Retinal detachments in the pediatric population

Retinal detachment in a neonate with congenital chylothorax and purpura fulminans associated with the PAK2 genetic variant: A case report

INTRODUCTION AND IMPORTANCE

A potential relationship between bilateral retinal detachment, chylothorax, and purpura fulminans in a female neonate with a PAK2 gene variant is not commonly reported. This emphasizes the significance of early ophthalmologic assessment in neonates with congenital chylothorax.

CASE PRESENTATION

A full-term female infant weighing 2.775 kg was delivered by cesarean section due to breech presentation. Prenatal imaging revealed fetal bilateral pleural effusion, suggestive of chylothorax. The neonate developed respiratory distress and purpura fulminans after birth. The absence of the red reflex in the right eye prompted a detailed ophthalmologic examination using a portable slit lamp and an indirect ophthalmoscope. The right eye revealed an ectatic pupil with posterior synechia extending from approximately 6 o'clock to 9 o'clock. Fundus examination of both eyes revealed funnel retinal detachment with multiple chronic features. A small amount of retina was draped between 4 and 7 o'clock, which may have been attached. Further ophthalmologic investigation under anesthesia, using B-scan ultrasonography and intravenous fluorescein angiography, confirmed bilateral retinal detachment. Genetic investigations revealed a PAK2 c.1115A>T, p.(Asp372Val) variant.

CLINICAL DISCUSSION

In addition to presenting our case report, we reviewed other recent case reports similar to ours. Retinal detachment and bilateral pleural effusions in neonates with Knobloch syndrome have been recently reported, but without purpura fulminans. Retinal detachment in neonates can result from both congenital and acquired conditions, and requires a thoughtful approach to establish the diagnosis and provide future counseling.

CONCLUSION

Bilateral retinal detachment, chylothorax, and purpura fulminans in a neonate with a PAK2 genetic variant is uncommon. This case underscores the importance of early ophthalmologic assessment and genetic testing for both neonates and their family members.

Pediatric Rhegmatogenous Retinal Detachments: Etiologies, Clinical Course, and Surgical Outcomes

Purpose: To describe the predisposing factors, clinical course, and surgical methods of pediatric rhegmatogenous retinal detachment (RRD) and determine which factors affect anatomic success. Methods: Data of patients 18 years or younger who had surgical repair for RRD from January 1, 2004, to June 31, 2020, with a minimum of 6 months of follow-up were retrospectively analyzed. Results: The study evaluated 101 eyes of 94 patients. Of the eyes, 90% had at least 1 predisposing factor to pediatric RRD, including trauma (46%), myopia (41%), prior intraocular surgery (26%), and congenital anomaly (23%); 81% had macula-off detachments and 34% had proliferative vitreoretinopathy (PVR) grade C or worse at presentation. The presence of PVR grade C or worse (P = .0002), total RRD (P = .014), and vitrectomy alone at first surgery (P = .0093) were associated with worse outcomes. Patients who had scleral buckle (SB) alone at the first surgery had statistically higher rates of anatomic success than those who had vitrectomy alone or combined with SB (P = .0002). After the final surgery, 74% of patients achieved anatomic success. Discussion: The majority of cases in this study were associated with 1 of the 4 risk factors predisposing to pediatric RRD. These patients often present late with macula-off detachments and PVR grade C or worse. The majority of patients achieved anatomic success after surgical repair using SB, vitrectomy, or a combination.

Neurofibromatosis type 1 presenting with retinal detachment and laryngeal plexiform neurofibroma in a toddler

Purpose

To present a 22-month-old girl with a complete retinal detachment who was found to have systemic exam findings consistent with neurofibromatosis type 1 during the course of multi-specialty exam under anesthesia.

Observations

During examination under anesthesia, ophthalmic exam findings demonstrated retinal detachment with cyst formation, as well as peripheral non-perfusion of the retina in the left eye. Non-ophthalmic findings discovered on difficulty with intubation included a laryngeal plexiform neurofibroma and café-au-lait spots.

Conclusions

Pediatric retinal detachments are uncommon compared to those in adults. Pediatric patients with neurofibromatosis type 1 can present with vision loss as the presenting symptom. Systemic signs and symptoms should be carefully screen and monitored.

Primary rhegmatogenous retinal detachment: evaluation of a minimally restricted face-down positioning after pars plana vitrectomy and gas tamponade

AIM

To evaluate the safety and efficacy of a minimally restricted face-down postoperative positioning following pars plana vitrectomy (PPV) with gas tamponade for primary rhegmatogenous retinal detachment (RRD).

METHODS

Patients with primary RRD treated with PPV and gas tamponade and followed up for at least 6mo were selected for the study. All phakic eyes underwent simultaneous cataract surgery. The patients were required to be in a postoperative position that prevented downward flow of retinal tears. Patients with macular detachment were positioned face-down for only a couple of hours. The patients were assessed for preoperative and postoperative best-corrected visual acuity (BCVA), anatomical retinal reattachment rate, and postoperative complications.

RESULTS

In total, 40 eyes of 39 patients with primary RRD were included in the study. A single tear was present in 30 eyes (75.0%), multiple retinal tears were present in nine eyes (22.5%), and oral dialysis was present in one eye (2.5%). The anatomical success rate was 90.0% (36 cases) after the primary surgery, and the final anatomical success rate was 100%. The BCVA improved significantly (P<0.001) from 0.75 logarithm angle of resolution (logMAR) preoperatively to 0.12 logMAR at the final visit. Postoperative complications included intraocular pressure elevation (≥25 mm Hg) in 11 patients (27.5%), fibrin formation in two patients (5.0%), pupillary capture of the intraocular lens in two patients (5.0%), and posterior synechia in one patient (2.5%).

CONCLUSION

A minimally restricted face-down and flexible postoperative positioning after PPV and gas tamponade for primary RRD is effective and safe.

Ophthalmic Emergencies for the Clinician

Primary care physicians are at the forefront of patient care and often are the first clinicians to triage and diagnose any eye-related complaints. They must be able to quickly identify vision-threatening pathologies, as delay in treatment of an ocular emergency can result in permanent vision loss. This concise review describes the definition, presentation, examination, and management of various ophthalmic emergencies including blunt ocular trauma, chemical ocular injury, orbital cellulitis, endophthalmitis, acute angle closure glaucoma, optic neuritis, giant cell arteritis, central retinal artery occlusion, retinal detachment, and homonymous hemianopia in a succinct manner.