TEN YEARS' EXPERIENCE IN LOW VISION PRACTICE

The Low Vision Clinic at the Palmerston North Hospital has now been oerating for 70 years. Over the course of these ten years a number of factors have emerged which can be as readily applied to general ophthalmological practice as to low vision practice. The philosophy of low vision care is one of which all ophthalmologists should be aware and includes factors to be taken into account when dealing with children, people in the workplace, and everyday factors involved in daily living activities, all of which are equally relevant in routine ophthalmological practice. This paper endeavours to share some thoughts on these factors and also discusses means by which the visually handicapped can be helped in areas where specialist low vision services are not readily available.     

Scoliosis repair in a teenager with Duchenne’s muscular dystrophy: who calls the shots?

In this exchange, a clinician (the first author) presents a case scenario for comment by an ethicist (the second author). The case concerns a 15-year-old boy with Duchenne's muscular dystrophy requested palliative surgical correction of a 60 degree thoraco-lumbar scoliosis. The surgical team were initially reluctant to offer surgery given their assessment of the perioperative and postoperative risks (anesthetic review suggested an 80% chance of surviving the surgery and 50% likelihood of returning home), but the operation proceeded. The case raises issues of the rights of patients to insist on nonfutile but high risk surgery, risk perception, resource allocation, autonomy, and the integrity of clinicians.     

Bacterial endocarditis in a child presenting with acute arterial ischemic stroke: should thrombolytic therapy be absolutely contraindicated?

Thrombolysis is considered to be contraindicated in acute ischemic stroke secondary to infective endocarditis (IE). We report a 12-year-old female who presented with acute dense right hemiparesis and aphasia. Cranial magnetic resonance imaging and angiography showed multiple diffusion-restricted lesions in the left hemisphere and absence of flow in the left internal carotid artery. She was treated with intra-arterial tissue plasminogen activator within 6 hours of her presentation. Subsequently she was diagnosed with pneumococcal endocarditis and underwent debridement of vegetations and patch repair of the mitral valve. The patient did not have hemorrhagic complications following thrombolytic therapy or surgery. Pathological analysis of the mitral valve vegetations revealed mostly fibrin thrombus. Follow-up imaging showed complete recanalization of the left internal carotid artery, and the patient had a remarkable neurological recovery. This is the first case report of successful intra-arterial thrombolytic therapy in childhood IE-related stroke. We believe that thrombolytic therapy contributed to a favorable outcome in our patient and may be safe in selected patients with childhood IE-related acute ischemic stroke.