Shaken baby syndrome: intending to harm or attempting to help?

PURPOSE: To describe the role of ophthalmologists in shaken baby syndrome evaluation. METHODS: Case report. RESULTS: A 3.5-month-old girl was admitted to the Pediatrics Clinic with lethargy. The mother, who brought in the baby, claimed that the baby had fallen from her cradle 6 hours ago. Clinical examination showed signs of head injury. Ophthalmologic examination was requested and revealed extensive retinal hemorrhages bilaterally covering the whole fundus, and retrohyaloid hematoma in the right eye. Computerized tomography neuroimaging documented large subdural hematomas exerting force on the brain parenchyma. The sum of the results of the clinical and neuroimaging examination-retinal hemorrhages and subdural hematomas-was indicative of violent shaking of the baby. Coronal evaluation was unable to determine whether the baby was abused by her parents or whether she was accidentally hurt. CONCLUSIONS: Ophthalmologic examination is necessary to document shaken baby syndrome since it reveals the retinal hemorrhages which together with the neuroimaging findings are almost always present in such cases. However, even when all the signs of shaken baby syndrome are present, it is difficult and sometimes destructive for a parent to be falsely accused of abusing his or her own child.     

Is it mandatory to treat amblyopia prior to surgery in esotropia?

PURPOSE: To determine whether presence of amblyopia has any influence on the outcome of motor and sensory success in cases of esotropia. METHODS: 100 patients were taken for this study. Patients were divided into two groups of 50 each. Amblyopia was fully treated in group I and patients in group II underwent surgery before full treatment of amblyopia. Motor success (+/- 10 PD of orthophoria) was assessed three months after surgery and at the child's most recent visit by comparing the motor alignment at 6 meter and 0.33 meter distance using accommodative target in primary position. Sensory success was assessed by comparing the frequency of detectable stereoacuity. RESULTS: There was no significant difference in motor success (84% vs 75%) and sensory success (55% vs 50%) whether amblyopia was fully treated or partially treated. CONCLUSION: It is not mandatory to treat ambloypia prior to surgery, unless it is a case of infantile esotropia with moderate amblyopia and amblyopia therapy is continued post operatively.     

Photodynamic therapy follow-up: when to retreat, when to observe, or when to propose an alternative treatment?

Clinical and angiographic progression after photodynamic therapy (PDT) is usually slow, sometimes fluctuating and therefore difficult to evaluate. After several sessions of PDT, angiographic follow-up remains the basis for therapeutic management involving either a new PDT session or an alternative treatment. It remains difficult, however, to evaluate the activity and progression potential of the remaining neovessels. Imaging (angiography, optical coherence tomography) and functional data both contribute to the therapeutic decision. Certain patients require several sessions for a progressive reduction of the exudation. For others, the persistence of metamorphopsias and accentuation of the scotoma despite the treatment may entail alternative treatment. Thus, a perifoveal photocoagulation can be proposed to limit the extension of the scotoma if after a reasonable number of sessions, central visual acuity is not recovered; direct photocoagulation of a persistent active neovascular contingent, distant from the fixation zone (foveal or exenterated) can be proposed if it remains on the border of a stabilized lesion; the treatment of a feeder vessel can be proposed if it becomes visible and is associated with active neovessels with a persistent central serous detachment of the neuroretina. Lastly, performance status and patient wishes are important elements in the overall therapeutic project, especially if the eye involved is the second eye, in view of quickly initiating low-vision rehabilitation.     

Low-Dose Rituximab for Active Moderate to Severe Graves’ Orbitopathy Resistant to Conventional Treatment

Purpose: To report low-dose rituximab effect in Graves’ orbitopathy (GO) resistant to conventional treatment.

Methods: Retrospective analysis of medical records, filled in according to the European Group on Graves’ Orbitopathy (EUGOGO) standards, of patients with active moderate-to-severe GO who received low-dose rituximab after failure of conventional treatment. Efficacy was defined by a decrease of the clinical activity score of 2 points or <4/10.

Results: Among 219 patients treated between 2012 and 2016 by pulse methylprednisolone, possibly followed by oral steroids and/or orbital radiotherapy, 15 (6.8%) finally received 100 mg rituximab doses (cumulative dose, 100–400 mg) owing to persistent active disease. Rituximab showed efficacy within 2 months in 13 of 15 (87%), stable at 1 year. No significant effect was observed on proptosis, lid fissure width, and eye motility.

Conclusion: Low-dose rituximab showed sustained anti-inflammatory effect in most patients with active GO resistant to conventional treatment.     

A double-masked, randomized study to investigate the safety and efficacy of daclizumab to treat the ocular complications related to Behçet's disease

PURPOSE: To investigate the safety and efficacy of daclizumab (Zenapax, humanized anti-Tac, HAT) in controlling the ocular manifestations of Beh?et's disease. DESIGN: Randomized, placebo-controlled, double-masked clinical trial. PARTICIPANTS: Seventeen participants with Beh?et's disease experiencing at least two prior ocular attacks and requiring treatment with immunosuppressive agents for the ocular complications of Beh?et's disease. METHODS: Participants received either intravenous placebo or daclizumab (1 mg/kg) infusions every two weeks for six weeks, then every four weeks while continuing their standard immunosuppressive regimens. If clinically indicated, tapering of the standard immunosuppressive medications was allowed after six months of study enrollment. Complete ocular and physical examinations and an adverse event assessment were performed at baseline and prior to each study infusion. MAIN OUTCOME MEASURES: Primary safety endpoints were the development of a life-threatening complication or a severe opportunistic infection. Primary efficacy outcomes were the number of ocular attacks and an assessment of systemic immunosuppressive medications required during the study, including the ability to taper concomitant immunosuppressive therapy. Results: Nine participants randomized to daclizumab and eight to placebo were followed monthly. Follow-up ranged from one to 34 months, with a median follow-up of 15 months. Two participants randomized to daclizumab discontinued study therapy prior to the end of the study for personal reasons. No participant experienced a safety endpoint, and visual acuity remained stable in all participants during the course of the study. Ten participants (six daclizumab, four placebo) experienced ocular attacks requiring therapy. The median ocular attack rate during the study was greater in the daclizumab arm than the placebo arm (median 1.27 vs. 0.17 attacks/year, respectively). Participants in the placebo arm also experienced a greater reduction in the immunosuppressive medication score compared to participants receiving daclizumab (median -4.0 vs. -1.0, respectively). CONCLUSIONS: The observed results in the placebo group demonstrate that careful follow-up and treatment with standard combination immunosuppressive therapy can be effective for the management of the ocular complications of Beh?et's disease. In our small study, there was no suggestion that daclizumab was beneficial in comparison with placebo. However, the low observed attack rate limited our ability to make a definitive treatment group comparison.     

Infants’ responsiveness to rivalrous gratings

The study investigated the early development of responsiveness to rivalrous gratings. Infants were tested weekly between 6 and 16 weeks of age for their ability to discriminate between interocularly identical (fusible) lines and interocularly orthogonal (unfusible, rivalrous) lines. The stimuli were presented on an autostereoscopic monitor equipped with a face-tracking device. Two psychophysical techniques, the forced-choice preferential looking (FPL) method and measurement of looking times, were employed. Contrary to earlier findings, infants at all ages avoided looking at the rivalrous gratings instead of showing a developmental shift from a relative preference for unfusible, rivalrous gratings to a relative preference for fusible gratings. Avoidance of the rivalrous gratings became significant at 8–9 weeks of age, suggesting that infants clearly exhibit binocular rivalry from that age onwards. Control experiments secured that the infants’ preference for the fusible gratings was not governed by a natural preference for less over more complex line patterns.     

Response to letter to editor “Measuring of retina function using microperimetry in diabetic retinopathy”

Graefe's Archive for Clinical and Experimental Ophthalmology -