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Background: This study was undertaken to determine whether a difference exists in treatment outcome between patients treated with tranexamic acid (TEA) plus topical steroids and those treated with topical steroids alone., Methods: A retrospective cohort study was conducted to compare treatment results for children with traumatic hyphema treated with TEA and topical steroids versus topical steroids alone. Patients were identified from a chart review of the Children's Hospital of Eastern Ontario eye clinic and the Queen's Department of Ophthalmology emergency eye clinic for charts coded "traumatic hyphema." The primary outcomes measured included visual acuity, rebleed rate, intraocular pressure, and time to hyphema resolution. Covariates were hyphema grade, the need for medications to lower intraocular pressure, and the presence of associated ocular traumatic complications. Analysis was performed with both bivariate analysis and multivariate models., Results: Two hundred and fifteen patients with traumatic hyphema were included in our study. One hundred and thirty-seven patients (63.1%) received TEA plus topical steroids, and the remaining 78 patients received topical steroids alone. There was no significant difference in rebleed rate between the TEA plus topical steroid group (1.6%) and the steroid-alone group (2.6%, p = 0.60)., Interpretation: Patients with traumatic hyphema treated with TEA plus topical steroids did not have a significantly lower incidence of rebleed than those treated with topical steroids alone.

Background: Visual outcome studies have shown that laser photocoagulation may result in more favourable clinical outcomes than cryotherapy in threshold retinopathy of prematurity (ROP). Comparative refractive outcome studies have shown that patients treated with laser photocoagulation have less myopia than those treated with cryotherapy. We carried out a study to determine whether a difference in visual outcome or refraction exists in patients with threshold ROP who have been treated with cryotherapy vs. laser photocoagulation., Methods: A retrospective cohort study was conducted comparing treatment results after at least 3 years of follow-up in patients with threshold ROP treated with cryotherapy or laser photocoagulation at a tertiary care children's hospital. Visual acuity and refraction were the outcomes studied. Covariates measured were sex, gestational age and birth weight. Analysis was performed with both bivariate analysis and multivariate models., Results: Seventy-one eyes of 37 patients with threshold ROP were included in the study. Thirty-seven eyes received cryotherapy, and 34 eyes received laser photocoagulation. The mean spherical equivalent refraction was significantly lower in the cryotherapy group than in the laser photocoagulation group (-9.21 dioptres vs. -1.80 dioptres, p = 0.001). Patients in the cryotherapy group were more likely than those in the laser photocoagulation group to have against-the-rule astigmatism (odds ratio 6.86, p = 0.004). Laser photocoagulation did not significantly lower the frequency of an unfavourable visual outcome (visual acuity worse than 20/200) (p = 0.09)., Interpretation: Eyes with threshold ROP treated with laser photocoagulation were significantly less myopic and less likely to have against-the-rule astigmatism than those treated with cryotherapy.

Summary: The goal of this study was to identify cerebral microemboli during scoliosis surgery and their potential relationship with visual alterations. Transcranial Doppler identified high-intensity transient signals (HITS) during surgery in both middle cerebral arteries, and ophthalmologic examination assessed their potential effects on the visual system. Thirteen children (age 13-17 years) undergoing surgery for scoliosis or kyphosis with spine curvature >45 degrees were studied. HITS were identified in 92%. Eleven patients had a total count of <15 HITS, but in the remaining two the count was unexpectedly high (63 and 265 HITS). Echocardiography in these two patients indicated the presence of an atrial right-to-left shunt. Uneventful preoperative and postoperative visual function was found in 11 patients. One patient had preoperative blindness and in another ophthalmologic complications developed not related to microembolization. Scoliosis surgery is frequently associated with low counts of cerebral microemboli. It appears that such low embolic counts have no effects on postoperative visual function as determined clinically. Some patients may show high rates of microemboli, which may be related to the presence of right-to-left cardiac shunts. The impact of these signals on brain function remains to be investigated.

Background: Tranexamic acid has been shown to greatly reduce the incidence of secondary hemorrhage when administered orally or intravenously. Topical administration of the drug should result in much lower serum concentrations, with fewer adverse effects. We performed a study to determine whether topical application of tranexamic acid would yield higher intraocular concentrations and lower serum concentrations of drug than intravenous administration., Methods: Ten New Zealand white rabbits received 25 mg/kg of tranexamic acid intravenously every 8 hours for 3 days. Another group of 10 rabbits received one drop (0.05 mL) of commercially available tranexamic acid solution (100 mg/mL) every 8 hours for 3 days to one eye. Tranexamic acid levels in the aqueous humour, vitreous humour and serum 1 hour after administration of the last dose of drug were determined., Results: Analysis of variance showed that aqueous concentrations of tranexamic acid were significantly higher with topical delivery than with intravenous administration (15 vs. 9 micrograms/mL)(p < 0.05). Serum concentrations were significantly lower following topical administration (9 vs. 19 micrograms/mL)(p < 0.01). The drug was not detected in the vitreous humour in either group., Interpretation: Topical delivery of tranexamic acid may prove to be valuable in yielding therapeutic intraocular concentrations of drug in patients with hyphema while minimizing systemic toxicity.

Purpose: To evaluate a hand-held portable autorefractor in a pediatric population and compare results with those found on retinoscopy by experienced pediatric retinoscopists., Methods: One-hundred and two children aged 5 to 72 months were examined with and without cycloplegia using an autorefractor, and the results compared with those found on standard retinoscopy by two ophthalmologists masked as to the autorefractor findings. Results were converted from conventional notation using plus cylinder to the h-space notation and compared in three-dimensional h-space., Results: There was remarkable agreement between the results found by autorefraction and manual retinoscopy using loose lenses or a phoropter. The findings were similar both for sphere and cylinder across the age ranges studied., Conclusions: The Nikon Retinomax is an accurate instrument to estimate refractive error in children younger than 6 and could prove useful in the office, the operating room, or as a screening device.

Purpose: Perforation of the retina is a major complication of strabismus surgery. The reported incidence of perforation varies from 0.13% to 12%. This study was undertaken to determine, from a large collaborative database, the incidence of suspected and unsuspected retinal and choroidal injury in pediatric horizontal muscle surgery., Method: All children with horizontal strabismus surgery seen between September 1992 and October 1995 were examined with Indirect ophthalmoscopy immediately following their procedure. Surgery was performed by both resident and attending physicians. Cases involving muscle reoperation, high myopia, or patients with connective tissue disorders were excluded., Results: Strabismus surgery was performed on 765 patients, who underwent 1129 muscle recessions and 349 muscle resections. These children also had 161 vertical or oblique muscle procedures performed. Intraocular trauma resulting from horizontal muscle surgery was noted in 14 patient, including three retinal perforations. One of these patients was treated with cryotherapy; the other two received no therapy other than intraoperative and postoperative antibiotics., Discussion: The incidence of retinal perforation was 0.4% and the incidence of choroidal injury without perforation was 1.4% in this large series of children undergoing horizontal strabismus surgery. Retinal detachment or endophthalmitis did not develop during the 6-week follow-up period.

Objectives: To determine the proportion of enucleation procedures attributable to injuries from air guns in people aged 18 years or less and to identify the associated pathological findings., Design: Case series., Setting: Ophthalmic Pathology Registry, University of Ottawa, and affiliated Children's Hospital of Eastern Ontario (Ottawa), Ottawa General Hospital and Ottawa Civic Hospital. In addition, information on air gun injuries from April 1990 to December 1993 was obtained from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) database, with data from 10 pediatric and 5 general hospitals across Canada., Patients: All patients aged 18 years or less who underwent enucleation between Jan. 1, 1974, and Dec. 31, 1993., Results: Eighty-five patients were identified as having undergone enucleation. Trauma accounted for 51 cases (60%), of which 13 (25%) were caused by air guns, the largest single cause of enucleation secondary to trauma. Overall, air gun injuries accounted for 15% of enucleation procedures, whereas retinoblastoma accounted for 21%. All air gun injuries were in boys (median age 14 years, range 9 to 16 years). Of the 13 eyes with air gun injuries 7 had ocular perforation and 6 had ocular penetration. In all cases the intraocular structures were severely disrupted. The CHIRPP database included 165 air gun injuries; 32 were to the eye or ocular adnexa, resulting in 26 hospital admissions., Conclusions: Air guns were the largest single cause of enucleation secondary to trauma in our study. These guns are widely available in Canada and are unrestricted at muzzle velocities capable of causing death or serious injury, especially to the eye. We feel that air guns should be licensed only to people aged 16 to 18 years or older and that education in their use should be mandatory.

An 11-month-old boy presented with uniocular hypopyon, elevated intraocular pressure, and iris nodules. A differential diagnosis of physical abuse, infection, retinoblastoma, juvenile xanthogranuloma, and histiocytosis X were considered but initial physical and laboratory investigations all had normal results. Three weeks following initial presentation, the child developed fulminant acute myelogenous leukemia. The clinical course, investigations, and outcome are reviewed.

We examined an infant who had prenatal onset of a skeletal dysplasia that had many features in common with acromesomelic dysplasia, including the clinical and light and electron microscopic findings of both corneas. Successful lamellar keratoplasty was performed on the left eye when histologic examination of the corneal button from the right eye showed that the corneal scar was only of partial thickness.

We describe the ocular findings in eight patients with congenital myotonic dystrophy in the newborn period. While three infants had normal findings, five infants had evidence of persistent tunica vasculosa lentis (TVL) at gestational ages ranging from 34 to 40 weeks. Atrophy of vessels on the anterior lens capsule is normally complete by 34 weeks gestation and its persistence should suggest congenital infection or congenital myotonic dystrophy. Diagnosis of myotonic dystrophy has serious implications for the baby and the mother, in whom the condition may have not been recognized earlier.

Twenty-one patients aged 4 to 15 years with microscopic or rim hyphemas were treated as out-patients with systemic tranexamic acid therapy. The protocol included limited activity at home, topical steroid therapy, no dilating drops, patching for comfort or surface abrasions only, and follow-up every 24 to 48 hours. With this regimen no patient had a secondary hemorrhage. The incidence of associated injuries was surprisingly high, including four patients with angle recession, two with choroidal ruptures and four with commotio retinae, two of whom manifested retinal holes, requiring cryotherapy. We conclude that tranexamic acid therapy decreases the risk of secondary hemorrhage in ambulatory patients with hyphema, but careful assessment and follow-up are necessary to rule out associated ocular injury.

The simultaneous occurrence of Brown's syndrome in one eye and inferior oblique overaction in the other eye is an infrequently reported association. Review of our series of 38 cases of Brown's syndrome disclosed six patients with overaction of the contralateral inferior oblique, of whom four stepped out to contralateral superior oblique palsy. We propose that these patients initially have bilateral Brown's syndrome in infancy, and spontaneous resolution occurs in one eye only. While Brown's syndrome is present the antagonist inferior oblique muscle undergoes isometric contracture. With spontaneous resolution of Brown's syndrome a relative imbalance of forces occurs, with the superior oblique muscle now being relatively paretic compared with the contracted and fibrotic inferior oblique. Up-shoot in adduction then becomes apparent.

Seventeen children were demonstrated to have completely asymptomatic overaction of one or both inferior oblique muscles. None had a constant vertical deviation in primary position, up gaze or down gaze, and significant patterns were absent. None had diplopia or complaints of torsion. The Bielschowsky head tilt test gave a negative result in all cases. No patient showed excyclorotation on fundus examination. Long-term follow-up (28 to 134 [average 75.6] months) of 13 of the patients showed that the condition did not worsen with time and may not require surgical weakening of the inferior oblique muscle.

In a prospective study 163 patients aged 17 years or less admitted to a children's hospital between April 1985 and December 1990 with traumatic hyphema were treated with tranexamic acid, 25 mg/kg given orally every 8 hours to a maximum of 1500 mg every 8 hours for 5 days. Secondary hemorrhage occurred in 5 patients (3%), none of whom had more than one rebleeding episode. In contrast, 24 (8%) of 316 patients aged 17 years or less admitted to the same hospital between January 1977 and March 1985 with traumatic hyphema who were not treated with antifibrinolytics had a secondary hemorrhage, several more than once, giving a rebleeding rate of 33/316 (10%). The results suggest that tranexamic acid reduces the incidence and number of secondary hemorrhages in children, without significant ocular or systemic side effects.

We studied the usefulness of topical cysteamine ophthalmic drops in reducing crystal formation within the corneas of patients affected by nephropathic cystinosis. A dosage of 0.3% cysteamine given four times daily was chosen as a more manageable method than a previously reported protocol of hourly administration of 0.11% drops. No reduction in crystal formation was observed in our patients; they were followed for seven months.

Surgical treatment of ectopia lentis has traditionally been associated with a poor visual outcome and a high complication rate. We treated a series of nine children (15 eyes) whose visual acuity could not be improved with optimal optical phakic or aphakic correction with limbal lensectomy. Preoperative visual acuity after amblyopia treatment ranged from 20/60 to 20/200. Improvement in postoperative visual acuity was documented in all operated-on eyes, ranging from 20/20 to 20/50 during a follow-up period ranging from 8 months to 118 months (median, 33 months). The only complication was a child who developed a secondary membrane requiring a neodymium-YAG capsulotomy.

A group of patients with the monofixation syndrome were assessed prospectively to compare performance on Titmus and Randot stereograms under monocular and binocular conditions. These patients achieved monofixation either as a result of surgery for infantile esotropia, or because of a partially accommodative esotropia or significant anisometropia. Their ability to detect elevation of the Titmus circles was not significantly better with two eyes as compared to that level achieved using only their monofixating eye. However, performance on the Titmus animals and on Randot circles or animals showed better discrimination. These data would suggest that the monocular clues available in determining elevation of the Titmus circles would invalidate establishing a diagnosis of monofixation.

A prospective study was carried out by the Department of Ophthalmology and the Division of Infectious Disease at the Children's Hospital of Eastern Ontario to assess the outcome of our medical management of orbital cellulitis in children using a predetermined antibiotic regimen and to determine whether computed tomographic (CT) evidence of a subperiosteal abscess alone was an indication for surgical drainage. Between February 1985 and January 1988, 23 patients with true orbital cellulitis were admitted. CT scans were ordered routinely at the time of admission. The scans were cancelled for 13 children because they responded rapidly to medical management. CT showed edema nasal to the medial rectus, or thickening or displacement of the muscle in 8 of the 10 children who underwent the procedure. Three children required sinus and orbital drainage, but frank purulent material was found subperiosteally in only one. The results suggest that most children with orbital cellulitis can be managed with the prompt use of the appropriate intravenous antibiotics. Therapy with cloxacillin sodium and chloramphenicol or, in children under age 6 years, cefuroxime best covers the spectrum of organisms responsible for most cases of orbital cellulitis in children. CT should be used as an ancillary guide to the need for surgical exploration of the orbit in patients who do not rapidly respond to medical management.

Among 78 children who had undergone surgery for intermittent exotropia, undercorrection was found in 39, an acceptable result in 33 and overcorrection in 6. A review conducted to determine what factors might explain the high frequency of undercorrection showed that the average age of the patients was higher than usual, and this was a significant prognostic factor. The presence or absence of associated hypertropias, lateral incomitance and A or V patterns was not of prognostic importance. Purposeful overcorrection of the exodeviation by 10 to 15 prism diopters tended to ensure a more satisfactory result.

In a prospective randomized study, we compared the results of surgical treatment of 25 patients with infantile esotropia, using bilateral medial rectus muscle recession of a graded amount without severing the check ligaments, to results obtained with a similar group of 23 patients in whom check ligaments were severed at the time of bimedial surgery. No significant difference could be found in the immediate postoperative and 6-month postoperative ocular alignment of the two groups.

Following the retrobulbar injection of anesthetic, the application of a mechanical device to lower the intraocular pressure will produce a rise in intraocular pressure that may be sufficient to compromise ocular perfusion. To increase the margin of safety for ischemic damage, a mechanical means of intraocular pressure reduction (Superpinkie) was applied prior to, rather than following, the retrobulbar injection of anesthetic. The study group consisting of 20 patients receiving the compression-injection sequence had a mean preoperative pressure of 4.70 mm Hg, while a control group of 20 patients receiving the injection-compression sequence had a mean preoperative pressure of 2.25 mm Hg. The proposed compression-injection method was well tolerated by the patients and attained surgically adequate anesthesia, akinesia, and ocular opening pressures. In selective cases, the compression-injection technique for the delivery of retrobulbar anesthesia may offer a means of better maintaining ocular perfusion and thereby lessening the risk of vascular compromise.

Ocular damage resulting from self-mutilation is not uncommon in severely retarded children. Such injuries are caused by repeated headbanging or self-inflicted blows to the face. We treated four children with self-inflicted ocular injuries ranging from corneal lacerations to vitreous hemorrhage and retinal detachment. One child, a 14-year-old boy with tuberous sclerosis, became blind. Persons caring for such children should be alert to changes in the appearance of the pupil, changes in the personality or performance level of the child, and to the development of exotropia. Early treatment and protective equipment (spectacles or helmets) may prevent permanent injury.

Three cases of depression in adduction syndrome are described. All occurred unilaterally, in the left eye, in boys and were characterized by depression and retraction of the involved eye with attempted adduction. This was accompanied by an inability to elevate the eye in adduction and a markedly abnormal head posture. Surgery, consisting of superior oblique tenotomy and recession of the lateral rectus muscle, did not allow the ocular rotation to improve but did allow the anomalous head posture to be corrected. The homogeneity of the clinical appearance and the lack of response to surgery suggests that this is a distinct clinical entity.

The authors reviewed the medical records of 316 children admitted between January 1977 and March 1985 with a diagnosis of traumatic hyphema. In this group of patients, 1 to 17 years old treated without antifibrinolytics, the incidence of secondary hemorrhage was 7.6% (24 of 316 patients) of whom three required surgical evacuation of the clot. The risk of rebleeding did not correlate with the patient's age, use of topical steroids, or cycloplegics. Of 176 patients followed from 1 month to 7 years post-hospital discharge, 91% achieved 20/30 vision or better, but only 77% of the patients with secondary hemorrhage attained this level of vision. Amblyopia, a potential threat in young children, occurred in only two children both of whom also required cataract extraction. From our captive pediatric population of 228,000 the incidence of traumatic hyphema is 17 per 100,000 children per year.

To determine whether the gastric content pH of paediatric patients could be raised in an effort to decrease post-aspiration morbidity and mortality, the antacid sodium citrate (0.4 ml.kg-1) was given preoperatively to 25 patients aged 1 to 14 (6.0 +/- 3.5, mean +/- SD) years. Their gastric content pH was measured following induction of anaesthesia. These values were compared to those obtained from a control group (n = 20) ranging in age from seven months to nine (3.3 +/- 2.7) years. A gastric content pH value of greater than 2.5 was measured in 23 of the 25 patients who received sodium citrate. There were only two patients in the control group with a gastric content pH greater than 2.5, p less than 0.001, Fisher exact test. Only one child refused to take the medication. The administration of sodium citrate appears to be an effective method of raising the gastric content pH in paediatric patients.

Many children with Brown's superior oblique tendon sheath syndrome do not have full fusion and stereopsis. Of 28 such patients 8 failed to demonstrate orthophoria in their assumed head position, and many continued to have a head tilt with one or the other eye patched. All eight showed an appropriate vertical deviation, but in addition six showed esotropia and two exotropia. The lack of fusion in their assumed head position led to amblyopia in seven patients.

Distinguishing between anomalous elevation of the optic disc caused by buried drusen and true papilledema can often be clinically difficult. In a prospective study of 18 children with drusen of the optic disc B-scan ultrasonography with a lowered sensitivity was found to be useful in the uncooperative child. A rational approach to the investigation of elevation of the optic disc in children is offered.

A 17-year-old female suffered first and second degree facial burns due to a lightning bolt. Retinal stria were noted 48 hours after the accident and a retinal pigment epithelial defect was documented on the third day. A dense posterior subcapsular cataract was present by the 14th week.

Three cases of large-angle infantile esotropia are presented. Over a minimum follow-up period of 37 months the angle of esotropia decreased spontaneously to less than 10 prism diopters without surgery or the use of glasses, and recognized late complications of infantile esotropia developed: bilateral overaction of the inferior oblique muscle in three cases, and latent nystagmus and dissociated vertical deviation in two cases each. The significance of these findings is discussed.

Of 54 consecutive infants referred for ophthalmoscopy with the pupils dilated, continuous electrocardiographic monitoring showed that 17 (31%) had bradycardia, ranging from 10% to 59% of baseline, coincident with instillation of eyedrops, insertion of an eyelid speculum, pressure on the globe, or stretching of the medial and lateral recti muscles.

We reviewed the charts of 119 children with infantile esotropia followed for 27 months to 16 years (average 82.5 months). Of the 119, 14 (12%) had fine (high frequency, low amplitude) rotatory nystagmus. The presence of the nystagmus may account for a decline in visual acuity of up to two lines under binocular viewing conditions.

A newborn with partial trisomy 2q, due to a maternal (2;6) translocation is presented. The baby had microcephaly, a prominent forehead, hypertelorism, a broad nose with a flat nasal bridge, a long philtrum, micrognathia, and low set ears which are common to cases with partial 2q trisomy. Additional findings of aniridia and marked corneal pathology are reported.

To the differential diagnosis of epiphora in children we propose to add paroxysmal lacrimal hypersecretion. While certainly not a new entity, it should be considered in a child who is tearing intermittently without mattering or evidence of infection. Recognition of this problem may prevent anesthetic morbidity or unnecessary instrumentation of the nasolacrimal apparatus.

Children with a Monofixation syndrome often show a small angle constant esotropia with an overlying esophoria of variable and often large angle. Commonly the phoria is well controlled unless the child is very tired, or the eyes are dissociated. Treatment of a concomitant amblyopia by patching may result in an inability to control the phoria, with breakdown of the strabismic angle to a large esotropia. Illustrative cases are presented.

Twenty-four children with classical chickenpox were referred for ophthalmic assessment because of lesions on the lids and in the eye. The appearance of these lesions, their treatment, and their complications are discussed. Twenty-five percent of these children were documented to have an anterior uveitis.