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Letters to the Editor

6 August 2011 Dear Editor, A DELAYED PRESENTATION OF CONGENITAL GLAUCOMA A 15-month-old boy presented to his GP after his parents noticed unusual looking wobbly eyes for 2 months. He was referred to a paediatric neurologist who diagnosed congenital idiopathic nystagmus commenting that he had big beautiful eyes. His parents were convinced that he wasnt quite seeing things as he should and he was referred to our Pediatric Ophthalmology Department, at 19 months of age. On examination he was found to be visually alert and was able to locate his toys normally. However, he was photophobic and very difcult to examine. He had large blue eyes and ne nystagmus. Examination under general anaesthesia found; high myopia (-10.00), signicantly raised intraocular pressures (IOPs) and large corneal diameters (15 mm) in both eyes. Bilateral corneal stromal oedema and Haabs striae were present. Both optic discs showed advanced glaucomatous changes. He was started on ocular antihypertensive drops and right and left trabeculotomies (glaucoma drainage surgery) were performed within 1 month of each other (Fig. 1) and repeated 1 year later. By the age of 5, his poor vision was becoming more obvious due to the increasing complexity of tasks demanded in relation to his age. Snellen visual acuity was 20/200 in both eyes. His parents reported continued difculties at school and he was registered as severely visually impaired. He has had active input for low vision aids from the teachers of the visually impaired and mobility ofcers. Glaucoma is much less common in children than adults.1 Our case illustrates that the rarity of the condition can lead to a misdiagnosis, which can lead to devastating consequences. Raised IOP in infants causes stretching of tissues in the eye, leading to the variety of unique clinical ndings in infantile glaucoma. Frequently, the rst and most striking sign of infantile glaucoma is the childs eye looking larger than it should (megalocornea). However, when both eyes are affected, as in our case, parents and even non-ophthalmologic health professionals may put this down to the baby simply having big, beautiful eyes. It is estimated that the disease is bilateral in 65% to 80%.1 Raised IOP can lead to symptoms of watery eye, conjunctival injection and photophobia which can be mistaken for the more common conjunctivitis and nasolacrimal duct obstruction. The management of paediatric glaucoma is primarily surgical. However the holistic care of these patients involves a multidisciplinary approach involving the vision assessment team, including paediatricians, optometrists, occupational therapists, psychologists and ophthalmologists.2,3

Fig. 1 Colour photograph of the patient after left glaucoma surgery. Note the clear appearance of the patients left eye compared to his (unoperated) right. This is due to the reduction in intraocular pressure that has resulted from the surgery leading to a clearer cornea on the left.

1 Kipp MA. Childhood glaucoma. Pediatr. Clin. North Am. 2003; 50: 89104. 2 Hill AE, McKendrick O, Poole JJ, Pugh RE, Rosenbloom L, Turnock R. The Liverpool Visual Assessment Team: 10 years experience. Child Care Health Dev. 1986; 12: 3751. 3 Hirst C, Poole JJ, Snelling GS. Liverpool Visual Assessment Team 19851989: 5 years on. Child Care Health Dev. 1993; 19: 18595.

11 July 2011 Dear Editor, THE TEDDY BEAR HOSPITAL IN AUSTRALIA Watching a sick and frightened childs rst interaction with a medical student recently, it was hard to tell who was more terried. Childrens fear of doctors, and medical students fear of children, is often a fear of the unknown. The Teddy Bear Hospital (TBH) in Australia is a project initiated by medical students that addresses these fears through a child-friendly hospital role-play conducted in schools and in the community. Children act as parents and bring the patient (their teddy bears) to be examined and treated by a teddy bear doctor (medical students). The aims of the TBH include: 1 To reduce childrens anxiety associated with the unfamiliarity of medical environments and treatments, through experiencing simulated age-appropriate medical encounters in a fun and safe environment; 2 To provide medical students with early experience of the rewards and challenges of interacting with children in a pseudomedical context, which they may otherwise not receive until clinical placements in later years of their studies; and 3 To facilitate medical students involvement with their local community and experience with organising teams and projects. TBH is an ofcial project of the International Federation of Medical Students Associations (IFMSA), with TBHs run by

Mr Henri Sueke1 Mr William Newman2 1 Royal Liverpool University Hospital Department of Ophthalmology 2 Royal Liverpool Childrens Hospital Department of Paediatric Ophthalmology Liverpool UK

Journal of Paediatrics and Child Health 48 (2012) 540544 2012 The Authors Journal of Paediatrics and Child Health 2012 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

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