Because of issues regarding their methodology and generalizability, we disagree with Smith and colleagues’1 conclusion that our recommendation2 that children with Horner syndrome of unknown etiology undergo urine screening and imaging be reappraised. Seven of their patients were labeled as idiopathic, and 7 congenital cases were attributed to birth trauma, but a thorough investigation was either incomplete or not done in these cases, making it possible that another underlying process was missed. In the authors' Table 2, 16% of pediatric patients in published series harbored an underlying neuroblastoma or mass lesion, while they found none.1 Smith and colleagues' population may be different or smaller than our area's and the others listed, so their results may not be generalizable. Because theirs is a population study,1 it is possible that a case of Horner syndrome was missed among the 14 patients with neuroblastoma seen during this 40-year period.3 The authors recognized these limitations of their study. Referral bias played no part in our results, as these children had no evaluation or underlying diagnosis prior to our evaluation. These days, once the family of a child with newly diagnosed Horner syndrome of unknown etiology has been told an underlying neoplasm is possible, most parents will not opt for a conservative approach. Unfortunately, urine metabolite screening for neuroblastoma4 and the physical examination are relatively insensitive in this setting, and not all responsible mass lesions are neuroblastomas. Therefore, we feel strongly that all such patients undergo magnetic resonance imaging of the brain, neck, and upper chest. Back to top Article Information Correspondence: Dr Liu, Ophthalmology Division, Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Wood Bldg, First Floor, Philadelphia, PA 19104 (firstname.lastname@example.org). Financial Disclosure: None reported. References 1. Smith SJ, Diehl N, Leavitt JA, Mohney BG. Incidence of pediatric Horner syndrome and the risk of neuroblastoma: a population-based study. Arch Ophthalmol. 2010;128(3):324-32920212203PubMedGoogle ScholarCrossref 2. Mahoney NR, Liu GT, Menacker SJ, Wilson MC, Hogarty MD, Maris JM. Pediatric Horner syndrome: etiologies and roles of imaging and urine studies to detect neuroblastoma and other responsible mass lesions. Am J Ophthalmol. 2006;142(4):651-65917011859PubMedGoogle ScholarCrossref 3. Smith SJ, Diehl NN, Smith BD, Mohney BG. Incidence, ocular manifestations, and survival in children with neuroblastoma: a population-based study. Am J Ophthalmol. 2010;149(4):677-682, e220149339PubMedGoogle ScholarCrossref 4. Smith SJ, Diehl NN, Smith BD, Mohney BG. Urine catecholamine levels as diagnostic markers for neuroblastoma in a defined population: implications for ophthalmic practice. Eye (Lond). 2010;24(12):1792-179620865029PubMedGoogle ScholarCrossref
Archives of Ophthalmology – American Medical Association
Published: Aug 1, 2011
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