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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 108  |  Issue : 4  |  Page : 167-172

Evaluation of large cupping in children with anemia


1 Department of Ophthalmology, Beni Suef University, Beni Suef, Egypt
2 Department of Ophthalmology, Fayoum University, Fayoum, Egypt
3 Department of Ophthalmology, Misr University for Science and Technology, October, Egypt
4 Department of Ophthalmology, Research Institute of Ophthalmology, Giza, Egypt
5 Department of Pediatric, National Institute for Laser Enhanced Sciences, Giza, Egypt
6 Department of Medicine, Beni Suef University, Beni Suef, Egypt

Date of Submission22-Nov-2014
Date of Acceptance05-May-2015
Date of Web Publication22-Jan-2016

Correspondence Address:
Mohamed Yasser S Saif
Department of Ophthalmology, Faculty of Medicine, Beni Suef University, 5 Sherif St, Babel Louk Sq, Cairo 11111
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2090-0686.174651

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  Abstract 

Introduction
In adults, large optic disc cups are often a sign of glaucoma. Children, however, show a lower prevalence of glaucoma than adults, but may present with optic disc cupping of nonglaucomatous origin.
Aim of the work
The purpose of this study is to evaluate with large cupping in children having anemia.
Patients and methods
This is a prospective analysis of patients attending the ophthalmology outpatient clinic in Beni Suef, Fayoum, and Misr universities. All patients were subjected to standard ophthalmological examination, optical coherence tomography (OCT), fundus photography, complete blood count (CBC), and stool analysis to diagnose the cause of anemia.
Results
In this study examination cupping of greater than 0.4 was detected in 236 patients out of 3361 patients examined within the same age. The mean age of the selected patients (236 patients) was 11.48 ± 3.2 ranging from 6 to 18 years of which 137 (58.05%) were girls and 99 (41.95%) boys. The mean best corrected visual acuity converted to logMAR is 0.093 ± 0.109 ranging from 0.301 (6/12) in 53 eyes to 0 (6/6) in 260, whereas the rest best-corrected visual acuity 0.176 (6/9). The mean intraocular pressure was 11.75 ± 1.539.The mean cup disc ratio was 0.498 ± 0.0934 (0.497 ± 0.095 for females and 0.501 ± 0.090 for males). The majority of patients (females more than males) had C/D ratio similarity between both eyes, whereas very few had 0.2 differences (males more than females). The mean Hb concentration was 10.79 ± 0.89 g/dl in females and 11.04 ± 1.09 g/dl in males. It was as low as 7.2 in males and 7.8 in females. The stool analysis for the patients showed that 126 patients (74 females, 52 males) were infected with Entamoeba histolytica, whereas 31 patients (22 females, nine males) were infected with Giardia lamblia and 79 patients did not have parasitic manifestations.
Conclusion
In conclusion to our work we found that functional optic nerve damage is a possibility in children with anemia and cupping and with normal intraocular pressure and that there is very high incidence of parasitic infestation in those children and young adolescents that warns for state intervention to deal with this problem. A larger scanning by the ministry of health may be needed to verify these results.

Keywords: anemia, C/D ratio, cupping in children, parasitic manifestations


How to cite this article:
Saif MS, Saif AS, Saif PS, El Saftawy HS, Dabbous OA, Salem MN. Evaluation of large cupping in children with anemia. J Egypt Ophthalmol Soc 2015;108:167-72

How to cite this URL:
Saif MS, Saif AS, Saif PS, El Saftawy HS, Dabbous OA, Salem MN. Evaluation of large cupping in children with anemia. J Egypt Ophthalmol Soc [serial online] 2015 [cited 2017 Sep 25];108:167-72. Available from: http://www.jeos.eg.net/text.asp?2015/108/4/167/174651


  Introduction Top


In adults, large optic disc cups are often a sign of glaucoma. Children, however, show a lower prevalence of glaucoma than adults, but may present with optic disc cupping of nonglaucomatous origin. Large disc cups in children may be diagnosed as physiologic large cups or may be associated with prematurity and periventricular leukomalacia [1],[2],[3],[4].

Children with large optic disc cups often present a clinical dilemma on initial examination, as tests to rule out glaucoma, including intraocular pressure measurement and formal visual field analysis, can be difficult within the pediatric age group. Small optic discs generally have small-to-absent optic cups. Large optic discs generally have large optic cups, but they may have a greater number of nerve fibers than small discs [3],[4],[5],[6]. Asymmetry of the cup-to-disc ratio greater than 0.2 or notching or focal or diffuse thinning of the rim of the optic nerve is characteristic of glaucomatous changes. The ISNT rule is a useful strategy in detecting glaucomatous optic nerves [6],[7],[8],[9].

Pathologic cupping of the optic nerve is most commonly associated with glaucomatous optic neuropathy [1]. However there are other nonglaucomatous causes of cupping as ischemic optic neuropathies either anterior or posterior as well as optic neuritis and hereditary optic atrophies but mostly associated with older age group than the age we are studying. Children with large optic nerve head cups often pose diagnostic difficulty due to concern over possible glaucoma [6],[7],[10],[11].

However, is anemia in children less dangerous than glaucoma?


  Aim of the work Top


The purpose of this study is to evaluate with large cupping in children having anemia.


  Patients and methods Top


This is a prospective analysis of patients attending the ophthalmology outpatient clinic in Beni Suef University, Fayoum University, Misr University, Research Institute of Ophthalmology, and National Institute of Laser Enhanced Science. The IRB and Ethical committee approved the study.

Inclusion criteria

Age: 6-18 years.

C/D ratio>0.4.

Exclusion criteria

  1. Cup disc ratio less than 0.4.
  2. Mixed or unclear diagnosis.
  3. Spherical equivalent> ± 5 D.
  4. Retinal pathology.


All patients were subjected to standard ophthalmological examination including: visual acuity (Snellen visual acuity chart), pupil examination, applanation tonometry, slit-lamp examination, dilated fundus examination, visual field testing, and OCT analysis of the disc.

The following was done for all patients: age, refractive error, optic nerve appearance (cup-to-disc ratio, presence of optic nerve pallor).

The visual field data mean and pattern SDs were recorded using the octopus visual field perimeter. Complete blood count with special reference to hemoglobin level was done and stool analysis to diagnose the cause of anemia.

The OCT was done using the Zeiss CIRRUS HD-OCT model (Carl Zeiss Meditec, Dublin, CA, USA) or Topcon 3D OCT-2000 machine (3D OCT-2000; Topcon Corporation, Tokyo, Japan).

Statistical analysis

Data were collected in a Microsoft excel 2007 sheet (Microsoft Corporation, Redmond, WA 98052, USA) and analyzed using the Microsoft excel 2007 (Microsoft Corporation, Redmond, WA 98052, USA) and SPSS v16 software (SPSS Inc., an IBM Company, Chicago, Illinois 60606, USA).


  Results Top


In this study examination cupping of greater than 0.4 was detected in 236 patients out of 3361 patients examined within the same age. The mean age of the selected patients (236 patients) was 11.48 ± 3.2 ranging from 6 to 18 years of which 137 (58.05%) were girls and 99 (41.95%) boys were included as shown in [Table 1].
Table 1: Details of demographic data of the patients

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The mean best-corrected visual acuity converted to logMAR is 0.093 ± 0.109 ranging from 0.301 (6/12) in 53 eyes to 0 (6/6) in 260, whereas the rest best-corrected visual acuity 0.176 (6/9) as shown in [Table 2].
Table 2: Statistical analysis of best-corrected visual acuity converted to logMAR

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The mean intraocular pressure was 11.75 ± 1.539; it ranged from 9-15 mmHg in all eyes which is shown in [Table 3].
Table 3: Statistical analysis of intraocular pressure for eyes included in this study

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The mean cup disc ratio was 0.498 ± 0.0934 (0.497 ± 0.095 for females and 0.501 ± 0.090 for males); it ranged from 0.4 to 0.8 for males and 0.4 to 0.7 for females. The mean difference between both eyes was 0.027 in females and 0.035 in males as shown in [Table 4] and [Figure 1]. The C/D ratio analysis is listed in [Table 5] with the percentage of cupping in the study group and prevalence of C/D ratio to all patients screened.
Figure 1: The mean C/D ratio and mean C/D difference between both eyes in the study group with the sex difference.

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Table 4: Statistical analysis of the C/D ratio for patients in the study group

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Table 5: Detailed analysis of the C/D ratio for patients in the study group

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The majority of patients (females more than males) had C/D ratio similarity between both eyes, whereas very few had 0.2 differences (males more than females) as shown in [Figure 2].
Figure 2: The C/D difference between both eyes in the study group with the sex difference.

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The hemoglobin concentration (Hb) was measured in all patients and they were considered as anemic if the blood level was less than that shown in reference [Table 6].
Table 6: Reference table used for diagnosis of the anemic patients [12],[13]

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The mean Hb concentration was 10.79 ± 0.89 g/dl in females and 11.04 ± 1.09 g/dl in males. It was as low as 7.2 in males and 7.8 in females as shown in [Table 7].
Table 7: Statistical analysis of the Hb level in blood for patients in the study group

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The stool analysis for the patients showed that 126 patients (74 females, 52 males) were infected with Entamoeba histolytica, whereas 31 patients (22 females, nine males) were infected with Giardia lamblia and 79 patients did not have parasitic manifestations as shown in [Table 8] and [Figure 3].
Figure 3: Statistical analysis for stool examination as regards the parasites.

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Table 8: Statistical analysis for stool examination as regards the parasites

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The significant visual field findings were present in 63 (26.69%) patients (13.98% females, 12.71% males) as shown in [Table 9].
Table 9: Statistical analysis for visual fields defects in tested eyes

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A sample data for patients were shown in [Figure 4], [Figure 5] and [Figure 6].
Figure 4: Male patient 16 years present with anemia and significant visual field changes that improved later after treatment of anemia.

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Figure 5: A female patient with visual field changes and colored photos of the cupping in both eyes. The visual field changes improved with treatment of anemia.

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Figure 6: A 9-year-male patient with anemia who shows visual field changes in the upper and lower visual fields on the left side. The visual field changes (upper and lower middle pictures) improved after correction of anemia. The right picture shows the retinal nerve fiber layer (RNFL) changes and large cupping.

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  Discussion Top


Pathologic cupping of the optic nerve is most commonly associated with glaucomatous optic neuropathy. The cause of optic nerve cupping in glaucoma has been studied histopathologically, suggesting that cup enlargement is the result of nerve fiber loss in conjunction with altered structural integrity of the lamina cribrosa. However, other types of optic neuropathies have been reported to cause cupping of the optic nerve, mimicking that found in glaucoma such as anterior ischemic optic neuropathy, posterior ischemic optic neuropathy, intracranial tumors, optic neuritis, dominant optic atrophy, methanol toxicity, shock optic neuropathy, and Leber hereditary optic neuropathy. Clinically, clues such as optic nerve head pallor can be useful in discerning glaucomatous from nonglaucomatous optic nerve cupping. However, the identification of optic nerve pallor is often variable and dependent upon clinical experience [14],[15],[16],[17].

In practice, the differentiation of glaucomatous from nonglaucomatous cupping can be difficult even for experienced observers. However, evaluation of parapapillary chorioretinal atrophy has been found to be useful in differentiating both types of optic neuropathy, neuroretinal rim pallor to be 94% specific for nonglaucomatous atrophy while focal or diffuse obliteration of the neuroretinal rim was 87% specific for glaucoma. These two signs were said to be the most useful in making the distinction between glaucomatous and nonglaucomatous atrophy. Thinning of the rim was, however, more common in glaucomatous atrophy and laminar dots were said to be present in both types of excavation. Also, glaucomatous optic neuropathy is not symptomatic until late in the disease course such that it is usually identified incidentally or by screening [17],[18].

In our study the difference of cupping between both eyes was less than 0.2 in most of the cases and this is a very important point in discrimination between glaucomatous and nonglaucomatous cupping as in glaucoma the difference between both is found in higher frequency in early cases. Pallor of the neural rim was a constant finding in our study.

The ISNT rule which states that for normal optic discs the neuroretinal rim width is greatest in the order inferior - superior - nasal - temporal, is violated with greater. Frequency in the pediatric population with large optic disc cups of nonglaucomatous origin, compared with the pediatric population with normal optic discs which decreased the predictability of the rule in this age group [19].

In our study we tried to apply the ISNT rule but our results matched that in the literature that this rule does not apply in children as well as in nonglaucomatous cupping; however, a larger study with the use of two groups of patients may be needed.

Anemia is a recognized risk factor in optic nerve head ischemia and this was recognized in anterior ischemic optic neuropathy and optic nerve head ischemia could be the cause of nonglaucomatous cupping [20],[21].

In our study the recognized cause of anemia was parasitic infestation in many cases and this may raise the question about requesting stools analysis with hemoglobin analysis in every case with disc pallor and cupping in Egypt. The cooperation with the pediatrician is a must in these cases.

The visual field defects were not significant in cases with visual field testing; however, in a number of cases there were significant field defects and in one case it was obviously reversed after correction of anemia. This raises the warning that anemia may in small percent cause functional damage of the optic nerve if it is left uncorrected for longer duration.

There were no similar studies found in the literature which connect directly anemia in children with cupping and possible functional damage; however, it was evident that this was possible and must not be ruled out but we admit that a larger study is needed in Egypt [22],[23],[24],[25].

The high incidence of parasitic infestation may be connected to the rural nature of both Fayoum and Beni Suef Governorates and this may alert the responsible authorities about the possible treatment campaigns for those disorders similar to that of bilharziasis.


  Conclusion Top


We found that functional optic nerve damage is a possibility in children with anemia and cupping even with normal intraocular pressure and that there is very high incidence of parasitic infestation in those children and young adolescents that warns for state intervention to deal with this problem. A larger scanning by the ministry of health may be needed to verify these results.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Jacobson LK, Dutton GN. Periventricular leukomalacia: an important cause of visual and ocular motility dysfunction in children. Surv Ophthalmol 2000; 45 :1-13.  Back to cited text no. 2
    
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McLoone E, O'Keefe M, Donoghue V, McLoone S, Horgan N, Lanigan B. RetCam image analysis of optic disc morphology in premature infants and its relation to ischaemic brain injury. Br J Ophthalmol 2006; 90 :465-471.  Back to cited text no. 3
    
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Marks PW, Glader B. Approach to anemia in the adult and child. Chapter 34. In: Hoffman F, Benz EJ, Shattil SJ, editors. Hematology: basic principles and practice. 5th ed. Philadelpha, PA: Churchill Livingstone; 2009. 439-446.   Back to cited text no. 12
    
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Brugnara C, Oski FA, Nathan DG. Diagnostic approach to the anemic patient. Chapter 10. In: Orkin SH, Nathan DG, Ginsburg D, et al., editors. Nathan and Oski's hematology of infancy and childhood. 7th ed. Philadelphia, PA: Saunders, an imprint of Elsevier Inc; 2009. 455-466.   Back to cited text no. 13
    
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PK Gupta, S Asrani, SF Freedman, M El-Dairi, MT Bhatti. Differentiating glaucomatous from non-glaucomatous optic nerve cupping by optical coherence tomography. Open Neurol J 2011; 5 :1-7.  Back to cited text no. 16
    
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Abdel-Malak DSM, Dabbous OAE, Saif MYS, Saif ATS. Ocular manifestations in children with Β thalassemia major and visual toxicity of iron chelating agents. J Am Sci 2012; 8 :633-638.  Back to cited text no. 23
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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Abstract
Introduction
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