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One important cause of retinal haemorrhages (RHs) in children is abusive head trauma (AHT). Our programme of research was conducted on children admitted to hospital over a seven‐year period who had RHs as part of their clinical presentation. This paper summarises important findings from previous publications. As a prerequisite, two basic studies were necessary: (i) a method of reporting the precise location of the RH in the retina; and (ii) defining a simple clinical classification of RHs based on the appearance of the retinal layer involved. Because raised intracranial pressure (RICP) is a frequent secondary brain insult following serious adult head injury, causing hypoxic‐ischaemic injury with a resultant poor outcome, it was considered whether such RICP might also cause RHs in children. Detailed, state‐of‐the‐art monitoring methods were used to investigate this relationship along with retinal imaging. Methodical documentation of the type, area and lifespan of RHs meant that it was possible to address the question of predicting AHT from RH numbers and characteristics, and to describe not only the duration of different layer haemorrhages, but also a previously unreported observation that some RHs transiently enlarge over two to three days before resolving normally. 'One important cause of retinal haemorrhages (RHs) in children is abusive head trauma' Key Practitioner Messages: A new retinal zone classification for research and legal purposes has been developed, as well as a simplified five‐point working classification of RHs, based on existing fundoscopic descriptions.In this cohort study, a young age and a high 'dot‐blot' count (>25 intraretinal haemorrhages) are strong predictors of AHT.There is a complex association between the burden of intracranial pressure insult and RHs.Time to resolution of different RHs has been calculated using two‐dimensional RH area pixel counts from sequential retinal imaging. Two patterns of resolution are reported. [ABSTRACT FROM AUTHOR]

To explore the feasibility of using Saccadic Vector Optokinetic Perimetry (SVOP) to differentiate glaucomatous and healthy eyes. A prospective case–control study was performed using a convenience sample recruited from a single university glaucoma clinic and a group of healthy controls. SVOP and standard automated perimetry (SAP) was performed with testing order randomised. The reference standard was a diagnosis of glaucoma based a comprehensive ophthalmic examination and abnormality on standard automated perimetry (SAP). The index test was SVOP. 31 patients with glaucoma and 24 healthy subjects were included. Mean SAP mean deviation (MD) in those with glaucoma was − 8.7 ± 7.4 dB, with mean SAP and SVOP sensitivities of 23.3 ± 0.9 dB and 22.1 ± 4.3 dB respectively. Participants with glaucoma were significantly older. On average, SAP sensitivity was 1.2 ± 1.4 dB higher than SVOP (95% limits of agreement = − 1.6 to 4.0 dB). SVOP sensitivity had good ability to differentiate healthy and glaucomatous eyes with a 95% CI for area under the curve (AUC) of 0.84 to 0.96, similar to the performance of SAP sensitivity (95% CI 0.86 to 0.97, P = 0.60). For 80% specificity, SVOP had a 95% CI sensitivity of 75.7% to 94.8% compared to 77.8% to 96.0% for SAP. SVOP took considerably longer to perform (514 ± 54 s compared to 267 ± 76 s for SAP). Eye tracking perimetry may be useful for detection of glaucoma but further studies are needed to evaluate SVOP within its intended sphere of use, using an appropriate design and independent reference standard. [ABSTRACT FROM AUTHOR]

Background: To examine the speed and accuracy of saccadic eye movements during a novel eye tracking threshold visual field assessment and determine whether eye movement parameters may improve ability to detect glaucoma.Methods: A prospective study including both eyes of 31 patients with glaucoma and 23 controls. Standard automated perimetry (SAP) and eye tracking perimetry (saccadic vector optokinetic perimetry, SVOP) was performed. SVOP provided data on threshold sensitivity, saccade latency, and two measures of accuracy of saccades (direction bias and amplitude bias). The relationship between eye movement parameters and severity of glaucoma was examined and Receiver Operating Characteristic curves were used to assess ability to detect glaucoma.Results: Patients with glaucoma had significantly slower saccades (602.9 ± 50.0 ms versus 578.3 ± 44.6 ms for controls, P = 0.009) and reduced saccade accuracy (direction bias = 7.4 ± 1.8 versus 6.5 ± 1.5 degrees, P = 0.006). There was a significant slowing of saccades and saccades became less accurate with worsening SAP sensitivity. Slower saccades were associated with increased odds of glaucoma; however, the AUC for saccade latency was only 0.635 compared to 0.914 for SVOP sensitivity.Conclusion: Patients with glaucoma had significant differences in eye movements compared to healthy subjects, with a relationship between slower and less accurate eye movements and worse glaucoma severity. However, in a multivariable model, eye movement parameters were not of additional benefit in differentiating eyes with glaucoma from healthy controls. [ABSTRACT FROM AUTHOR]

Gout was diagnosed based on 8 points on the ACR/EULAR gout criteria. Characteristics of ocular abnormalities in gout patients. [Extracted from the article]

Aim: To explore the relationship between raised intracranial pressure (RICP) and retinal haemorrhages in traumatic and non-traumatic childhood encephalopathies.Method: A prospective study of 112 children (35 females and 77 males, age range 0.01mo-17y 8.3mo; mean 5y 8.6mo, median 4y 5.6mo) included 57 accidental traumatic brain injuries (ATBIs), 21 inflicted traumatic brain injuries (ITBIs), and 34 non-traumatic encephalopathy cases. Measurements included intracranial pressure (ICP), cerebral perfusion pressure, pressure-time index of ICP, and number, zone, and layer of retinal haemorrhages on retinal imaging.Results: Group I had measured elevated ICP (n=42), Group II had clinical and/or radiological signs of RICP (n=21), and Group III had normal ICP (n=49). In the combined Groups I and II, 38% had retinal haemorrhages. Multiple logistic regression confirmed that the presence of retinal haemorrhages was significantly related to the presence of RICP independent of age and aetiology; however, the occurrence and overall numbers were not significantly related to the specific ICP level. The numbers of intraretinal (nerve-fibre layer and dot blot) retinal haemorrhages were significantly greater in those with RICP. The ITBI population was significantly different from the other combined aetiological categories.Interpretation: The study results indicate a complex RICP/retinal haemorrhage relationship. There was no evidence of existing retinal haemorrhages being exacerbated or new retinal haemorrhages developing during periods of confirmed RICP. [ABSTRACT FROM AUTHOR]

Background There is currently no universally accepted classification of childhood retinal haemorrhages. Aim To measure the inter- and intra-observer agreement of clinical classifications of retinal haemorrhages in children. Methods Four examiners (two consultant ophthalmologists and two other clinicians) were shown 142 retinal haemorrhages on 31 RetCam photographs. The retinal haemorrhages were from children with accidental or abusive head injury, or other encephalopathies, and included retinal haemorrhages of different ages. Specified haemorrhages were initially classified by each examiner according to their clinical understanding. Altogether, 26 haemorrhages were represented to test intra-observer consistency. Examiners then agreed a common description for each haemorrhage type and five categories were described (vitreous, pre-retinal, nerve fibre layer, intra-retinal/subretinal or indeterminate) and the study repeated. Results There was 'fair agreement' initially (Fleiss' unweighted κ=0.219) and, with the agreed classification, slight improvement (0.356). Intra-observer agreement marginally improved on re-test. The two consultant ophthalmologists showed 'fair' agreement on both occasions (paired κ statistic). The other rater pair improved from 'fair' to 'substantial' agreement with the new classification. Conclusions The classification of retinal haemorrhage in children by appearance alone shows only fair agreement between examiners. Clinicians who are not consultant ophthalmologists appear to benefit from the new succinct classification. [ABSTRACT FROM AUTHOR]

Objectives Post-traumatic hypopituitarism is well described amongst adult traumatic brain injury (TBI) survivors. We aimed to determine the prevalence and clinical significance of pituitary dysfunction after head injury in childhood. Design Retrospective exploratory study. Patients: 33 survivors of accidental head injury (27 boys). Mean (range) age at study was 13·4 years (5·4-21·7 years) and median (range) interval since injury 4·3 years (1·4-7·8 years). Functional outcome at study: 15 good recovery, 16 moderate disability, two severe disability. Measurements Early morning urine osmolality and basal hormone evaluation were followed by the gonadotrophin releasing hormone (GnRH) and insulin tolerance ( n = 25) or glucagon tests (if previous seizures, n = 8). Subjects were not primed. Head injury details were extracted from patient records. Results No subject had short stature (mean height SD score +0·50, range −1·57 to +3·00). Suboptimal GH responses (<5 μg/l) occurred in six peri-pubertal boys (one with slow growth on follow-up) and one postpubertal adolescent (peak GH 3·2 μg/l). Median peak cortisol responses to insulin tolerance or glucagon tests were 538 and 562 nm. Nine of twenty-five and two of eight subjects had suboptimal responses, respectively, two with high basal cortisol levels. None required routine glucocorticoid replacement. In three, steroid cover was recommended for moderate/severe illness or injury. One boy was prolactin deficient. Other basal endocrine results and GnRH-stimulated LH and FSH were appropriate for age, sex and pubertal stage. Abnormal endocrine findings were unrelated to the severity or other characteristics of TBI or functional outcome. Conclusions No clinically significant endocrinopathy was identified amongst survivors of accidental childhood TBI, although minor pituitary hormone abnormalities were observed. [ABSTRACT FROM AUTHOR]

Background: Preterm infants receiving supplemental oxygen therapy experience frequent fluctuations in their blood oxygen levels, the magnitude of which has been associated with the incidence and severity of retinopathy of prematurity in such infants. Objective: Our objective was to investigate in a relevant animal model whether the immature brain with its poorly vascularised white matter might also be susceptible to injury when exposed to such fluctuations in blood oxygen. Methods: Newborn rats were reared in an atmosphere in which a computer reproduced the oxygen fluctuations derived from the transcutaneous oxygen levels of a 24-week preterm infant who had developed severe retinopathy. Following 14 days of exposure, we measured the expression of active caspase-3, myelin basic protein (MBP) and glial fibrillary acidic protein (GFAP) in the brains comparing with rat pups raised in room air. Results: Compared to room air controls, at day 14, the expression of active caspase-3 was increased by up to 162% (significant increase in 7 of 9 regions), MBP decreased by up to 70% (significant in the hypothalamus only) and GFAP increased by up to 103% (significant in 6 of 7 regions. On day 21, following 7 days of reparative recovery, GFAP levels in most areas of oxygen-exposed brains had returned to near control levels. There were no longer significant differences in caspase-3 levels apart from the cerebral cortex, cerebellum and striatum. In contrast, MBP expression was now much higher in most regions of the treated brains compared to controls. Conclusion: We conclude that fluctuations in blood oxygen, observed in preterm survivors, may constitute a source of injury to the white matter and corpus striatum of the developing brain and contribute to the neurological sequelae in extremely premature infants. Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Homocystinuria due to 5,10-methylenetetrahydrofolate reductase deficiency may present with variable neurological manifestations. Radiological features include white matter changes (leukoencephalopathy). Clinical, biochemical, and radiological response to treatment may again be variable. Here we present a 12-year follow-up of two siblings on the same treatment regimen, with contrasting long-term findings. The first patient, a female presenting at 15 years, showed a good clinical response, substantial intellectual gain, and complete reversal of leukoencephalopathy. Her brother presented at 13 years 9 months and showed limited clinical and cognitive improvement with persistence of the leukoencephalopathy. Both siblings showed a partial biochemical response to treatment. [ABSTRACT FROM AUTHOR]

The literature regarding the outcome of non-accidental head injury (NAHI) is scarce and lacks specific detail even though it is generally considered to be poor. The purpose of this study is to review the literature to date and report the neurological outcome of these children in detail. Twenty-five children were enrolled and 68% of children were neurologically abnormal at an average follow-up of 59 months. A wide range of abnormalities and outcomes was seen. Speech and language difficulties were present in 64% including autistic spectrum disorder. Cranial nerve abnormalities were present in 20%. Visual deficits and epilepsy compounded learning difficulties in 25% of survivors. Consent for follow-up was more likely to be obtained where the perpetrator was known. The spectrum and degree of severity of neurological abnormalities in survivors of NAHI is extremely variable, with the majority of these children being moderate or severely abnormal. These children require the support of a multi-disciplinary team in the community. Further study regarding the process of follow-up, where complex medicolegal issues exist, are needed in order to facilitate maximum neurological development. [ABSTRACT FROM AUTHOR]

Because of its noninvasive and repeatable nature, Doppler ultrasound has been increasingly used to assess changes in cerebral haemodynamics in infants and children with hydrocephalus. There is general agreement that a direct correlation exists between the intracranial pressure (from experimental, fontanometric and direct measurement evidence) and the resistance index. In addition, this increasing index has been predominantly due to a reduction in the end-diastolic velocity. Stable ventriculomegaly is associated with normal pulsatility. The cerebral blood flow velocity parameters change significantly following CSF drainage by tapping or shunting. The measurement of intracranial pressure and cerebral blood flow velocity are currently the best ways of assessing the need for CSF diversion and monitoring subsequent shunt function. [ABSTRACT FROM AUTHOR]

Transcranial Doppler ultrasonography (TCD) was performed on 14 patients with hydrocephalus (age range 1 day to 12 years old) before and after ventriculoperitoneal shunting. TCD was also perfomed with simultaneous intracranial pressure (ICP) measurements during ventricular taps through a reservoir in 7 patients. Measurements of the resistance index (RI)=(S-D)/S, peak systolic (S), enddiastolic (D) and time-averaged mean flow velocities were made. After ventricular taps and ventriculoperitoneal shunting there was a significant decrease in RI in all patients. This was due to a greater increase in D compared to S, which suggests a decreased distal cerebrovascular resistance. There was a significant correlation between RI and ICP in the older infants and children and in individual neonates. Successful cerebrospinal fluid diversion reduces ICP and cerebrovascular resistance, thus improving cerebral perfusion. The RI is a reliable index for serial monitoring of cerebrohaemodynamic change in patients with hydrocephalus. [ABSTRACT FROM AUTHOR]

Transcranial Doppler ultrasound monitoring of cerebral blood flow velocity (CBFV) was performed on 17 children (age range 8 days to 6 years) with pyogenic meningitis. Serial measurements of the peak systolic, end diastolic, mean flow velocity, and resistance index (equal to peak systolic velocity minus end diastolic velocity divided by peak systolic velocity) were obtained over the period of their hospital admission. In all 16 survivors there was a significant decrease in the final resistance index compared with the initial resistance index due to a significant increase in the end diastolic velocity. There was a significant increase in the final mean flow velocity. In four patients the decrease in intracranial pressure and increase in cerebral perfusion pressure after mannitol infusions was accompanied by a corresponding decrease in resistance index and increase in mean flow velocity. A pressure passive CBFV response with a significant linear correlation for resistance index/mean arterial pressure may suggest a loss of cerebrovascular autoregulation. These results suggest that in the early phase increased cerebrovascular resistance may contribute to a relative impairment of cerebral perfusion. Non-invasive monitoring by transcranial Doppler ultrasound may be helpful for early detection of deterioration in cerebral haemodynamic trends. [ABSTRACT FROM AUTHOR]

Purpose: To examine the diagnostic ability of saccadic vector optokinetic perimetry (SVOP), a new eye tracking perimeter, by assessing its capacity to differentiate healthy and glaucomatous participants, and to compare performance to standard automated perimetry (SAP). Methods: A prospective case‐control study including patients with glaucoma and healthy volunteers recruited from the glaucoma clinic at a university hospital and from the Scottish Health Research Register (SHARE). Participants underwent a comprehensive ophthalmic examination and performed SAP and SVOP in both eyes with the order of testing randomised. Results: 61 eyes of 31 participants with glaucoma and 47 eyes of 24 healthy participants were included in the study. Average SAP mean deviation (MD) in glaucomatous eyes was ‐8.72 ± 7.37 dB, with average SAP and SVOP sensitivities of 23.28 ± 0.89 dB and 22.1 ± 4.25 dB respectively. There was strong correlation between average SAP and SVOP sensitivities (r = 0.951 , P<0.001). On average, SAP sensitivity was 1.16 ± 1.43 dB higher than SVOP sensitivity, with 95% limits of agreement of ‐1.64 to 3.96 dB. SVOP average sensitivity had excellent ability to differentiate healthy and glaucomatous eyes with an AUC of 0.90 (95% CI 0.84 to 0.96), which was not significantly different to the performance of SAP average sensitivity (AUC = 0.92, 95% CI.0.86 to 0.97, P = 0.60) (Figure 6). SVOP had 85.2% sensitivity for 80% specificity, compared to 86.9% sensitivity for 80% specificity for SAP. Conclusions: The results of this study suggest that eye tracking perimetry using SVOP could offer a feasible alternative to SAP for detection of glaucoma. Overall, there was good agreement between differential light sensitivity values measured using SVOP and those measured using SAP, and average SVOP and SAP sensitivities had similarly good ability to differentiate glaucomatous and healthy eyes. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor on the topic of shaken baby syndrome.

A letter to the editor is presented in response to a letter on the occurrence of neurological deficits in children due to shaken baby syndrome.