Hereditary lymphedema and distichiasis

Ocular lymphatics: state-of-the-art review

Research involving the lymphatic system has experienced an exponential progression during the past decade largely because of advancement of modern technology and discovery of several lymphatic specific molecules. The eye provides an excellent site for lymphatic studies due to its accessible location and the unique feature of tissue heterogeneity--while some tissues are lymphatic-rich, others are lymphatic-free or -inducible. This review provides an update on our current understanding of ocular lymphatics and possible associated eye diseases.

Conjunctival edema and distichiasis in association with congenital lymphedema of the lower legs

An 8-year-old boy with mild congenital lymphedema of both legs was noticed to have a conjunctival lesion of the right eye since birth. Topical corticosteroid eyedrops for slight irritation did not alter the appearance of the lesion. On ocular examination, diffuse conjunctival edema in the inferotemporal and inferonasal quadrants and mild injection of the right eye was noted. There was no edema on the left eye. Three extra rows of eyelashes (congenital distichiasis) were found bilaterally on upper and lower eyelids. Related systemic anomalies included mild aortic coarctation, left ventricular hypertrophy, and simian crease on each palm. Conjunctival edema and distichiasis are important ophthalmic features of the congenital lymphedema distichiasis syndrome.

Mapping of primary congenital lymphedema to the 5q35.3 region

Primary lymphedema is a chronic tissue swelling, most frequently of the lower limbs, resulting from deficient lymphatic drainage. The variability of the affected phenotype, incomplete penetrance, lack of large families, and possible genetic heterogeneity have hampered the identification of causative genes until now. We carried out a genomewide search, using a four-generation North American family with dominantly inherited primary congenital lymphedema (PCL), otherwise known as "Milroy disease," or "hereditary lymphedema type I" (MIM 153100). Linkage to markers from the 5q35.3 region in this and four additional, British families was established. A minimum of 79 directly scorable haplotypes (37 affected) in five families conspicuously segregated with the most telomeric region of 5q35.3, thus suggesting a major locus for PCL in this vicinity. No recombination was observed with D5S408 (Z = 10.03) and D5S2006 (Z = 8.46) with a combined multipoint score of 16.55. While D5S2073 and WIAF-2213 defined the upper centromeric boundary, no recombinants were obtained for the last telomeric marker of D5S2006. Four unaffected subjects were identified as gene carriers and provided an estimated penetrance ratio of.84 for this condition. A few of the positionally mapped genes in the 5q35 region that may potentially be involved in the etiology of this condition are CANX, FGFR4, HK3, and hnRPH1.

Distichiasis-lymphedema syndrome: tetralogy of Fallot, chylothorax, and neonatal death

We describe a newborn female with a severe presentation of distichiasis-lymphedema syndrome (McKusick 15340). She was initially evaluated because of a phenotype suggestive of Ullrich-Turner or Noonan syndrome (low posterior hairline, cupped ears, severe pterygium colli, heart murmur, and pectus excavatum). Distichiasis was noted at age 6 weeks. Subsequent to surgery for tetralogy of Fallot, patent ductus arteriosus, and branch pulmonic stenosis, she developed persistent chylothorax and sepsis. She died at 3 months. Family history indicated segregation of distichiasis-lymphedema syndrome. She was the sixth member in her family to have this disorder and was the most severely affected.

The swollen leg and primary lymphoedema

Children who present with unilateral or bilateral swelling of the legs are often suspected of having a deep venous thrombosis. The incidence of deep venous thrombosis in children is low and lymphoedema may be a more appropriate diagnosis. Lymphoedema can be primary or secondary. In childhood, primary lymphoedema is more common and may be seen associated with other congenital abnormalities, such as cardiac anomalies or gonadal dysgenesis. Primary hypoplastic lymphoedema is the most often encountered type. It is more common in girls, especially around puberty, and is typically painless. Atypical presentations produce diagnostic confusion and may require imaging to confirm the presence, extent, and precise anatomical nature of the lymphatic dysplasia. This article describes four patients presenting with limb pain and reviews the clinical features and imaging options in children with suspected lymphoedema.

The swollen and droopy eyelid. Signs of systemic disease

Swollen and droopy eyelids are obvious ocular findings, unlike many ocular conditions that require the use of special equipment to observe. Neither of these findings is a specific diagnosis but rather each is evidence of localized disease and often is a sign of underlying systemic disorder. Therefore, it is important for the clinician evaluating the child with a swollen or droopy lid to have a working knowledge of these diagnostic possibilities. In this article the author presents the various causes of the swollen and droopy eyelid, focus on the most relevant clinical characteristics, and emphasize systemic associations.

Distichiasis: management with cryotherapy to the posterior lamella

Distichiasis is the congenital condition of partial or complete accessory rows of eyelashes which exit from the posterior lid margin at or near the meibomian gland orifices. A series of 24 patients with distichiasis is presented with clinical features and results of treatment. The treatment modes of epilation, lid margin cryotherapy, or eyelid splitting cryotherapy to the posterior lamella are evaluated. The latter was found to effectively relieve symptoms without retreatment in 87% patients. Keratinisation of the lid margin was found at long term follow up in a few cases and retinoic acid has been used successfully in the treatment of this. Two previously unreported associations of distichiasis are Pierre Robin syndrome and idiopathic eyelid oedema. A family history of distichiasis was found in 50% patients, and of distichiasis with lymphoedema in 30%.