Faculty Bibliography

OBJECTIVES/OBJECTIVE:To determine whether DNA methylation patterns in genes coding for selected T-lymphocyte proteins are associated with perinatal psychiatric distress or with complications of pregnancy. METHODS:T lymphocyte DNA was obtained from pregnant women across three time points in pregnancy and the postpartum period and epigenetic patterns were assessed using Illumina 450 ​K Methylation Beadchips. Seven selected genes critical for T cell function were analyzed for methylation changes during pregnancy and for associations of methylation patterns with psychiatric distress or with pregnancy complications, with particular attention paid to spatial aggregations of methyl groups, termed 'hotspots,' within the selected genes. RESULTS:hotspot was more malleable and changes over time were coordinated across the nine cytosines in the hotspot. CD3 CpGs did not pass array-wide tests for significance, but CpG clusters in two other genes, DTNBP1 and OXSR1, showed array-wide significant associations with anxiety. CONCLUSIONS:appear linked to both symptoms of depression and anxiety in pregnancy and, less strongly, to adverse pregnancy outcomes.

Maternal prenatal stress influences offspring neurodevelopment and birth outcomes including the ratio of males to females born; however, there is limited understanding of what types of stress matter, and for whom. Using a data-driven approach with 27 variables from questionnaires, ambulatory diaries, and physical assessments collected early in the singleton pregnancies of 187 women, 3 latent profiles of maternal prenatal stress emerged that were differentially associated with sex at birth, birth outcomes, and fetal neurodevelopment. Most women (66.8%) were in the healthy group (HG); 17.1% were in the psychologically stressed group (PSYG), evidencing clinically meaningful elevations in perceived stress, depression, and anxiety; and 16% were in the physically stressed group (PHSG) with relatively higher ambulatory blood pressure and increased caloric intake. The population normative male:female secondary sex ratio (105:100) was lower in the PSYG (2:3) and PHSG (4:9), and higher in the HG (23:18), consistent with research showing diminished male births in maternal stress contexts. PHSG versus HG infants were born 1.5 wk earlier (P < 0.05) with 22% compared to 5% born preterm. PHSG versus HG fetuses had decreased fetal heart rate-movement coupling (P < 0.05), which may indicate slower central nervous system development, and PSYG versus PHSG fetuses had more birth complications, consistent with previous findings among offspring of women with psychiatric illness. Social support most strongly differentiated the HG, PSYG, and PHSG groups, and higher social support was associated with increased odds of male versus female births. Stress phenotypes in pregnant women are associated with male vulnerability and poor fetal outcomes.

Ocular Baylisascaris procyonis infection results from ingestion of infective eggs of B. procyonis, the raccoon ascarid. Herpes simplex virus type 2 (HSV-2) infection of the retina is the result of either primary infection or reactivated disease. Herein, we report a case of a 12-year-old female resident of the Bronx in New York City, who presented with pan-uveitis and vision loss. Initial evaluation for etiologic causes was nondiagnostic. Serology for anti-Baylisascaris procyonis antibodies in serum and vitreous fluid were both positive. Polymerase chain reaction (PCR) of vitreous fluid was positive for HSV-2. Treatment with vitrectomy, albendazole, and acyclovir resulted in mild improvement of visual acuity. The atypical presentation of B. procyonis in this case, as ocular larva migrans with a peripheral granuloma and retinal detachment, underscores the importance of maintaining a high degree of suspicion for this pathogen even in non-diffuse unilateral subacute neuroretinitis (DUSN) patients in urban areas. This case further illustrates that it is possible to have coexisting infections in cases of posterior uveitis.

PURPOSE/OBJECTIVE:To determine if a pharmacological test could be developed to determine iris dilator dysfunction in patients taking tamsulosin. METHODS:Patients taking tamsulosin and controls were recruited from the Urology and Ophthalmology clinics at the Montefiore Medical Center. The patient's right eye (OD) was dilated with phenylephrine hydrochloride 2.5% and tropicamide 1%. The patient's left eye (OS) was dilated with tropicamide 1% alone. Forty minutes after dilation, pupillary diameter was measured in both eyes. RESULTS:Thirty-eight tamsulosin subjects and 43 controls met the inclusion criteria for the study. The tamsulosin-treated patients dilated less with phenylephrine than controls (0.61±0.4 vs. 1.10±0.45 mm, respectively P<0.001). Receiver operating characteristic curves comparing maximal pupillary dilation versus differential pupillary dilation in tamsulosin patients relative to controls shows a greater area under the curve for differential dilation (0.8 vs. 0.6, respectively). A correlation between smooth muscle dysfunction and length of time on tamsulosin was observed. Patients using tamsulosin for <1 month had an average OD-OS difference of 0.85±0.5 mm. Patients who were on tamsulosin for >1 month had an average OD-OS difference of 0.52±0.32 mm (P<0.01, Mann-Whitney). CONCLUSION/CONCLUSIONS:Patients treated with tamsulosin demonstrated a significantly decreased iris dilatory response to the selective adrenergic effects of phenylephrine compared to controls. Additionally, it appears that longer duration of exposure to tamsulosin increases the likelihood of dilator dysfunction.

PURPOSE/OBJECTIVE:To determine the sensitivity and specificity of orbital ultrasonography in distinguishing papilledema from pseudopapilledema in adult patients. METHODS:The records of all adult patients referred to the neuro-ophthalmology service who underwent orbital ultrasonography for the evaluation of suspected papilledema were reviewed. The details of history, ophthalmologic examination, and results of ancillary testing including orbital ultrasonography, MRI, and lumbar puncture were recorded. Results of orbital ultrasonography were correlated with the final diagnosis of papilledema or pseudopapilledema on the basis of the clinical impression of the neuro-ophthalmologist. Ultrasound was considered positive when the optic nerve sheath diameter was ≥3.3 mm along with a positive 30° test. RESULTS:The sensitivity of orbital ultrasonography for detection of papilledema was 90% (CI: 80.2-99.3%) and the specificity in detecting pseudopapilledema was 79% (CI: 67.7-90.7%). CONCLUSIONS:Orbital ultrasonography is a rapid and noninvasive test that is highly sensitive, but less specific in differentiating papilledema from pseudopapilledema in adult patients, and can be useful in guiding further management of patients in whom the diagnosis is initially uncertain.

PURPOSE: To evaluate the efficacy of bilateral posterior superior oblique tenectomy for the treatment of A-pattern strabismus due to superior oblique overaction regardless of the magnitude of the pattern. METHODS: The medical records of patients with A-pattern esotropia or exotropia in the presence of superior oblique overaction who underwent combined horizontal muscle surgery along with bilateral superior oblique posterior 7/8 tenectomy from 2003 to 2013 were retrospectively reviewed. Patients with at least 3 months' follow-up were included. RESULTS: A total of 73 patients were included. Of these, 46 had esotropia; 27, exotropia. The preoperative A-pattern deviation for the study population was 19.6Delta +/- 11.4Delta (range, 10-60), with a final postoperative patten collapse of 18.2 +/- 3.6. Superior oblique overaction was 2.3 +/- 0.7 preoperatively and 0.3 +/- 0.7 postoperatively. Overall, 87.7% of patients had a successful collapse of their pattern to <10Delta following the initial bilateral superior oblique posterior tenectomy, with an additional 4.1% following a second procedure. Of patients with a pattern deviation of <25Delta, 87.9% had successful collapse of the pattern following 1 surgery, and 86.7% of patients who had a pattern of >/=25Delta had successful collapse. Postoperatively, 7 patients demonstrated mild inferior oblique overaction. No surgical complications were noted. CONCLUSIONS: A uniform dose of bilateral posterior 7/8 tenectomy surgery successfully collapses A-pattern deviations of all magnitudes.

PURPOSE OF REVIEW: To describe recent evidence regarding the surgical approach of strabismus in children with various forms of developmental delay. RECENT FINDINGS: There remains variability in surgical outcomes with or without dose adjustment in strabismus surgery for children with developmental delay. However, this should not deter one from performing surgery - even early surgery, as fusional potential remains possible, which can especially impact the quality of vision and quality of life in developmentally delayed children.Future prospective, comparative, long-term studies with larger sample sizes for strabismus surgery in children with developmental delay are still needed. SUMMARY: Strabismus is one of the most common ophthalmologic findings in children with developmental delay. Surgical correction of strabismus in children with developmental delay is well tolerated and effective, although it remains slightly less predictable, which can depend on the specific type of delay or underlying neurological deficit. Careful consideration of types and severity of developmental delay and attempts to measure binocular potential can help guide the timing, dosage, and type of treatment.Reoperations tend to be more frequently encountered in this population, and this higher degree of variability should be addressed in the consent process.Considering adjusting the surgical dosage in this population, taking careful preoperative measurements, and checking for fusional potential should be taken into account when managing children with developmental delay.

We report a 12-year-old boy with a rare condition consisting of familial bilateral anterior lentiplane (a flat anterior lens capsule) posterior lenticonus, and microcornea.

PURPOSE: Recent literature reports that patients and parents of pediatric patients prefer their physician to wear a white coat and to address them informally. This study aims to characterize current practice patterns of pediatric ophthalmologists regarding their use of white coats and salutations during outpatient pediatric encounters. METHODS: An eight-question survey was e-mailed to members of the American Academy of Pediatric Ophthalmology and Strabismus in 2012. The questions focused on clinical setting, use of white coats in out-patient encounters, and preferred language used to address the patient's parents. Surveys not completed in full were excluded from data analysis. RESULTS: Of approximately 1,266 members who received the survey, 606 completed the survey. Five hundred ninety-nine surveys were included in the data analysis. Sixty-three percent of attending physicians and 80% of fellows reported they did not routinely wear white coats while examining outpatient children. Forty-six percent of attending physicians and 48% of fellows addressed the patient's parents as "mom" or "dad". There was no significant association between wearing a white coat and type of practice setting, practice characteristics, or location in a children's hospital for attending physicians or fellows. CONCLUSIONS: Contrary to preferences expressed by patients and their parents, a majority of pediatric ophthalmologists do not routinely wear white coats during pediatric outpatient examinations. Practice patterns appear to be in line with previously reported parental greeting preferences.