Ocular complications of diabetes mellitus in a pediatric population and proposals for screening and follow-up programs

Background

Diabetes mellitus (DM) is one of the world's greatest health emergencies of the 21st century. Ocular complications of DM are commonly chronic and progressive, but vision loss can be effectively prevented or delayed with early detection and timely treatment. Therefore, regular comprehensive ophthalmologic examinations are mandatory. Ophthalmic screening and dedicated follow-up for adults with DM are well established, whereas, there is no consensus on optimal recommendations for the pediatric population, reflecting the lack of clarity about the current burden of disease in this age group.

Objectives

To determine the epidemiology of ocular complications of diabetes and to assess optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) macular features in a pediatric population with DM. To review ophthalmological screening and follow-up plans for the diabetic pediatric population.

Design

Observational study.

Methods

Retrospective consecutive cohort study of all 165 diabetic patients (330 eyes) aged 0-18 years, examined between January 2006 and September 2018 at the Pediatric Department of 'S. Maria della Misericordia' Udine Hospital who underwent at least one complete ophthalmologic examination at the Ophthalmology University Clinic at the Udine Hospital. OCT and OCTA data were available for 37 patients (72 eyes, 2 excluded). The associations between ocular complications and selected potential risk factors were evaluated by univariate analyses.

Results

No patient had signs of ocular diabetic complications or any macular morphological or micro-vascular impairment, regardless of any potential risk factor. The prevalence of strabismus and refractive errors in the study group, was found to be similar to non-diabetic pediatric populations.

Conclusion

Screening and follow-up of ocular diabetic complications in children and adolescents could be performed less frequently than in adults with diabetes. There is no need to screen potentially treatable visual disorders in diabetic children earlier or more frequently than in the healthy children thus reducing time spent in hospital and permitting a better tolerance to medical examinations in diabetic pediatric patients. We described the OCT and OCTA patterns in a pediatric population with DM.

Lens-sparing vitrectomy for stage 4A retinopathy of prematurity in infants with aggressive-posterior ROP: Anatomic and functional results

AIM

To assess long-term anatomic and functional outcomes of early lens-sparing vitrectomy (LSV) for stage 4A retinopathy of prematurity (ROP) in infants with aggressive-posterior ROP (AP-ROP) which progressed to retinal detachment despite laser treatment.

METHODS

Chart review of infants who underwent early 25-gage LSV for stage 4A ROP. Outcomes were anatomic success, mean visual acuity (VA), development of postoperative complications, and refractive changes. Follow-up examinations were performed at 1, 3, 6, 12, and then every 6 months.

RESULTS

Ten eyes of seven preterm infants who underwent LSV were included. Mean follow-up was 36 ± 13.4 months and mean postmenstrual age (PMA) at last follow-up was 37 ± 13.7 months. Mean gestational age (GA) and weight at birth was 26 ± 1.4 weeks and 639 ± 180 g. Two eyes had vitreous hemorrhage 4 and 14 days after surgery, respectively. At last follow-up anatomic success was 100%, mean VA was 20/80 and eight eyes (80%) had high myopic refractive correction (mean spherical equivalent -11.25 D).

CONCLUSION

Early LSV for stage 4A ROP with AP-ROP and progression to retinal detachment is efficacious in terms of anatomic and functional outcomes. Anatomic success is associated with visual improvement despite possible myopic refraction changes during follow-up.

Optical coherence tomography (OCT) and OCT angiography allow early identification of sickle cell maculopathy in children and correlate it with systemic risk factors

PURPOSE

To determine the presence of sickle cell retinopathy and maculopathy and to identify associations between markers of hemolysis and systemic and ocular manifestations in children affected by sickle cell disease.

METHODS

Eighteen children with sickle cell disease, aged 5-16 years, underwent complete eye examination including best-corrected visual acuity, slit-lamp biomicroscopy, ophthalmoscopy after pharmacological mydriasis, spectral-domain optical coherence tomography (SD-OCT), and optical coherence tomography angiography (OCTA). Blood test results and clinical history information were collected for each child, including fetal hemoglobin (HbF), hemoglobin (Hb), hematocrit (Htc), mean corpuscular volume (MCV), mean corpuscular hemoglobin concentration (MCHC), reticulocytes percentage (%ret), lactic dehydrogenase (LDH), total and direct bilirubin, glomerular filtration rate, number of painful crises, acute chest syndromes, and splenic sequestration. Therapeutic regimen and transfusion therapy were also evaluated.

RESULTS

Sixteen of 36 eyes (44.4%) had non-proliferative sickle cell retinopathy on ophthalmoscopic evaluation. No patients had proliferative sickle cell retinopathy. In 13 of 36 eyes (36.1%), SD-OCT and OCTA detected signs of sickle cell maculopathy. Nine eyes (25%) presented sickle cell retinopathy and maculopathy, 7 eyes (19.4%) sickle cell retinopathy alone, and 4 eyes (11.1%) sickle cell maculopathy alone. A statistically significant association was found between sickle cell retinopathy; lower levels of HbF, Hb, and Htc; and higher MCV and percentage of reticulocytes. Sickle cell maculopathy was associated with lower values of H and Htc and higher levels of reticulocytes and total bilirubin.

CONCLUSIONS

We identified early signs of sickle cell retinopathy and maculopathy in a pediatric population with SD-OCT and OCTA. These two retinal complications were more frequent in children with higher hemolytic rates.

Optic Nerve Hypoplasia, Corpus Callosum Agenesis, Cataract, and Lissencephaly in a Neonate with a Novel <b><i>COL4A1</i></b> Mutation

We report the case of a girl with a novel mutation of the COL4A gene (c.2716+2T>C) presenting microcephaly, parenchymal hemorrhages, lissencephaly, and bilateral cataracts, associated with agenesis of the corpus callosum and hypoplasia of the optic nerve. COL4A1, located on chromosome 13, encodes the α1 chain of type IV collagen, a key component of the basement membrane in various organs, such as eye, brain, kidneys, and muscles. Different mutations have been described and may remain asymptomatic or determine porencephaly, cerebral hemorrhages, renal cysts, hematuria, and dysgenesis of the anterior segment of the eye.

Fungal Endogenous Endophthalmitis Secondary to Magnusiomyces capitatus

We report the case of a 68-year-old immunocompetent patient with a dilatation of the ascending aorta, intraluminal vegetations, and pseudoaneurysmatic bulging who presented with unilateral fungal endogenous endophthalmitis 8 days after coronary angiogram. The isolated pathogen resulted to be Magnusiomyces capitatus, a filamentous, yeast-like fungus that can be commonly found in normal human microflora, with an immunosuppression-related pathogenicity. A literature research revealed a single case of ophthalmic infection – a keratitis – caused by this pathogen. Furthermore, we add a review of mycotic endophthalmitis related to aortic infection.

Long-Term Anatomic and Visual Outcome Following Vitrectomy for Stage 4B and 5 Retinopathy of Prematurity

BACKGROUND AND OBJECTIVES

Surgical indications in stages 4B and 5 retinopathy of prematurity (ROP) are not universally accepted. The authors' purpose is to evaluate the long-term anatomic and visual outcomes of vitrectomy for retinal detachment (RD) associated with stages 4B and 5 ROP.

PATIENTS AND METHODS

Data of patients who consecutively underwent vitrectomy for stages 4B and 5 ROP from 1999 to 2013 were retrospectively reviewed and included grade of retinal attachment and visual acuity (VA) at the last follow-up.

RESULTS

Seventy eyes of 38 infants were included: 23 with stage 4B and 47 with stage 5 ROP. Lens-sparing vitrectomy was performed in 11 eyes, combined lensectomy / vitrectomy in 59 eyes. Mean follow-up was 8.5 years. Anatomic success was maintained in 41 eyes (58.5%), and among them, VA greater than 5/200 was achieved in 17 eyes (41.4%).

CONCLUSION

The long-term visual and anatomic success rates were encouraging for the surgical correction of RD associated with late stages ROP. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:208-214.].

A 5-Year-Old Case of Choroidal Neovascularization in Enhanced S-Cone Syndrome Treated with Ranibizumab

Introduction

We describe the youngest case of enhanced S-cone syndrome (ESCS) associated with choroidal neovascularization (CNV) successfully treated with intravitreal ranibizumab injections.

Case Report

A 5-year-old boy presented with round-shaped fibrotic subretinal lesions in both eyes with surrounding subretinal fluid and progressive visual deterioration in the right eye. Fine foci of increased autofluorescence were observed along the arcades in both eyes. Fluorescein angiography revealed the presence of CNV in his right eye, and treatment with ranibizumab was initiated, with significant improvement in vision. Subsequent electroretinogram examination and genetic studies of the patient and his two younger siblings confirmed the diagnosis of ESCS.

Conclusion

CNV has been reported to occur in different inherited retinal degenerations, including ESCS. Our experience confirms that treatment with ranibizumab in patients with CNV-complicated ESCS can be potentially vision-saving.

Predictive algorithms for early detection of retinopathy of prematurity

PURPOSE

To evaluate sensitivity, specificity and the safest cut-offs of three predictive algorithms (WINROP, ROPScore and CHOP ROP) for retinopathy of prematurity (ROP).

METHODS

A retrospective study was conducted in three centres from 2012 to 2014; 445 preterms with gestational age (GA) ≤ 30 weeks and/or birthweight (BW) ≤ 1500 g, and additional unstable cases, were included. No-ROP, mild and type 1 ROP were categorized. The algorithms were analysed for infants with all parameters (GA, BW, weight gain, oxygen therapy, blood transfusion) needed for calculation (399 babies).

RESULTS

Retinopathy of prematurity (ROP) was identified in both eyes in 116 patients (26.1%), and 44 (9.9%) had type 1 ROP. Gestational age and BW were significantly lower in ROP group compared with no-ROP subjects (GA: 26.7 ± 2.2 and 30.2 ± 1.9, respectively, p < 0.0001; BW: 839.8 ± 287.0 and 1288.1 ± 321.5 g, respectively, p = 0.0016). Customized alarms of ROPScore and CHOP ROP correctly identified all infants having any ROP or type 1 ROP. WINROP missed 19 cases of ROP, including three type 1 ROP. ROPScore and CHOP ROP provided the best performances with an area under the receiver operating characteristic curve for the detection of severe ROP of 0.93 (95% CI, 0.90-0.96, and 95% CI, 0.89-0.96, respectively), and WINROP obtained 0.83 (95% CI, 0.77-0.87). Median time from alarm to treatment was 11.1, 5.1 and 9.1 weeks, for WINROP, ROPScore and CHOP ROP, respectively.

CONCLUSION

ROPScore and CHOP ROP showed 100% sensitivity to identify sight-threatening ROP. Predictive algorithms are a reliable tool for early identification of infants requiring referral to an ophthalmologist, for reorganizing resources and reducing stressful procedures to preterm babies.

A case of CRB1-negative Coats-like retinitis pigmentosa

Retinitis pigmentosa is a heterogeneous group of ocular diseases that causes progressive degeneration of the photoreceptor cells mainly affecting the rods of the peripheral retina. The association between retinitis pigmentosa and exudative retinopathy was first described in 1956 and has been called "Coats-like retinitis pigmentosa." Mutations in the Crumbs homolog 1 (CRB1) gene have been reported as a risk factor for developing Coats-like changes in patients with autosomal recessive retinitis pigmentosa. We report the case of a 15-year-old girl affected by CRB1 gene-negative retinitis pigmentosa and Coats-like exudative vasculopathy who was successfully treated with laser photocoagulation.

Diode laser, vitrectomy and intravitreal triamcinolone. A comparative study for the treatment of diffuse non tractional diabetic macular edema

PURPOSE

To determine the effectiveness and safety of diode laser, pars plana vitrectomy (PPV) with gas tamponade, and intravitreal triamcinolone (IVT) as possible treatments for diffuse diabetic macular edema (dDME). To determine whether the new macular edema Classification previously proposed by some of the authors may help as a guide in the choice of treatment.

METHODS

A retrospective, comparative study of 169 eyes with dDME that underwent treatment. The eyes divided into 3 groups: in the PPV Group, 59 eyes received PPV with gas tamponade; in the DIODE Group, 53 eyes received a laser grid; in the IVT Group, 57 eyes received an intravitreal injection of 4 mg of triamcinolone acetonide. The follow up ranged from 6 to 24 months. The eyes were classified according to the new DME Classification based on OCT.

MAIN OUTCOMES

Change in foveal thickness as determined by Optical Coherence Tomography (OCT); change in visual acuity; intra and postoperative complications.

RESULTS

Mean visual acuity (VA) improved at 3 months with every treatment. At one year only eyes which underwent PPV still had better VA than the pre-op value, while eyes which underwent IVT and laser treatment showed regression. PPV show the greater percentage of eyes which gain 3 or more lines of VA at one year (17%). Mean foveal thickness improved at 3 months with every treatment. Only the eyes into the PPV Group showed relatively low foveal thickness at one year. Better final VA and foveal thickness were obtained if preop VA is > or = 0.3 and if earlier stages of DME were treated according to the new DME Classification. PPV was the treatment which offered the most stable results with at one year or longer. Similar results were observed into the PPV Groups as a whole and into a subgroup of eyes with preoperative PVD. No complications were encountered with laser diode treatment. Long term complications into the IVT Group were elevated IOP (8%), retinal detachment (3.5%) and posterior cataract (15%). Long term complications into the PPV Group were retinal detachment (3.4%) and cataract (90%).

CONCLUSIONS

Diode laser, PPV with gas tamponade and IVT are effective alternative treatments to decrease foveal thickness and improve visual acuity in eyes with DME. However while the results of PPV are stable in the long term follow-up, diode laser and IVT do not offer stable results. Complications may be severe with PPV and IVT. It is necessary to carefully select cases which would benefit from these types of treatments. The authors think that the OCT Classification may serve as a guide for the choice of treatment.

The Photographic Screening for Retinopathy of Prematurity Study (Photo-ROP): study design and baseline characteristics of enrolled patients

OBJECTIVE

The Photographic Screening for Retinopathy of Prematurity Study (Photo-ROP) sought to evaluate the utility of digital wide-angle photographic fundus screening for retinopathy of prematurity (ROP) as compared to bedside indirect ophthalmoscopy. This article describes the study design and presents baseline characteristics of the subjects.

DESIGN

Prospective, multicenter, masked, Internet-based clinical trial.

PARTICIPANTS

Premature infants <31 weeks postmenstrual age at birth and <1000 g birthweight.

INTERVENTIONS

Examinations began at 31 weeks postmenstrual age or 4 weeks postnatal age, whichever was later. Both eyes of all infants were imaged with a panoramic fundus imaging system followed by indirect ophthalmoscopic fundus examination. Images were transmitted via Internet to the Reading Center for interpretation by masked graders. Clinical interpretations based on indirect ophthalmoscopy were recorded for comparison with the Reading Center determinations. Examinations were performed weekly for 10 weeks or until an infant was discharged from the hospital.

MAIN OUTCOME MEASURE

Sensitivity, specificity, and positive and negative predictive values of Reading Center image interpretations were compared to clinical impressions based on bedside indirect ophthalmoscopy.

RESULTS

Enrollment began in February 2001 and was completed in February 2002. The target number of infants was 50, and 62 were enrolled. Of those enrolled, 51 infants (102 eyes) were considered eligible, and are the subject of this article. Mean postmenstrual age (+/- SD) at time of delivery was 26.80 +/- 1.73 weeks (median = 26.86 weeks, interquartile range [IQR] = 2.43 weeks). Mean postmenstrual age at first examination (+/- SD) was 32.19 +/- 2.86 weeks (median = 31.71 weeks, IQR = 2.29 weeks). Mean birthweight (+/- SD) was 830.51 +/- 219.57 g (median = 817 g, IQR = 225 g). Female infants comprised 49.02% of the patients. Race distribution was as follows: white 45.10%, African or black 39.22%, Hispanic 3.92%, Asian 9.80%, and other races 1.96%. Mean follow-up (+/- SD) was 5.73 +/- 3.22 weeks (median = 6 weeks, IQR = 5, range = [1, 15]).

CONCLUSIONS

The Photo-ROP Study Cooperative Group successfully recruited and enrolled at-risk premature infants into a longitudinal, prospective clinical trial comparing two different diagnostic approaches. Technology employed in this study is comparable to that currently available. Design issues for this trial included establishing the information technology infrastructure for an ROP study based on digital imaging, defining the study endpoints, estimating event rates, defining a standardized imaging protocol, and defining standards for interpretation of image quality and clinical findings.

Diabetic macular edema: an OCT-based classification

PURPOSE

More than ten years after ETDRS, Optical Coherence Tomography (OCT) greatly enhanced our ability to detect macular thickening and has brought new insights on the morphology of edema and on the presence of vitreal traction. In this study we propose a new classification of macular edema based on OCT findings to better catalogue and follow this complex clinical entity.

METHODS

Since January 2000 we analysed with OCT 2 (Zeiss Inc.) more than one thousand and two hundred eyes with DME.

RESULTS

The classification takes into account five parameters: retinal thickness, diffusion, volume, morphology and presence of vitreous traction. Standard figures and numerical values for every parameter are given.

CONCLUSION

Although ETDRS guidelines for laser treatment of DME still remain the only proven therapy for this condition, many other strategies are now on trial, and the vast majority of authors use OCT as the best indicator of therapeutic benefit. The amount of information given by OCT demonstrates that macular edema is a complex clinical entity with various morphology and gravity, and disclaimed the limitations of a simple "clinical" definition. As in many other examples such as macular holes and choroidal neovascularization, a uniform and precise definition of macular edema would increase the possibility to compare and judge the result of different therapeutic strategies. Aim of this classification is to implement the ETDRS clinical definition of DME with the precise and useful data given by OCT to better diagnose, catalogue and follow macular edema.

Clear lens phacoemulsification for correction of high myopia

PURPOSE

To assess phacoemulsification and posterior chamber intraocular lens (IOL) implantation as an effective, safe, and predictable technique for the correction of high myopia.

SETTING

University Eye Clinic of Verona, Verona, Italy.

METHODS

A series of 25 eyes with myopia higher than -12.0 diopters (D) had clear lens extraction by phacoemulsification and IOL implantation in the capsular bag. The mean postoperative follow-up was 42.92 months +/- 3.76 (SD).

RESULTS

No serious intraoperative complications occurred. Uncorrected visual acuity improved in all cases. The mean postoperative best corrected visual acuity improved by an average of 1 line. One case (4.0%) of postoperative retinal detachment (RD) occurred at 12 months. One case (4.0%) of biometric error (3.0 D) occurred.

CONCLUSION

Clear lens extraction by phacoemulsification and IOL implantation in a series of highly myopic eyes was effective and had an acceptable predictability and a low rate of complications. Careful evaluation of the retinal periphery by indirect ophthalmoscopy is recommended to avoid postoperative RD.