Clinical Picture

• Cola/tea-colored urine = gross hematuria from glomerular bleeding
• Reduced urine output = oliguria from falling GFR
• Healed skin lesions on legs = resolved impetigo (streptococcal pyoderma) - the latent period between skin infection and nephritis is 2-6 weeks, consistent with "healed" lesions
• BP 150/100 = hypertension from salt/water retention

Approach

• Onset and duration of decreased urine output, color of urine, amount/frequency
• History of sore throat (latency 1-3 weeks) or skin infection/impetigo (latency 2-6 weeks) preceding this illness
• Facial/periorbital or pedal edema, headache, visual disturbance, seizures (features of hypertensive encephalopathy)
• Breathlessness/orthopnea (pulmonary edema from fluid overload)
• Prior similar episodes, family history of renal disease (Alport, IgA nephropathy)

• Vitals: BP (already elevated - 150/100 is stage 2 hypertension for age, needs urgent attention), pulse, respiratory rate, JVP
• Volume status: periorbital/pedal/sacral edema, ascites
• Fundus examination for hypertensive retinopathy/papilledema
• Signs of pulmonary edema (basal crepitations)
• Confirm healed skin lesions - typical of resolved impetigo/pyoderma
• CNS: sensorium, signs of encephalopathy (hypertension-related)

• Urinalysis: RBCs/RBC casts, dysmorphic RBCs, proteinuria (usually sub-nephrotic), pyuria
• Renal function: blood urea, serum creatinine (assess degree of AKI)
• Serum electrolytes, especially potassium - critical given oliguria, risk of hyperkalemia
• Complement levels: low C3 with normal C4 in >90% during first week - key supportive finding
• ASO titer / anti-DNase B / streptozyme panel - positive in 80-95%; throat/skin swab culture (often negative by the time nephritis appears)
• CBC, ESR
• ECG - screen for hyperkalemia changes and LVH
• Renal ultrasound - kidney size (usually normal/mildly enlarged), rule out obstruction
• Chest X-ray if pulmonary edema suspected
• Harrisons's Principles of Internal Medicine, 22nd Ed., p. 2460
• Tintinalli's Emergency Medicine, p. 925

• Anuria or rapidly progressive renal failure (suspect RPGN/crescentic GN)
• Nephrotic-range proteinuria or persistent nephrotic syndrome
• Absence of latent period or no evidence of preceding streptococcal infection
• Normal or rising C3 (instead of falling), or C3 remaining low beyond 8 weeks
• Age outside the typical 2-14 year range, or features suggesting SLE/vasculitis/HSP/IgA nephropathy

• Admit - given hypertension (150/100) and oliguria, this child needs inpatient monitoring for complications (hypertensive encephalopathy, pulmonary edema, hyperkalemia, severe AKI)
• Fluid and sodium restriction; monitor daily weight, strict input-output charting
• Loop diuretic (e.g., furosemide) for volume overload and to help control BP
• Antihypertensives if BP remains high despite diuresis - calcium channel blockers (nifedipine/amlodipine) preferred in acute setting; avoid starting ACE inhibitors/ARBs while oliguric/hyperkalemic (can add later if hypertension persists)
• If hypertensive emergency (encephalopathy, seizures) - IV agents (labetalol, sodium nitroprusside, or hydralazine)
• Restrict dietary potassium while oliguric; treat hyperkalemia if it develops
• Antibiotics (penicillin/amoxicillin) to eradicate residual streptococcal infection - treat patient and household contacts, though this does not alter the course of nephritis
• Dialysis if severe/refractory hyperkalemia, symptomatic uremia, refractory fluid overload, or severe oliguric AKI
• Bed rest during the acute phase

• Serial BP, urine output, weight, renal function, and serum C3 (should normalize by 6-8 weeks - failure to do so warrants biopsy and reconsideration of diagnosis, e.g., membranoproliferative GN or lupus nephritis)
• Microscopic hematuria may persist for months to 1-2 years but resolves; overall prognosis in children is excellent (>95% complete recovery)

Key Differentials to Exclude

• IgA nephropathy (usually synpharyngitic, no latent period)
• Henoch-Schonlein purpura nephritis (look for purpuric rash, arthralgia, abdominal pain)
• Membranoproliferative glomerulonephritis (persistently low C3 beyond 8 weeks)
• Rapidly progressive (crescentic) glomerulonephritis
• Hemolytic uremic syndrome (if diarrhea, anemia, thrombocytopenia present)

Small Incision Cataract Surgery (SICS)

• Kanski's Clinical Ophthalmology, 10th Ed.

Why SICS was developed

Advantages of SICS

• Small self-sealing incision - usually no sutures required
• Less induced astigmatism than conventional ECCE
• Faster than phacoemulsification, cheaper (no phaco machine needed)
• Effective even for hard, brunescent/mature cataracts where phaco is difficult
• Quicker visual rehabilitation than standard ECCE
• Lower risk of posterior capsule rupture compared to phaco in inexperienced hands, and shorter learning curve

Steps of the Procedure

1. Anesthesia: Peribulbar or retrobulbar block (topical/sub-Tenon's also used).
2. Conjunctival flap: Fornix-based conjunctival peritomy, exposing the sclera.
3. Scleral/sclerocorneal tunnel construction:
   • A frown-shaped or straight scleral groove is made 1.5-2 mm behind the limbus.
   • A partial-thickness scleral tunnel is dissected forward into clear cornea using a crescent knife, creating a self-sealing valve architecture.
   • A keratome enters the anterior chamber to complete the internal opening; tunnel width is usually 6.5-7.5 mm (sized to the nucleus).
4. Side-port incision: Made for instrument access and anterior chamber maintenance.
5. Capsulotomy/capsulorhexis: Continuous curvilinear capsulorhexis (CCC) or can-opener capsulotomy is performed; trypan blue staining is used in white/mature cataracts to improve visibility of the anterior capsule (as noted in Kanski's Fig. 10.11B).
6. Hydrodissection and hydrodelineation: Fluid is injected beneath the capsule to separate the nucleus from the cortex and facilitate free rotation of the nucleus.
7. Nucleus delivery - several techniques exist:
   • Irrigating vectis technique - nucleus is prolapsed into the anterior chamber and delivered using an irrigating vectis
   • Phacosandwich technique - nucleus sandwiched between vectis and a Sinskey hook/spatula
   • Phacofracture technique - nucleus is fractured into two halves within the anterior chamber and delivered piecemeal
   • Viscoexpression - viscoelastic is used to express the nucleus out through the tunnel
8. Cortical aspiration: Residual cortical matter is removed by irrigation-aspiration (Simcoe cannula).
9. IOL implantation: A rigid PMMA posterior chamber IOL is implanted in the capsular bag (most commonly used given the incision size).
10. Wound closure: The self-sealing tunnel usually needs no sutures; the conjunctival flap is repositioned/cauterized.
11. Postoperative: Topical antibiotic-steroid combination, cycloplegic if needed, and staged follow-up.

Complications

• Intraoperative: posterior capsule rupture, vitreous loss, nucleus drop, iridodialysis, Descemet's membrane detachment, hyphema
• Postoperative: striate keratopathy, corneal edema, uveitis, raised IOP, cystoid macular edema, wound leak (rare given self-sealing design), endophthalmitis (rare)

Comparison with Phacoemulsification