Far Eastern University INSTITUTE OF NURSING

EVIDENCE BASED NURSING

Is There A Need For Ophthalmological Examinations After A First Seizure In Paediatric Patients? Submitted by: Bryan Paolo C. Visarra BSN407 Group 28 Submitted to: Maam Rebecca Guarino Clinical Instructor

I.

CLINICAL QUESTION

Aside from blood tests and EEG, is there a need for ophthalmological examinations after a first seizure in pediatric patients? II. CITATION

Bernhard, M. K., Glser, A., Ulrich, K., & Merkenschlager, A. (2010). Is there a need for ophthalmological examinations after a first seizure in paediatric patients?. European Journal Of Pediatrics, 169(1), 31-33. doi:10.1007/s00431-0090966-4

III.

STUDY CHARACTERISTICS

Patient Included All children aged 1 month to 18 years who were admitted to the children's university hospital of Leipzig with the clinical diagnosis of a first convulsive or nonconvulsive afebrile seizure between 1999 and August 2005 were evaluated. The observation time after the seizure was at least 36 months. Interventions Compared There were no interventions compared in the conduct of the study. As the researchers aim only to define the general value of the ophthalmic examinations in pediatric patients with seizures, no control group was made. The type of research utilized was a quantitative non-experimental descriptive study. The researchers conducted a study to analyze the value of a complete ophthalmological examination, as well as its benefits. This research study aims to answer if ophthalmic examinations have significance and supportive outcomes when it is included in the tests for pediatric patients with seizures. According to the guidelines of the International Liga against Epilepsy and the German Association of Neurology, the only routinely used diagnostic tools after a first seizure areapart from blood testselectroencephalography and cerebral imaging. To date, there is no study available that analyses the clinical benefit of eye examinations in seizure diagnosis. Sorensen et al. found no value of ophthalmological examinations in children with febrile seizures. The researchers of the study conducted an observational study to evaluate ophthalmologic findings in children who required hospital admission after a first unprovoked seizure.

IV.

METHODOLOGY USED

SOURCE OF DATA All children aged 1 month to 18 years who were admitted to the children's university hospital of Leipzig with the clinical diagnosis of a first convulsive or nonconvulsive afebrile seizure between 1999 and August 2005 were evaluated. The observation time after the seizure was at least 36 months. INCLUSION CRITERIA: All children who had obtained routinely a complete ophthalmological examination within 72 hours after the seizure were included in the study. EXCLUSION CRITERIA Eye examinations more than 72 hours after the seizure are at higher risk to overlook retinal haemorrhages and were therefore excluded. Children who presented a seizure as a symptom of an underlying disease already known at admission, e.g. meningitis or cerebral tumour, or who had a febrile seizure were also excluded. METHOD OF DATA COLLECTION The ophthalmological examination was performed by an expert ophthalmologist and consisted of the determination of visus, subjective and objective refraction (depending on age and cooperation of the child), binocular status, slit-lamp examination of the anterior segment and ophthalmoscopy in mydriasis. Seizure classification was done by a neuropaediatrician. V. RESULTS OF THE STUDY

A total of 725 children were admitted to our hospital because of a first seizure between 1999 and August 2005. Three hundred eighty-four patients experienced febrile seizures and were therefore excluded. Three hundred ten of the remaining 341 patients underwent a complete ophthalmological examination within 72 h after the seizure and were finally included in the study. Their age ranged from 1 month to 18 years with a median of 3.2 years. The seizure classification of the 310 children was as follows: 230 (76.1%) tonic clonic afebrile seizures (including 16 patients with status epilepticus), 24 (7.9%) simple focal seizures, 20 (6.6%) tonic seizures, 18 (6.0%) complex-partial seizures and 18 (6.0%) absences. Focal seizures and absences seem to be underrepresented as a greater part of these patients did not meet the criteria for immediate admission and evaluation after the event of the first seizure. In 207 out of 310 patients, no ophthalmological pathologies were seen. Eighty-three

children (26.8%) had refraction anomalies or strabism. Optic atrophy was seen in 12 children (4.0%) among whom nine were associated with infantile cerebral palsy. Three children had congenital eye muscle paresis; three others had malformations (microphthalmia, coloboma) that have already been known prior to admission in two patients. Two patients presented with a partial visual defect and a retinal hemorrhage, respectively: Patient 1 A 16-year-old girl experienced a first generalized tonicclonic seizure that lasted about 3 min and was selflimiting. The girl did not report any complaints or problems prior to this event. An EEG was performed 5 h after the seizure and was normal. The following day, an ophthalmological examination was conducted. Funduscopy and slitlamp examination were normal and visual acuity for the right eye was 1.0 and for the left eye 0.7. As the confrontating visual field test suspected a partial visual field defect, an automated perimetry exam was done. A homonymous quadrantanopia of the right upper quadrant was confirmed. MR imaging of the brain revealed a 5 cm measuring tumour of the occipital lobe (glioglioma, grade 1). A second secondary seizure occurred 4 days after admission. Treatment with oxcarbamazepine was started, and the patient remained seizure free. Post-operative ophthalmological controls revealed a slightly reduced butpersisting quandrantanopia. Patient 2 An 11-year-old girl was reported to have had a first unprovoked generalised tonicclonic seizure while she was swinging on a playground. Due to the seizure, she fell down approximately 1.5 m and had several minor bruises on the arms, legs and the face. Neurological examination at admission was normal. Vision was undisturbed, and cerebral MR imaging was normal. The eye examination showed a bilateral peripheral retinal haemorrhage without involvement of the macula. Control ophthalmoscopy performed 4 days later was normal again as was an automated perimetry examination. The patient developed another generalized seizure 6 weeks later and a third seizure 3 months later. There was no other retinal haemorrhage detectable. Under treatment with valproate, no more seizures occurred. VI. AUTHORS CONCLUSIONS/ RECOMMENDATIONS

Although many pediatric departments perform eye exams as a routine diagnosis in children after a first seizure, there is a lack of studies analyzing the benefit of these examinations. It is argued that the ophthalmological examination helps to distinguish differential diagnosis that could cause seizures

as a concomitant symptom. Therefore, diagnostic aims are the exclusion of a prominent papilla and papilloedema, a retinal haemorrhage, an optic nerve hypoplasia and other evidence for an underlying disease (brain tumours, metabolic disorders, genetic diseases and infections. Thirty-three percent of the patients had a noticeable ophthalmological finding. However, most of these patients had refraction anomalies or strabism as statistically expected in an average hospitalised children population. Only two findings were associated with the seizure. A 16-year-old girl had an occipital glioglioma that has caused both the partial visual defect (that was unnoticed by the patient until then) and the seizure. The other girl developed a peripheral retinal haemorrhage that was probably caused when she fell from the playground equipment due to the seizure. The study does not support any benefit of a routine ophthalmological examination in the diagnostic management after a first seizure. An ophthalmological screening might be still useful in selected patients with prolonged seizures or post-ictal lateralizing signs. Although we did not find any retinal haemorrhages in the infant patient group, literature suggests also including funduscopy in all infants up to 12 months with a first apparently unprovoked seizure. VII. APPLICABILITY

The research study presented was able to illiterate a response to the clinical question asked. It was very applicable and directed to the problem presented. It showed the value of significance of the ophthalmic examinations performed on pediatric patients with seizures. VIII. REVIEWERS CONCLUSION/ COMMENTARY a. Safety: Safety of the study is high since the tests were done by duly licensed practitioners who specialized in that certain area. Furthermore, the researchers opted to review the results of the tests done and no control group was made. b. Competence The study is very competent as it is the first one to have a study in this particular field. As mentioned, no other studies were done to explain or define the necessity of ophthalmic examinations in children with seizures, so their study would bring a lot of help in the medical practice.

c. Acceptability The study is highly acceptable because as the researchers explained above, this is like the first time they have pursued this type of field. Future studies may be able to benefit from the results of this study, which then can help improve scientific knowledge to medical practitioners. d. Effectiveness The study would be very effective to medical practitioners who specialize in the field of neurology and pediatrics. New management in implementing tests in children with seizures will be improved. e. Appropriateness The appropriateness is not questioned since the study have explained that some hospital protocol really include in their routine check-up the ophthalmic exams for children with seizures. f. Efficiency The study should be very efficient because there was a focus made on patients experiencing seizures. As this is a specialty in the medical practice, it should elicit many benefits in the field of neurology and pediatrics. g. Accessibility Here in our country, this may not be a point of interest, especially few hospitals here are globally-known and competent. Many hospitals here lack equipment in diagnosing diseases, and if there are, it is costly. But in spite of these, the study will be very essential because it may help the patients to cut down the expense in laboratory examinations as the results show that eye tests are not so essential in pediatric seizures. This will lessen the financial burden to the families and less workload on the hospital setting.