Persistent pupillary membrane associated with aniridia

Persistent anterior tunica vasculosa lentis in multisystemic smooth muscle dysfunction syndrome: A case report

RATIONALE

Multisystemic smooth muscle dysfunction syndrome (MSMDS) is a genetic disease that affects multiple organs. The report here concerns a patient with MSMDS, who is known so far as the youngest among all the reported patients. In addition to the typical manifestations, we observed previously unreported ocular abnormalities, including persistent anterior tunica vasculosa lentis (TVL) and early-onset retinal arteriolar tortuosity, by the fluorescein angiography (FA).

PATIENT CONCERNS

The patient was admitted to the neonatal intensive care unit immediately after birth for a diagnosis of urinary system dysplasia during fetal life. After a thorough examination, the patient was found with patent ductus arteriosus, pulmonary hypertension, cerebrovascular disease, hypotonic bladder, intestinal malrotation, and congenital mydriasis. The FA of the eyes undertaken in her 6-week demonstrated perfused vasculature in the persistent anterior TVL and prominent retinal arteriolar tortuosity. The whole exome sequencing revealed a de novo heterozygous ACTA2 gene missense mutation p.R179H.

DIAGNOSES

The patient was diagnosed with MSMDS.

INTERVENTIONS

Follow-up observation.

OUTCOMES

At the 3-month follow-up, no change of the ocular disease was observed.

LESSONS

The persistent anterior TVL in this case implies that ACTA2 p.R179H mutation affects not only the smooth muscle cells but also the pericytes, and further affects the TVL regression. The prominent retinal arteriolar tortuosity in this 6-week-old infant indicates that the retinal arteriolar tortuosity can present early in MSMDS.

Remnants of the anterior tunica vasculosa lentis and long anterior lens zonules

PURPOSE

To investigate presence of remnants of the tunica vasculosa lentis, a possible indication of anterior segment dysgenesis, in subjects with the long anterior zonule (LAZ) trait.

METHODS

Retroillumination photographs of the pupil region had been collected in earlier study of the LAZ trait in African Americans. Secondary image analysis was performed to assess the frequency of intact persistent pupillary membrane iris strands (PPMIS).

RESULTS

The analysis included 148 subjects, comprised of 74 LAZ subjects (median age=70 y; range, 50 to 91 y; 64 females) and 74 controls (68 y; 50 to 83 y; 64 females). While controlling for age and sex, analysis showed that LAZ subjects were 3.1 times more likely than controls (odds ratio=3.1; 95% confidence interval, 1.4-6.7; P=0.004) to exhibit PPMIS in at least one of their eyes.

CONCLUSION

The LAZ trait, which is being studied as a potential risk factor for glaucoma, was associated with presence of PPMIS in our study population.

Outcome of hyperplastic persistent pupillary membrane

PURPOSE

To evaluate the long-term visual outcome of eyes with hyperplastic persistent pupillary membrane.

PATIENTS AND METHODS

We adopted a retrospective approach involving 39 eyes of 24 Korean patients diagnosed as having hyperplastic persistent pupillary membrane, excluding patients who could not be observed beyond 3 years of age and eyes that had any other ocular anomalies that affect vision. Final best-corrected visual acuity and refractive status were compared according to treatment type and laterality. Mean visual acuity was transformed to the logarithm of the minimum angle of resolution (logMAR).

RESULTS

The mean final best-corrected visual acuity was 0.32 (standard deviation, +/- 0.41). Five eyes had a best-corrected visual acuity less than 20/70 at the last follow-up. Four eyes were unilateral (deprivation amblyopia) and one eye was bilateral (anisometropic amblyopia). There were no significant differences in final best-corrected visual acuity according to treatment type or laterality. Significant anisometropia was found in 11 of the 24 patients. The mean absolute value of anisometropia was greater in the surgical treatment group than in the medical treatment and observation groups (P = .048).

CONCLUSIONS

The visual prognoses for individuals with hyperplastic persistent pupillary membrane can be relatively good if the condition is appropriately managed. Unilaterality and poor initial visual acuity are indicators of a poor visual outcome. Surgery is effective when the opaque membrane retards visual maturation. Close follow-up with evaluation of visual acuity and refractive status is mandatory because this condition can lead to deprivation amblyopia and anisometropic amblyopia.

Management of atypical epicapsular star

An 18-year-old woman had brown pigment deposits on the central anterior capsule of the lens associated with poor visual acuity and significant anisometropia. Surgical removal of the deposits, phacoemulsification, and intraocular lens implantation resulted in visual improvement. Epicapsular stars are formed by the confluence of multiple fine pigmentary deposits. Although they cause amblyopia, this does not appear to be dense. Surgical removal of these central deposits may improve vision, even if the patient presents as an adult.

Persistent pupillary membranes

Extensive persistent pupillary membranes which occlude the pupil may occur in isolation or in association with other ocular anomalies. Amblyopia may result if the membranes are extensive. We favor nonsurgical intervention except if unusual circumstances are present as demonstrated in one of our two cases.

Selected eye defects of special importance in pediatrics

This article reviews six defects of special importance in the care of children: aniridia, ectopia lentis, cataracts, glaucoma, colobomata, and optic nerve hypoplasia. In addition to causing potentially serious impairment of vision, these ocular disorders may be associated with significant systemic disease and genetic abnormalities.

An alternative hypothesis for iris maldevelopment (aniridia)

Two principal hypotheses for the pathogenesis of hypoplastic iris development ("aniridia") have been proposed: 1) the ectodermal theory, positing incomplete elaboration of the cup, resulting in an absence of framework for further development; and 2) the "mesodermal" theory, wherein inadequate migration or proliferation of mesenchymal elements is proposed. Two eyes of two patients with persistent "anterior leaf" iris strand remnants which traverse the pupillary space are reported. They are differentiated from the previously described persistent tunica vasculosa lentis. The presence of a persistent pupillary iris strand suggests portions of the iris may have formed and inappropriately regressed. Recent work in cell biology highlights the importance of remodeling and cell death in revealing ultimate phenotypic expression. This alternative hypothesis suggests that aniridia may be explained in part on the basis of excessive remodeling and cell death.

Unusual variant of familial aniridia

A woman and her two children had apparent dominantly inherited ocular abnormalities including aniridia, ptosis, nystagmus, corneal pannus, persistent pupillary membrane, lenticular opacities, and foveal hypoplasia. A broad spectrum of iris abnormalities was observed: the daughter had aniridia with persistent pupillary membrane strands traversing the anterior lens capsule; the iris of the mother and son had a velvety surface with no detailed crypts, but did have some persistent pupillary membrane tags extending from the collarette. All three family members had moderately severe bilateral ptosis, pendular nystagmus, corneal pannus, and visual acuity of 20/200. Several systemic abnormalities also were noted, including obesity and mental retardation in the two children, and alopecia, cardiac abnormalities, and frequent spontaneous abortion in the mother. Family history indicated that the children's maternal grandmother also had similar ocular findings. We believe that this constellation of findings represents a rare, apparently dominant, variant of aniridia.

Hyperplastic persistent pupillary membrane--surgical management

Two infants, aged three days and six weeks, respectively, presented with dense extensive persistent pupillary membranes as sporadic isolated findings. A clear central pupillary aperture was unable to be achieved with mydriatic agents. The patients were treated by surgical removal of the membranes at age five days and six months respectively. Surgery was without complication and visual development has been normal. We suggest that early intervention in the first weeks or months of life is necessary to prevent the development of amblyopia. If mydriasis is unsuccessful, surgery is recommended followed by optical correction and occlusion therapy as necessary.