This is to certify that Dr. A. Nandhini, MS. Post Graduate Student in Ophthalmology, Regional Institute of Ophthalmology, Government Ophthalmic Hospital, Madras Medical College, carried out this dissertation titled Study of Uveitis in Children and FactorsAffectingVisualOutcome by herself under my guidance and direct supervision during the period of May 2004 to March 2007. This dissertation is submitted to Tamil Nadu Dr. MGR Medical University, Chennai in partial fulfillment of the award of MS Degree (Ophthalmology).
Treatment consists of the combined use of pyrimethamine, folinic acid supplement and sulfadiazine. Clindamycin may be used in addition to these medications or in substitutions for pyrimethamine. The ELISA is the most sensitive and specific test. Any positive titer is significant in evaluating the diagnosis of toxoplasmosis. Systemic corticosteroids used under antimicrobial coverage. Not all cases are treated in immunocompetent children. The cases that are treated either have a lesion in the papulo macular bundle or near a major vessel or close to the optic disc. In immunosupressed children all the lesions irrespective of locations has to be treated vigorously.
Nevertheless, we feel that some useful observations can be made on the basis of this review of patients. There seem to be two general categories of patients with con- genital and developmental cataracts. One is characterized by extensive lens opacity and an early, obvious reduction in vision. These patients, who come for cataract surgery in the first year of life, often have smaller-than-normal corneal diameters, poorly dilating pupils, and a vulner- ability to delayed postoperative open-angle glaucoma. The other category includes patients with partial, often lamellar lens opacities, corneas of normal size, and a remarkably good visual prognosis. Lamellar cataract did significantly better when compared with other mor- phologies in the non-traumatic group, similar to other studies (Table 13) . Of the patients in the first cate- gory, 222 (17%) developed nystagmus at 2 - 4 months of age, which was accompanied by a reduction in visual acuity despite a good anatomical result from surgery (Table 6). Early surgery, within the time frame indicated in , did not appear to stop the development of nys- tagmus, although some investigators have suggested that this may be so, based on anecdotal experiences with small numbers of patients [10,18,19]. It is possible that even earlier surgery than we have done, undertaken in the first few weeks of life, would have a more favourable influence on the development of nystagmus. On the other hand, the nystagmus may be a manifestation of a more general ophthalmic disorder that would not be influenced by the timing of surgery. Further evaluation of this ques- tion will require a randomized controlled study, because patient selection could influence the prevalence of nys- tagmus in any small series of patients, especially if all patients with congenital cataracts, regardless of type, were subjected to early surgery.
We acknowledge a number of limitations in our work. Conducting this study in a tertiary center for uveitis might have biased the study population to include the more severe cases. Other weaknesses include the small sample size (49 patients, 80 eyes); division of the popula- tion into subgroups might have decreased the power of the conclusions. The study is of a retrospective nature, which could increase the chances of lead-time biases. Furthermore, since children with chronic anterior uveitis or intermediate uveitis may remain asymptomatic until the development of complications, some of the children included in the older age group might have onset of dis- ease before age 8. However, it would be impossible to determine the exact start date of uveitis in children with complete certainty, as a significant proportion of uveitis in children is asymptomatic and since young children cannot verbalize their symptoms. As such, we chose the first date of inflammation symptoms reported by parents (based on general ophthalmologist assessment or symp- toms) as the first date of uveitis.
Young adults are typically affected, with prevalence believed to be more in males. However the sex ratio varies with geographic location and women have been found to be more commonly affected in USA and Western Europe 9-13. Men usually tend to have a younger age of onset and this in turn is related to higher prevalence of ocular disease, and worse potential visual acuity. Age and sex however have been found to be independent risk factors for the development of visual loss. 14,15 Although Behçet’s Disease affects primarily young adults, typically presenting in the second to fourth decade of life, the onset however can occur at any age ranging from infants to the elderly, though it is rarely seen in children. 16-21
The study was conducted after getting approval from our institutional ethics committee and after obtaining a written informed consent from the legal guardians of the children who underwent cochlear implantation in our hospital. The data was collected from patient registers, fully completed clinical records and information regarding the present performance levels of the implantees was obtained from ENT surgeons and Audiologists and from the parents of the children. Hearing was assessed by CAP score, MAIS score and SIR score as a parent reported scale in an interview format. The interview was carried out by independent observer i.e. the audiologist who was not involved in the selection of the patient for the surgery.
Baron first performed ACIOL implantation on May 13, 1952. There were two design groups one being the rigid or semi rigid ACIOL fashioned after Baron, Scharf and Strampelli, the other group being flexible or semi flexible ACIOL which further can be classified into lens with open or closed haptic loops. Peter Choyce modified the Strampelli lens. Barraquer modified the Dannheim lens and developed the first open loop ACIOL with J haptic 14 . Due to biodegradation of the material , decentration occured over time and the haptics eroded the ciliary body leading to chronic uveitis. The main complications of ACIOL implantation were corneal decompensation and uveitis- glaucoma-hyphaema syndrome due to poorly manufactured AC lens.
penetrating therapeutic keratoplasty. This study was undertaken to study the results of penetrating keratoplasty with respect to their anatomical and visual improvement. In the present study 62% of cases were males and 38% were females. Male to Female ratio was 1.63:1. Among these 42 PKPs, 22(52%) PKPs were diagnosed as bacterial keratitis, 15(36%) suffered from fungal keratitis, and 5 (12%) suffered from acanthamoebic keratitis. The age group between 31-60 years seemed to be affected more, i.e. (83%) compared to the older people.
A similar hospital based study was done in Taiwan in 156 children. The study showed that the preponderance of injuries in boys over girls was 2.1:1. Their study showed that the most common place of pediatric eye injuries is home (15.4%) followed by street (9.0%), school (7.7%) and sports venues (5.8%). The objects responsible for ocular injury were: unspecified sharp object(16.7%), scissors(13.5%), pencils/pens(12.2%), broken spectacles (7.7%), knife(6.4%), animal claws(5.8%), metal nails(2.6%), fingernails(1.3%). Their study also showed that the predictors of worst outcome were open globe injuries with large wound size, posterior segment involvement and the presence of an intraocular foreign body 1 .
Diarrhoea after amoxicillin or co-amoxiclav was the common reason for missing/stopping the medication in our study population, vomiting was the other reason. A number of factors usually influence the doctor’s choice of antibiotic and patient adherence. These include the likely causative organism and its sensitivities, and the site and severity of infection. The child’s age and known allergies, and drug route, formulation, degree of penetration, side effects and toxicology are also important issues. However, the taste of an antibiotic and the child’s ability to tolerate oral drugs, although widely cited, is often not considered. Acknowledging the importance of palatability to children and parents in patient-centered management will improve adherence and influence clinical outcome. The majority of doctors have not tasted every antibiotic they prescribe. 12
Results: Of 55 children enrolled, definite etiology could be determined in 44 (80%) children. The common risk factors identified were vasculitis (30.9%), vasculopathy (23.6%), hypercoagulable states (18.1%), cardiac diseases (12.7%) and bleeding diathesis (7.2%). Focal neurologic deficits (69%), convulsions (58%), altered sensorium (41.8%), fever (45.4%) and aphasia (34.5%) were the chief presenting features. The overall mortality was 30.9% and neurologic deficits were observed in 54.5%. Children with undetermined etiology had a favorable outcome compared to those with definite etiology (p=0.007). Poor outcome was witnessed with vasculitis and cardiac diseases; recurrence was common with Moyamoya disease. Presence of either of altered sensorium (p=0.0005) or convulsions (p=0.046) or visual complaints (p=0.032) or headache (p=0.042) were associated with poor outcome whereas presence of focal neurologic deficits alone predicted a better outcome (p=0.036).
that mothers are a good source of in- formation regarding children ’ s acute health care use. Third, the summary ﬁ ndings are based on a single cohort. There are, however, some limitations to our study. First, data were collected during a single month (October). Sea- sonal variations of disease incidence and prevalence, especially in children, could result in estimates different from the current data. October is soon after school begins in the United States and is a time of relatively high numbers of upper respiratory infections and minor illnesses that may result in a signi ﬁ cant increase of health care utilization. In contrast, in Japan, the school year begins in April. As such, October repre- sents a typically uneventful and calm month for children in terms of health status. Second, we did not evaluate the appropriateness of particular health care – seeking behaviors because dis- ease outcome data related to indi- vidual children ’ s symptoms were not collected.
The 10-year cumulative incidence of cataract surgery in patients with diabetes in the Wisconsin Epidemiological Study of Diabetic Retinopathy was two to five times higher than in comparable non diabetic population Cataract in diabetic patients decreases the visual acuity and makes an adequate examination as well as photocoagulation of the retina more difficult or nearly impossible. Therefore, it is necessary and important to perform cataract surgery for visual rehabilitation and also for diagnostic and therapeutic reasons. This is also postulated in other studies.
This study has shown that there is a major setback in the compliance. About 40% of children who completed the study were not given tablets daily. There were remaining tablets at each of the visit. The reasons as derived from the questionnaires are side effects like vomiting, stomachache, constipation etc., More over, these children took the tablets in empty stomach and didnot follow the advice given at the start of study by the investigator. Parents have to be still taught more about the importance of giving the tablets regularly and as prescribed, as to avoid to ill effects of anemia and to minimize side effects of iron.
Australian children were reported, findings based on the combined Australian and New Zealand samples of the large global internet study (Teng et al., 2011) showed that parents of 33.85% of 6–8 month olds and 38.94% of 9–11month olds believed their infant had a sleep problem. In overseas community studies infant sleep problems have been reported by 38% (1999b) and 22% (Zuckerman et al., 1987) of parents. Cross cultural differences in parents’ perceptions of sleep problems in children aged from birth to 3 years are also evident (Mindell, Sadeh, Wiegand, et al., 2010) with more than 50% of parents from primarily Asian countries compared to 26% of parents from primarily Caucasian countries reporting that their child had a sleep problem. The findings from the current study also demonstrated that infant sleep problems as defined by mothers (39%) are more common than infant sleep problems based on research criteria (Morrell, 1999a). According to the ISQ Research Criteria derived from Richman (Morrell, 1999a), in the current study 25% of infants had a possible settling and/or waking problem. More infant night waking problems (n = 23) than settling problems (n = 9) were present for infants in the current sample although eight infants had both waking and settling problems. This result is somewhat higher than the figure of 19% reported by Morrell (1999b) in a sample of 13 month old infants using the same outcome measure. Richman (1981) reported a prevalence rate of 20% for infants aged between 1 and 2 years with waking problems only. The difference in findings may be age related. Infants in the current study had a mean age of seven months and some may not have developed a pattern of longer sleep during the night (Adair et al., 1991; Bayer et al., 2007).
Results: Eighty four patients were recruited and out of them, 151 eyes were taken into analysis after excluding eyes with missing data. Mean age of patients were 45.4 years with 70.2% of them were male. Visual disturbance is the commonest presenting symptom with mean duration of symptom prior to surgery is 9.7 months. Majority of them were pituitary adenomas (75%) followed by sellar meningioma (19%), craniopharyngioma (4.8%), and rathke cleft cyst (1.2%). 70.9% of patients showed improvement in VF based on MD outcome. Mean MD for pre surgery and post- surgery were -14.0 dB and -12.4 dB, respectively. Univariate analysis reveals younger age, female sex, shorter duration of symptom, pituitary adenoma, transsphenoidal approach, and transcranial approach favours improvement in VF. Multivariate analysis shows only shorter symptom duration, transphenoidal approach, and transcranial approach are significant for favourable VF outcome when other factors adjusted.
In a study of over 10,000 patients with DM in the UK the prevalence of diabetic retinopathy has been reported to be 16.5% [16,17]. Our cohort had diabetic retinopathy in 24 patients (66.7%), which is four times higher. The UK Prospective Diabetes Study showed that people with improved glucose control reduced the requirement of laser treatment of the eye by a quarter . Progression of diabetic retinopathy to the proliferative stage over a 4-year follow up in WESDR study in 1075 patients was reported to be 4.7% . In our study 18.4% of patients went on to develop proliferative diabetic retinopathy over an average of 4.36 years. The co-existing uveitis could trigger mechanisms for progression of diabetic retinopathy amongst other factors. However we were unable to identify other main risk factors, such as hypertension and hyperlipidaemia to have a contribu- tory role in our cohort. It was interesting to note rapid progression of non-proliferative diabetic retinopathy to proliferative in one eye of a patient with panuveitis in that eye. There are a number of reports in the litera- ture suggesting either a causative or a protective role of uveitis in relation to proliferative diabetic retinop- athy [20-23]. In the current literature 6 uveitic eyes progressed to PDR in patients with DM whereas two eyes did not progress. This suggests a possible role of worsen- ing diabetic retinopathy in patients with uveitis.
Overall, our study demonstrated that the successful outcome and response of surgical correction of exotropia was influenced by preoperative angle of deviation, the greater the preoperative angle, the better the surgical response, which also better with unilateral recess/resect procedure than bilateral lateral rectus recession. We also found that the success rate of surgery decreased over the course of follow-up, therefore, immediate postoperative overcorrection should be seriously considered to maintain a satisfactory postoperative alignment. Age at onset, age of the patient at surgery, interval between onset and surgery, refraction error, amblyopia, anisometropia and type of surgery were found not to influence the surgical outcome and response to surgery.
Evaluation of the visual status, dilatation and retinoscopy was routinely done. The patient underwent detailed ophthalmic and systemic evaluation, Pupils were dilated with cycloplegic. Anterior segment examination with a slit lamp biomicroscope was done paying attention to corneal, lenticular and vitreous opacities which hinders fundus visualization. Signs of uveitis and pigment dispersion in the vitreous phase were looked for.
uveitis (13%) and pars planitis (4%). Herpetic kerato uveitis (22%), Fuch’s iridocyclitis (19%), Juvenile Rheumatoid arthritis – associated iridocyclitis (16%), Syphilis (14%) and sarcoidosis (12%) were the leading types of uveitis associated with SG. Despite aggressive medical and surgical therapy, SG was associated with progressive visual field loss and optic nerve head damage in 39 patients (33%). So SG is an under appreciated vision threatening complication in patients with uveitis.