system (WORMS) was calculated for each patient at baseline and after 1 year. This score combined individual scores for articular cartilage, osteophytes, bone marrow abnormality, subchondral cysts and bone attrition in 14 locations. It also incorporated scores for the medial and lateral menisci, anterior and posterior cruciate ligaments, medial and lateral collateral ligaments and synovial distension. Lateral and medial femoro-tibial joint space width (JSW) measurements, performed by digital image analysis, were assessed from fixed-flexion, postero-anterior knee radiographs.

RESULTS

One-year changes in medial femoro-tibial JSW reach 6.7 (20.5) % and changes in medial cartilage volume and thickness reach 0.4 (16.7) % and 2.1 (11.3) %, respectively. Medial femoro-tibial joint space narrowing (JSN) after 1 year, assessed by radiography, was significantly correlated with a loss of medial tibial cartilage volume (r=0.25, P=0.046) and medial tibial cartilage thickness (r=0.28, P=0.025), over the same period. We found also a significant correlation between the progression of the WORMS and radiographic medial JSN over 1 year (r=-0.35, P=0.006). All these results remained statistically significant after adjusting for age, sex and body mass index.

CONCLUSION

This study shows a moderate but significant association between changes in JSW and changes in cartilage volume or thickness in knee joint of osteoarthritic patients.

Osteoarthritis, magnetic resonance imaging, and biochemical markers: a one year prospective study

OBJECTIVE

To investigate the relation between biochemical markers of bone, cartilage, and synovial remodelling and the structural progression of knee osteoarthritis.

METHODS

62 patients of both sexes with knee osteoarthritis were followed prospectively for one year. From magnetic resonance imaging (MRI), done at baseline and after one year, the volume and thickness of cartilage of the femur, the medial tibia, and the lateral tibia were assessed. A whole organ magnetic resonance imaging score (WORMS) of the knee was calculated for each patient at baseline and at the one year visits. This score consists in a validated, semiquantitative scoring system for whole organ assessment of the knee in osteoarthritis using MRI. Biochemical markers (serum hyaluronic acid, osteocalcin, cartilage glycoprotein 39 (YKL-40), cartilage oligomeric matrix protein (COMP), and C-telopeptide of type I collagen (CTX-I), and urine C-telopeptide of type II collagen (CTX-II)) were measured at baseline and after three months.

RESULTS

Baseline markers were not correlated with one year changes observed in cartilage volume and thickness. However, an increase in CTX-II after three months was significantly correlated with a one year decrease in mean thickness of medial tibial and lateral tibial cartilage. Patients in the highest quartile of three month changes in CTX-II experienced a mean loss of 0.07 (0.08) mm of their medial thickness, compared with a mean increase of 0.05 (0.19) mm for patients in the lowest quartile (p = 0.04) Multiple regression analysis showed that high baseline levels of hyaluronic acid are predictive of a worsening in WORMS (p = 0.004).

CONCLUSIONS

These results suggest that a single measurement of serum hyaluronic acid or short term changes in urine CTX-II could identify patients at greatest risk of progression of osteoarthritis.

Closure of the ventral hernia in the management of giant exomphalos: a word of caution

Giant exomphalos containing liver as its major component and with visceroabdominal disproportion presents difficult management options to a paediatric surgeon. At Starship Children's Hospital, we deal with these with primary skin closure, if possible, followed by staged repair of the ventral hernia beginning in the 2nd year of life. During the closure of a ventral hernia, we encountered major hepatic venous bleeding resulting from the inadvertent injury to the right hepatic vein, resulting in the death of the child. An autopsy report showed the position of the hepatic veins superficially just beneath the skin. Subsequently, we performed magnetic resonance imaging (MRI) of the abdomen to look at the hepatic venous and caval anatomy in two children before closure of the ventral hernia. This was of immense help in limiting the dissection in the area and thus avoiding catastrophe. We recommend routine imaging with MRI before closure of a ventral hernia in children with giant exomphalos.

Factors predisposing to cavity margin positivity following conservation surgery for breast cancer

AIMS

Incomplete excision leads to local recurrence following breast conservation therapy (BCT). The aim of this study was to examine factors associated with cavity margin (CM) positivity and return to theatre rates.

METHODS

Breast conservation surgery with entire CM excision was the initial procedure in 301 patients with 303 breast cancers. Of these, 258 patients were treated successfully with breast conservation surgery and 43 patients subsequently required a mastectomy for persistent involved margins. The mean and median follow-up was 38 and 42 (range 6-78) months, respectively.

RESULTS

Positive CMs were found in 73 out of 303 tumours. Large tumour size (p<0.001) and tumour type (invasive lobular cancer and ductal carcinoma in-situ) (p=0.043) were significant predictors of CM positivity both by univariate and multivariate analysis. As a result of CM status in relation to initial margin (IM) status, 60 cancers treated that were IM positive but CM negative avoided return for further excision at a second operative procedure.

CONCLUSION

Complete CM excision should avoid the need for further re-excision surgery in most patients where initial specimen margin was positive.