A Modified Bicanalicular Crawford Placement Method for Congenital Nasolacrimal Duct Obstruction: Reducing Need for Operative Room Removal

PURPOSE

This study introduces a method for Crawford bicanalicular stent placement for congenital nasolacrimal duct obstruction by looping the ends to themselves which are tied together with dissolvable sutures to ease in-office removal.

METHODS

This is a single institution, retrospective study that evaluates outcomes of patients aged 5 years and under who underwent bicanalicular stenting for congenital nasolacrimal duct obstruction by a single surgeon (G.S.E.) between 2004 and 2020. Only primary surgeries were included in the analysis. Stenting could be accompanied by balloon dilatation and/or turbinate infracture. Age, sex, follow-up time, complications, type of intervention, extrusion, recurrence, and operative room removal were recorded.

RESULTS

This study included 56 eyes from 54 patients with a mean age of 19.0 ± 9.5 months (range, 8-50 months). There was a 30.3% extrusion rate, a 5.4% rate of recurrence of disease, and a 3.6% rate of operative room removal. The average follow-up time was 25.1 ± 39.8 months (range, 1-132 months). For patients with or without extrusion, there were no significant differences between age, sex, laterality, type of intervention, follow-up time, or rate of recurrence. Each eye that had recurrence (3 total) or needed operative room removal (2 total) underwent only bicanalicular stenting without accompanying procedures, although the difference in rates between procedures was also not statistically significant.

CONCLUSIONS

This method had a low recurrence and operative room removal rate, with similar extrusion and complication rates to other bicanalicular stent and intubation methods for the treatment of congenital nasolacrimal duct obstruction.

Ocular Complications in PHACE Syndrome: A True Association or a Coincidence?

OBJECTIVE

To characterize the risk for ocular complications in patients with PHACE syndrome.

STUDY DESIGN

This study included consecutive patients with PHACE syndrome who were seen at Lurie Children's Hospital of Chicago from January 2000 through May 2017. A complete ophthalmic examination was performed in all patients, with extra attention for findings typically associated with PHACE syndrome.

RESULTS

Thirty patients (67% female, median age of onset 0.08 months) were included: 38 (93%) demonstrated a segmental infantile hemangioma distribution. Twenty-one (70%) cases had a periocular involvement, and 47% had an infantile hemangioma with a deep component. Among 21 patients with periocular distribution, 9 had ocular complications secondary to the periocular location (mainly ptosis, nasolacrimal duct obstruction, and refractive errors), and one had an ocular complication specifically associated with PHACE syndrome (Horner syndrome). None of the patients without periocular distribution had an ocular complication.

CONCLUSIONS

In patients with PHACE syndrome who have a periocular infantile hemangioma, a complete eye examination is recommended. Although specific ocular anomalies related to PHACE syndrome are rare, serious ocular complications secondary to the location of the hemangioma may be present. Eye examination in patients with PHACE syndrome without a periocular infantile hemangioma distribution is likely of low yield.

Optic Nerve Hypoplasia and Crouzon Syndrome

Crouzon syndrome is the most common cause of syndromic craniosynostosis. The authors present a previously unreported association between Crouzon syndrome and optic nerve hypoplasia. A male infant was transferred to the center for treatment of respiratory distress. He was diagnosed as having dysmorphic features, a membranous choanal stenossi bilaterally, and bilateral optic nerve hypoplasia. Genetic testing confirmed a molecular diagnosis of Crouzon syndrome. He had a complicated course in relation to choanal stenosis management, and was discharged home at 10 weeks of age. Although uncommon in Crouzon syndrome, the association with optic nerve hypoplasia changes the initial work-up and the management of parental expectations. [J Pediatr Ophthalmol Strabismus. 2018;55:e45-e48.].

Visual function in infants with antenatal Zika virus exposure

PURPOSE

To report the findings of a cross-sectional study of visual function in infants with confirmed or suspected antenatal Zika virus (ZIKV) infection seen at a single referral center in Rio de Janeiro.

METHODS

Infants were examined following the ZIKV outbreak period at Instituto Fernandes Figueira/FIOCRUZ. Visual function was considered abnormal if an infant could not fix and follow a standardized high-contrast target (10 cm) by 3-6 months of age. Visual function and associations with structural eye abnormalities, central nervous system (CNS) abnormalities, microcephaly, and nystagmus were assessed. Sensitivity and specificity of screening criteria for structural eye abnormalities was assessed.

RESULTS

A total of 173 infants met inclusion criteria. Abnormal visual function was found in 52 infants (30.0%) and was significantly associated with eye abnormalities (40/52; OR = 44.2; 95% CI, 16.6-117.6), CNS abnormalities (50/52; OR = 64.0; 95% CI, 14.7-277.6), microcephaly (44/52; OR = 31.5; 95% CI, 12.7-77.8), and nystagmus (26/52; OR = 120.0; 95% CI, 15.6-924.5). Using microcephaly as screening criteria for the detection of eye abnormalities provided a sensitivity of 88.9% (95% CI, 76.0-96.3) and specificity of 82.8% (95% CI, 75.1-88.9). Using both abnormal visual function and microcephaly increased sensitivity to 100% (95% CI, 92.1-100.0) and decreased specificity to 80.5% (95% CI, 72.5-86.9).

CONCLUSIONS

Infants with suspected antenatal ZIKV infection and reduced visual function should be referred to an ophthalmologist. Visual function assessments are helpful in screening for antenatal ZIKV exposure in resource-limited settings and can identify infants who may benefit from visual habilitation.

Hospital based surveillance of congenital rubella syndrome cases in the pre-vaccine era in Amhara Regional State, Ethiopia: A base line information for the country

Background

Rubella virus infection in early pregnancy lead to serious multi-organ birth defects known as congenital rubella syndrome (CRS). The incidence of CRS varies in different populations and the highest burden is found in developing countries in which rubella vaccination is not included in their national immunization programs. In Ethiopia, there is scarcity of data about congenital rubella syndrome. Therefore, the aim of this study was to determine the burden of CRS-related birth defects and its incidence in the pre-vaccine era in Amhara Regional State, Ethiopia.

Materials and methods

A cross sectional study was conducted in Dessie, Felege-Hiwot and University of Gondar Referral Hospitals, from December 2015 to August 2017. After getting informed assent from each parent/guardian, blood was collected from infants < 1 year of age for laboratory determination of anti-rubella virus antibodies. Their socio-demographic data and clinical information compatible with congenital rubella syndrome were collected using WHO guideline.

Results

During the study period, a total of 50 infants suspected for congenital rubella syndrome were included in the study. All infants suspected for CRS were tested against rubella specific IgM and IgG [for infants ≥ 6 months of age] antibodies using ELISA method. Of these, 9/50 (18%) and 4/14 (28.6%) of them were laboratory confirmed and potential CRS cases, respectively. In the present study, the most common laboratory confirmed defect was ocular manifestations 6 (66.7%) followed by heart related problems 5 (55.6%). In the present study, most of the laboratory confirmed cases (66.7%) were reported among 1–5 months of age infants. In addition, 5 (55.6%) of the infants with laboratory confirmed CRS cases were male and 6 (66.7%) of them were from urban settings. In this study, the incidence of CRS was 0.4 per 1000 live births.

Conclusion

In this study, nearly one fifth of the infants had laboratory confirmed congenital rubella syndrome and most of them had multiple rubella associated congenital defects at a time. Most of these congenital anomalies were reported among infants ≥ 1 month of age. Based on our result, the incidence of the CRS was line with the global incidence of the CRS in the pre-vaccine era. Therefore, establishing strong rubella/CRS surveillance system as well as introducing the rubella containing vaccine in the national immunization program might be important to reduce the burden of rubella and CRS in the country.

Optic Nerve Hypoplasia in Fetal Alcohol Syndrome: An Update

Optic nerve hypoplasia was detected in up to one half of a group of Swedish children born to alcoholic mothers. Using an experimental model of pre- and postnatal alcohol exposure in rats fed a liquid diet, reduced optic nerve size from gestational day 21 (294 ± 26×102 μm2 vs 502 ± 16×102 μm2; n=6; p≤0.001) to later in development was observed as a result of the daily mean blood alcohol levels achieved in dams and their offspring. Altered glial cells and degenerating and atrophic optic axons, myelin sheaths and ganglion cells were frequent in the alcohol-exposed optic nerves.

Smaller optic nerve (1,918 ± 61×102 μm2 vs 2.195 ± 40×102 μm2; n=4; p≤0.001), reduced gaglion cell and axonal densities, and ultrastructural damage to the macroglial cells and myelin sheaths were also detected in the treated group. All these changes remained in the retina and optic nerve of the oldest rats, as a consequence of the long-lasting effects of prenatal alcohol exposure. In summary, alcohol as a major teratogenic agent may induce dysmorphogenesis and irremediable damage to the retina and optic nerve, which frequently manifests itself as hypoplastic optic nerve.

Eye Tracking as a Marker of Hyperphagia in Prader-Willi Syndrome

This study examined the feasibility of eye tracking measures as markers of hyperphagia in 42 children and adults with Prader-Willi syndrome (PWS). Gaze data collected during free visual exploration of complex displays revealed that food images may not have an overall superior salience in PWS. However, increased attention to food in the context of other high-interest items was associated with higher scores on caregiver reports of hyperphagia. The study also provided preliminary evidence of test-retest reliability of eye tracking measures, suggesting that gaze characteristics may be a promising objective marker of food-related interests in PWS.

Ocular Manifestations in Fetal Alcohol Syndrome

PURPOSE

To report the prevalence of ocular abnormalities in a group of Portuguese children with a complete fetal alcohol syndrome (FAS).

METHODS

Complete ophthalmologic examination in a sample of consecutive children with FAS. Ocular fundus photography was carried out on the cooperative FAS children and on 25 reference children. Ocular fundus anomalies were recorded by the observation of ocular fundus photography. The ratio between the distance of the center of the disc to the fovea and optic disc diameter (DM/DD) was determined. Small optic disc was defined as a DM/DD ratio above mean control group +1 SD.

RESULTS

The authors studied 32 children with FAS (mean age: 9 +/- 5 years; 72% boys). The mean corrected visual acuity (VA) was 0.8 +/- 0.2. Refraction ranged from -23.00 to +6.50 spherical equivalent. Ocular findings included short horizontal palpebral fissure (81% of children), strabismus (28% of children), epicanthus (27% of eyes), blepharoptosis (16% of eyes), telecanthus (13% of children), nystagmus (1 child), and cataract (1 eye). Ocular fundus photography analysis showed retinal vessel tortuosity in 30% of the eyes and optic disc hypoplasia in 25%. The mean DM/DD for the control and FAS groups was 2.72 +/- 0.20 and 2.89 +/- 0.25 (p=0.001). Forty percent of the eyes of FAS children had small optic discs.

CONCLUSIONS

The most common ocular findings were anomalies of retinal fundus and minor changes in the outer region of the eyes. The authors noted better VA and less severity of disease than others, which might be due to a different selection of patients, different pattern of alcohol consumption, or genetic differences.

Zika virus infection in children: epidemiology and clinical manifestations

PURPOSE

The purpose of this review is to comprehensively review Congenital Zika Syndrome in regard to their epidemiology and clinical manifestations.

METHODS

This subject review of congenital Zika syndrome was composed after conducting a thorough review of the available literature on this topic using PubMed and other primary sources.

RESULTS

The first epidemic of Zika virus infection in Brazil was followed by an unexpected sharp increase in the incidence of infants born with microcephaly and the description of a new disease, the congenital Zika syndrome. This review focuses on the epidemiological and clinical aspects of Zika infection in children. We conducted a brief historical account of the virus description in 1947, the rare cases of Zika infection occurring up to 2007, and the first epidemics in the Pacific between 2007 and 2014. We also discussed the isolation of the virus in Brazil in 2015 and its spread in the Americas, the microcephaly outbreak in Brazil and its association with Zika virus, and the current epidemiological panorama. We address the known clinical spectrum of Zika virus infection in the pediatric population, including manifestations of acute infection and congenital Zika syndrome, with emphasis on cranial, ophthalmic, and orthopedic abnormalities.

CONCLUSION

While much has been learned about congenital Zika syndrome, the full spectrum of this infection is not yet known. This review is based on current, limited data about Zika vírus infection. As more information becomes available, we will have a more accurate picture of this new disease.

[Research progresses in the pathogenesis, diagnosis and treatment of infantile hemangioma with PHACE syndrome]

Infant hemangioma, the most common benign tumor in children, is characterized by rapid proliferation, followed by slower spontaneous involution. However, some patients with facial segmental hemangioma are associated with PHACE syndrome. PHACE syndrome is characterized by vascular nerve and vascular cutaneous lesions of multiple systemic systems, often resulting in structural and functional impairments. Recent studies have demonstrated that the possible pathogeneses of PHACE syndrome mainly include hypoxia, abnormality of mesodermal vascular endothelial cells, genetic abnormality, and abnormality of interstitial mesenchymal stem cells. The current medications for hemangioma with PHACE syndrome include beta blockers, glucocorticoids, and mTOR inhibitors. This review article mainly describes the pathogenesis, diagnoses and treatments of PHACE syndrome, in order to provide directions for diagnosis and treatment of this disorder.

Effects of maternal hypoglycemia on fetal eye and skeleton development in rats

The relationship between insulin-induced maternal hypoglycemia and teratogenicity was investigated in detail. We injected 4 different forms of insulin (insulin human, aspart, glargine, and detemir) subcutaneously at 1 or 2 dose levels to Sprague-Dawley rats from Days 6 to 11 of pregnancy, measured blood glucose levels, and conducted fetal examination. In the insulin human and aspart (low dose) groups, while severe hypoglycemia (approximately 50mg/dL) was seen, it lasted only 6h and no fetal anomalies were observed. Fetal axial skeleton anomalies were observed in the aspart (high dose) group, which exhibited intermediate-duration of severe hypoglycemia (9h). Eye and axial skeleton anomalies were observed in the glargine and detemir groups, which exhibited continuous severe hypoglycemia (≥9h). These results revealed that insulin-induced maternal hypoglycemia caused fetal eye and skeleton anomalies and the causative key factors were duration of maternal severe hypoglycemia.

The Origin of Subretinal Fluid in Optic Disc Pit Maculopathy

A surgical approach for the drainage of fluid leaking over the pit in optic disc pit maculopathy is described, and a theory of the origin of fluid is discussed. In two cases, complete fluid-air exchange was performed. The air infusion pressure was decreased to 5 mm Hg, and the collected fluid was drained by raising the infusion pressure to 25 mm Hg. The fluid inside the back-flush needle was routed via a microcentrifuge tube. Biochemical analyses of the fluids were conducted in order to find their origin. Results of the first and second case were comparable to normal cerebrospinal fluid (CSF) levels (chloride: 125 mmol/L, 122 mmol/L; sodium: 146 mmol/L, 147 mmol/L; potassium: 2.8 mmol/L, 3.0 mmol/L; protein: 29 mg/dL, 18.4 mg/ dL; and glucose: 60 mg/dL, 57 mg/dL, respectively). These findings suggest that the origin of subretinal fluid found in the submacular space in optic disc pit maculopathy is CSF.

Deiodinase knockdown affects zebrafish eye development at the level of gene expression, morphology and function

Retinal development in vertebrates relies extensively on thyroid hormones. Their local availability is tightly controlled by several regulators, including deiodinases (Ds). Here we used morpholino technology to explore the roles of Ds during eye development in zebrafish. Transcriptome analysis at 3 days post fertilization (dpf) revealed a pronounced effect of knockdown of both T4-activating Ds (D1D2MO) or knockdown of T3-inactivating D3 (D3bMO) on phototransduction and retinoid recycling. This was accompanied by morphological defects (studied from 1 to 7 dpf) including reduced eye size, disturbed retinal lamination and strong reduction in rods and all four cone types. Defects were more prominent and persistent in D3-deficient fish. Finally, D3-deficient zebrafish larvae had disrupted visual function at 4 dpf and were less sensitive to a light stimulus at 5 dpf. These data demonstrate the importance of TH-activating and -inactivating Ds for correct zebrafish eye development, and point to D3b as a central player.

[Posterior vitrectomy with gas endotamponade and retinal laser therapy in treatment of patients with macular complications of the optic disc pit]

PURPOSE

Retrospective evaluation of functional and anatomical treatment outcomes in patients with macular cornplications of optic disc pit.

MATERIAL AND METHODS

9 patients (eyes) underwent central posterior vitrectomy in conjunction with posterior vitreous detachment, retinal laser therapy to the optic disc pit area and endotamponade with expansile gas. It was followed by the patient's forced positioning (recommended for a few days especially at night), which ended the treatment protocol.

RESULTS

Improved anatomical relationships, accompanied by functional improvement were achieved in each reported case. The resolution of macular lesions was slow, lasting even for several months. Too long delay in performing the surgery (over 5 months since the onset of visual impairment) was associated with the development of retinal complications, mainly macular hole formation, most likely caused by the long-term ischemia.

CONCLUSIONS

The central posterior vitrectomy combined with posterior vitreous detachment, laser therapy, andd expansile gas tamponade offers good outcomes in patients with retinal complications of optic disc pit. Surgery performed shortly after the onset of visual dysfunction gives the best functional outcomes. Restoration of normal anatomical relationships is a long-term process. In some cases, though, these abnormalities may not resolve completely.

Range of ocular deformities in calves due to hypovitaminosis A

Hypovitaminosis A responsible for ocular deformities in suckler calves A review of type D clostridial enterotoxaemia in cattle Nitrate/nitrite poisoning in kale fed lambs Louping ill in sheep in mid-winter Rhodococcus equi abscessation identified at meat inspection of fattening pigs These are among matters discussed in the disease surveillance report for December 2013 from SAC Consulting: Veterinary Services (SAC C VS).

Arl13b in primary cilia regulates the migration and placement of interneurons in the developing cerebral cortex

Coordinated migration and placement of interneurons and projection neurons lead to functional connectivity in the cerebral cortex; defective neuronal migration and the resultant connectivity changes underlie the cognitive defects in a spectrum of neurological disorders. Here we show that primary cilia play a guiding role in the migration and placement of postmitotic interneurons in the developing cerebral cortex and that this process requires the ciliary protein, Arl13b. Through live imaging of interneuronal cilia, we show that migrating interneurons display highly dynamic primary cilia and we correlate cilia dynamics with the interneuron's migratory state. We demonstrate that the guidance cue receptors essential for interneuronal migration localize to interneuronal primary cilia, but their concentration and dynamics are altered in the absence of Arl13b. Expression of Arl13b variants known to cause Joubert syndrome induce defective interneuronal migration, suggesting that defects in cilia-dependent interneuron migration may in part underlie the neurological defects in Joubert syndrome patients.

Axenfeld-Rieger syndrome: new perspectives

Axenfeld-Rieger syndrome is a genetic disease affecting multiple organ systems. In the eye, this condition manifests with varying degrees of anterior segment dysgenesis and carries a high risk of glaucoma. Other associated systemic issues include cardiovascular outflow tract malformations, craniofacial abnormalities and pituitary abnormalities, which can result in severe endocrinological sequelae. Recent advances in molecular genetics have identified two major genes, PITX2 and FOXC1, demonstrating a wide spectrum of mutations, which aids in the molecular diagnosis of the disease, although evidence exists to implicate other loci in this condition. The management of individuals affected by Axenfeld-Rieger syndrome requires a multidisciplinary approach and would include dedicated surveillance and management of glaucoma, sensorineural hearing loss, and cardiac, endocrinological, craniofacial and orthopaedic abnormalities.

The eye in metabolic diseases: clues to diagnosis

Ophthalmologic manifestations occur in various inborn errors of metabolism (IEM), including small molecule disorders and organelle disorders. In a minority of diseases the occurrence of eye abnormalities could be attributed to direct toxic mechanisms of abnormal metabolic products or accumulation of normal metabolites by errors of synthetic pathways or by deficient energy metabolism. The age of onset of ocular abnormalities in IEM is variable, but onset often begins from birth to childhood. The major IEM associated with eye abnormalities include errors of lipid metabolism, carbohydrate metabolism, protein metabolism, and metal metabolism. IEM disorders with ocular motor manifestations include lipid storage diseases, neurotransmitter disorders and respiratory chain disorders. The purpose of this article is to describe ocular phenotypes associated with IEM, focusing on those diseases in which the ocular involvement is seen relatively early in the course of the disease. As therapeutic approaches become available for certain groups of IEM, the need for early diagnosis is increasingly important.

Canadian palpebral fissure length growth charts reflect a good fit for two school and FASD clinic-based U.S. populations

BACKGROUND

Short palpebral fissure lengths (PFL) are one of three facial features that define the unique facial phenotype of fetal alcohol syndrome (FAS). Published PFL growth charts vary greatly in both rate and magnitude of growth, placing their accuracy and validity in question. New PFL growth charts were recently published to reflect a racial/ethnic cross section of Canadian girls and boys 6-16 years of age. PFLs were measured from digital facial photographs using the FAS Facial Photographic Analysis Software.

OBJECTIVES

Assess the goodness of fit of two U.S. populations (healthy children and children with prenatal alcohol exposure) when plotted on the Canadian, Hall, and other published PFL charts.

METHODS

The PFLs of 106 healthy children and 822 children with prenatal alcohol exposure from Washington State were measured from digital facial photographs using the FAS Facial Photographic Analysis Software. Goodness of fit was assessed graphically and by computation of the mean PFL z-score.

RESULTS

Our predominantly Caucasian, healthy group of children scattered along the mean growth curve on the Canadian charts (mean PFL z-score +0.2), and fell 1.6 SDs below the mean on the Hall chart (mean PFL z-score -1.6). The mean PFL z-score for the children with FAS was 2.4 SDs below the mean on the Canadian charts and 3.9 SDs below the mean on the Hall chart. African Americans were not a good fit.

CONCLUSION

The Canadian PFL charts were a good fit for our predominantly Caucasian populations of healthy U.S. school-aged children. Children with FAS continued to present with PFLs 2 or more SDs below the mean when plotted on the Canadian PFL charts, supporting the FAS PFL diagnostic criteria used by the FASD 4-Digit Diagnostic Code. Use of PFL charts normed for African Americans is recommended. Updated PFL charts for 0-6 years of age are vital to prevent an artificial over-estimation of short PFLs in this age group.

Management of the delayed traumatic medial telecanthal deformity

BACKGROUND

The normal shape of the medial canthus is a very important aesthetic and functional determinant of the eyes. Disruption of the medial canthal ligament (through trauma or cancer resection, for example) can lead to medial telecanthal deformities, including shortened palpebra, obtuse-angled medial canthi with infraplacement, increased intercanthal distance, and an absent naso-orbital valley.

OBJECTIVES

The authors describe the successful application of microscrew and microplate fixation for medial canthoplasty.

METHODS

Thirty-eight patients (38 eyes) with unilateral medial telecanthal deformity were included in this series. For 31 patients, a self-tapping, titanium, low-profile head microscrew was propelled into the solid bone on the posterior aspect of the anterior lacrimal crest at the estimated attachment position of the medial canthal ligament, without a predrilled hole. For the remaining patients, four required placement of a microplate into which the wire could be affixed and three required autologous fascia lata graft injections into the soft tissue because of prior loss. Preoperative and postoperative measurements of each patient's lateral displacement distance were recorded and compared.

RESULTS

The patients corrected with microscrews only were divided into three preoperative groups. The patients in group 1 had a displacement distance between 4 mm and 6 mm (seven patients); group 2, between 7 mm and 9 mm (20 patients); and group 3, more than 9 mm (four patients). Postoperative lateral displacement measurements showed that the displacement distance was less than or equal to 2 mm in 27 patients, about 3 mm in one patient, and about 5 mm in the remaining three patients. Of the entire series, the majority (84.2%) of the patients were successfully corrected, with a difference in the canthal distance between their two eyes of less than or equal to 2 mm. For comparison, 60.5% of the patients had a preoperative difference of 7 to 9 mm.

CONCLUSIONS

Based on the outcomes obtained in this series of 38 patients, the authors' titanium microscrew and microplate approach is shown to be an excellent choice for correcting medial telecanthal deformity. The technique, when applied in appropriate cases, achieves optimal anatomic outcomes while minimizing facial incisions.

Ocular malformation in a newborn secondary to maternal hypovitaminosis A

We report a case of microphthalmia, inferior adherent leukoma, and optic nerve hypoplasia in an infant whose mother underwent biliopancreatic diversion surgery for obesity 7 years before his birth. The pregnancy was complicated by severe, maternal hypovitaminosis A despite oral supplementation. The infant was found to have undetectable serum vitamin A levels in the perinatal period. At 8 weeks of age, the infant underwent sector iridectomies. At 9 months of age, electroretinography suggested rod dysfunction. His visual performance is poor.

Ocular and orbital manifestations of the inherited bone marrow failure syndromes: Fanconi anemia and dyskeratosis congenita

PURPOSE

The inherited bone marrow failure syndromes (IBMFS) are a heterogeneous group of genetic disorders that share the inability of the bone marrow to produce an adequate number of blood cells. The 4 most frequent syndromes are Fanconi anemia (FA), dyskeratosis congenita (DC), Diamond-Blackfan anemia (DBA), and Shwachman-Diamond syndrome (SDS). All 4 syndromes have been associated with various physical abnormalities. As part of a genotype/phenotype/cancer susceptibility study, we determined the prevalence of ophthalmic manifestations in these 4 syndromes.

DESIGN

Cross-sectional study of a patient cohort.

PARTICIPANTS

Seventy-five patients with an IBMFS and 121 of their first-degree relatives were seen in the National Eye Institute, National Institutes of Health, from 2001 to 2007. The patient group included 22 with FA, 28 with DC, 19 with DBA, and 6 with SDS.

METHODS

Every participant underwent a complete ophthalmic evaluation and digital facial photography with an adhesive paper ruler on the patient's forehead for an internal measure of scale. Interpupillary distance (IPD), inner canthal distance (ICD), outer canthal distance (OCD), palpebral fissure length (PFL), and corneal diameter (CD) were measured. Thirteen of the 22 patients with FA underwent axial length (AL) measurements by A-scan ultrasonography.

MAIN OUTCOME MEASURES

Type and prevalence of ophthalmic manifestations.

RESULTS

Ninety-five percent of patients with FA had at least 1 abnormal parameter, and 25% of patients had at least 4 abnormal parameters. Eighty-two percent of patients had small palpebral fissures, 69% of patients had simple microphthalmia, 64% of patients had small OCD, 55% of patients had microcornea, 28% of patients had ptosis, and 6% of patients had epicanthal folds. In patients with DC, abnormalities of the lacrimal drainage system (29%) were the most prevalent findings, followed by retinal abnormalities (pigmentary changes, retinal neovascularization, retinal detachment, exudative retinopathy) in 21%, cicatricial entropion with trichiasis and blepharitis in 7% each, and sparse eyelashes and congenital cataract in 3.5% each. No significant ophthalmic abnormalities were seen in patients with DBA or SDS.

CONCLUSIONS

Syndrome-specific ocular findings are associated with FA and DC and may antedate diagnosis of the specific syndrome. Early recognition of these abnormalities is important for optimal management.

Normal distribution of palpebral fissure lengths in Canadian school age children

BACKGROUND

Fetal alcohol syndrome (FAS) includes the facial dysmorphic feature of short palpebral fissures (PFs) and short PFs are a key physical marker for identifying children with FAS and some other rarer conditions. There is concern that normative data on PFs now available may not reflect all racial/ethnic groups and might be inaccurate in general.

OBJECTIVES

To accomplish a large population based study that would accurately determine normative PF values across the full diversity of the Canadian school age population.

METHODS

A normative sample of school age children was identified in Vancouver, British Columbia and Winnipeg, Manitoba to reflect the diversity of racial and national groups in Canada. The sample included students in grades 2, 4, 6, 8, and 10 from 17 schools in Vancouver and 31 schools in Winnipeg. Schools were selected based on racial diversity obtained from data from the 2001 Statistics Canada census. 1064 students in Vancouver and 1033 students in Winnipeg were photographed in a standardized way. Photographs were analyzed using a computerized method.

RESULTS

Analysis demonstrated that PFs do grow with age and there is a slight but meaningful difference between boys and girls in each age group. It is possible to define Canadian standards without reference to racial or ethnic origin.

CONCLUSION

Mean results with norms and standard deviations are presented in figures for clinical use and are clinically smaller than those found in the most commonly used reference book.

Concordance of three methods for palpebral fissure length measurement in the assessment of fetal alcohol spectrum disorder

BACKGROUND

The assessment of individuals at risk of fetal alcohol spectrum disorders (FASD) includes the assessment of the craniofacial features that can result from prenatal alcohol exposure. The characteristic facial features of fetal alcohol syndrome (FAS) consist of short palpebral fissures, smooth or flattened philtrum, and thin vermilion border of the upper lip. There are various methods for measuring palpebral fissure lengths (PFLs) and it can be challenging for clinicians to obtain reproducibly accurate measurements. The development of the FAS Facial Photographic Analysis Software by the University of Washington FAS Diagnostic and Prevention Network (DPN) is one such means of improving the accuracy and reproducibility in these measurements.

OBJECTIVES

To assess concordance across three methods of PFL measurement: 1) a clear plastic handheld ruler, 2) blunt precision slide calipers, and 3) digital photometric photography (FAS Facial Photographic Analysis Software).

METHODS

The PFLs of 50 children (referred to the Clinic for Alcohol and Drug Exposed Children, CADEC) at Children's Hospital in Winnipeg and 50 adults from the University of Manitoba Medical Class of 2008 were measured once by a single clinician, using each of the three methods. The frequency and magnitude of discordance was tabulated. No method served as a gold-standard.

RESULTS

The PFLs ranged from 20 to 32 mm. The ruler and photometric measures were concordant in 42% of the subjects. When measures were discordant, half the ruler measures were larger and half were smaller. The caliper measure was concordant with the photometric and ruler measures on 18% and 24% of the subjects, respectively. When measures were discordant, the caliper measures were almost always larger than the photometric and ruler method (0.5 to 2.5 mm larger, 83% and 95% of the time, respectively). The presence of epicanthal folds did not appear to be a factor that contributed to discordance.

CONCLUSION

This study demonstrates the challenge in measuring the PFL, even when a single trained clinician is involved. Factors that can contribute to error include the subject's willingness to cooperate, ability to tolerate placement of the tool close enough to the eye to obtain an accurate measure, and precision of the tool. When controlling for the clinician performing the measurements and the quality of the photographs, the ruler and photometric measures were most concordant. The caliper measures tended to measure larger than the ruler and photometric measures.

Abnormal vessel morphology in boys born after intracytoplasmic sperm injection

AIM

Children born after intracytoplasmic sperm injection (ICSI) are at risk of preterm birth, low birth weight and perinatal morbidity which may predispose for diseases of the central nervous and vascular systems. Our aim was to investigate the ocular fundus morphology in children born after ICSI.

METHOD

Children born after ICSI (n = 82) had ocular fundus photographs taken at the age of 5 years and results were compared with those of a control group (n = 203). The ocular fundus morphology with the central retinal vessels was evaluated by digital image analysis.

RESULTS

Children born after ICSI (n = 57) had abnormal retinal vascularization as evidenced by a lower number of vascular branching points compared with the control group (n = 181) (p = 0.0002). A gender difference was found whereby the ICSI boys (n = 35) had significantly fewer retinal branching points (median 24, range 19-29.5) compared with the control boys (median 27.5, range 20-37) (p < 0.0001).

CONCLUSION

Our findings showed that ICSI boys have abnormal vessel morphology as demonstrated by a reduced number of central retinal branching points. The difference still remained after elimination of factors earlier shown to be associated with a low number of vascular branching points, i.e. low birth weight and preterm, suggesting other mechanisms responsible for the low number of vascular branching points.

[Secondary reconstruction of posttraumatic orbital deformities with canthus dislocation]

OBJECTIVE

To explore the secondary surgical reconstruction for orbital bone deformities accompanied with canthus dislocation after trauma.

METHODS

From June 1998 to July 2007, 37 patients with secondary orbital bone fracture deformity accompanied with medial or lateral canthal ligament dislocation posttraumatically were treated, among whom there were 22 males and 15 females, aged 13-46 years old (21 on average). There were 29 cases of traffic accident, 6 of boxing injury and 2 of beating injury by sticks. The latest reconstruction was performed on these 37 cases during 3 months to 8 years after injuries. There were 11 cases of orbital maxillary zygoma (OMZ) fracture, 15 of naso-orbito-ethmoid (NOE) fracture, 8 of OMZ and NOE fracture and 3 of frontal fracture. There were 31 patients who were reconstructed for the first time and 6 for the second time. Typical bicoronal and subciliary incisions and intra-oral approach were employed to expose all the fractured sites. According to the fractured position and the degree of deformity and dislocation, the orbito-zygomatic fracture was repositioned after osteotomy and rigid fixation, or the healed fragments were trimmed with a burr and the depressed fragments were filled with autogenous bone such as ilium, cranial outer table or Medpor in order to reconstruct orbital wall framework; the orbital walls were repaired to correct the enophthalmos with autogenous bone or Medpor after the herniated orbital contents were released. The medial canthal ligament was anchored superior-posteriorly to the lacrimal fossa with transnasal wires fixation or fixed with titanium miniplates and nails.

RESULTS

The 36 patients' incisions obtained healing by first intention after the operation, and 1 case failed because of wound infection from maxillary sinusitis. There were 24 patients who were cured successfully with facial appearance and function improved significantly. During the follow-up for 3-6 months, no complication was found such as dislocation of the implant, rejection and infection. Two patients still showed slight enophthalmos while 3 patients with canthus dislocation regained improved appearances but not satisfactory. At 6 months after operation, the CT scan conducted in 3 patients with autogenous bone and Medpor grafting showed all fractures were fixed rigidly.

CONCLUSION

Surgical reduction combined with bone grafting is a satisfactory method for the correction of secondary orbital bone deformity, and the repair of canthus dislocation and correction of enophthalmos should be considered at the same time. An ideal result could be achieved only through all-round consideration and comprehensive treatment.

SOX2 plays a critical role in the pituitary, forebrain, and eye during human embryonic development

CONTEXT

Heterozygous, de novo mutations in the transcription factor SOX2 are associated with bilateral anophthalmia or severe microphthalmia and hypopituitarism. Variable additional abnormalities include defects of the corpus callosum and hippocampus.

OBJECTIVE

We have ascertained a further three patients with severe eye defects and pituitary abnormalities who were screened for mutations in SOX2. To provide further evidence of a direct role for SOX2 in hypothalamo-pituitary development, we have studied the expression of the gene in human embryonic tissues.

RESULTS

All three patients harbored heterozygous SOX2 mutations: a deletion encompassing the entire gene, an intragenic deletion (c.70_89del), and a novel nonsense mutation (p.Q61X) within the DNA binding domain that results in impaired transactivation. We also show that human SOX2 can inhibit beta-catenin-driven reporter gene expression in vitro, whereas mutant SOX2 proteins are unable to repress efficiently this activity. Furthermore, we show that SOX2 is expressed throughout the human brain, including the developing hypothalamus, as well as Rathke's pouch, the developing anterior pituitary, and the eye.

CONCLUSIONS

Patients with SOX2 mutations often manifest the unusual phenotype of hypogonadotropic hypogonadism, with sparing of other pituitary hormones despite anterior pituitary hypoplasia. SOX2 expression patterns in human embryonic development support a direct involvement of the protein during development of tissues affected in these individuals. Given the critical role of Wnt-signaling in the development of most of these tissues, our data suggest that a failure to repress the Wnt-beta-catenin pathway could be one of the underlying pathogenic mechanisms associated with loss-of-function mutations in SOX2.

Spasmus Nutans-Like Nystagmus is Often Associated With Underlying Ocular, Intracranial, or Systemic Abnormalities

BACKGROUND

There is uncertainty as to whether spasmus nutans (SN) is an isolated idiopathic entity or whether there are underlying conditions that could cause or be associated with the nystagmus. We undertook this study to determine the frequency of ocular, intracranial, and systemic conditions in patients with nystagmus having characteristics of SN.

METHODS

We performed a chart review of 22 consecutive patients examined from 2000 through 2005 at the Dean McGee Eye Institute and Children' Hospital of Oklahoma with nystagmus consistent with SN. We collected information related to gender, age at presentation and age at final visit, visual acuity, refractive error, laterality of nystagmus, presence of head nodding and torticollis, pattern of strabismus, neuroimaging and electroretinography results, and other associated clinical findings.

RESULTS

Visual acuity was reduced in 75% of eyes at presentation and 58% of eyes at last visit. Eight patients had significant refractive error. Seven patients had strabismus. Two patients had chiasmal gliomas. Four patients had cone or rod/cone dystrophy. Only three patients had no associated ocular, intracranial, or systemic conditions.

CONCLUSIONS

A substantial proportion of patients presenting with SN-like nystagmus have important underlying ocular, intracranial, or systemic abnormalities that may require evaluation and management.

[Are screening examinations necessary in ruling out ocular malformations after reproduction treatment?]

BACKGROUND

In-vitro fertilization (IVF) is an established procedure frequently used for the treatment of infertility. However, the risk of twin or triplet pregnancies with premature birth and presumably also malformations is increased in IVF/ICSI pregnancies. Specific ophthalmological examinations so far were published by Anteby et al., who reported about an increased incidence of ocular malformations.

METHODS

In a retrospective study we analysed the medical histories of 30 newborn and premature children born after IVF/ICSI (almost exclusive twin pregnancies) which were cared for in the department of neonatology and intensive care from 2002 to 2004 and had an ophthalmological examination. A follow-up control was carried out in 2005 to check the developmental status of the visual organ.

RESULTS

Systemic malformations such as cardiovascular malformations of different severity and haemangioma were diagnosed in 6 children. Malformations of the visual organ were only found in one male infant (congenital glaucoma because of missing Schlemm canal). His twin sister had showed a cardiovascular malformation. The father of these children suffered from OAT (oligoasthenoteratozoospermia) syndrome with an inversion at chromosome 3. Retinopathia prämaturorum requiring treatment was not observed in any child.

CONCLUSIONS

Pregnancies following reproduction treatment are associated with a higher risk for malformations. Systematic ophthalmological examinations maybe considered in infants of IVF/ICSI pregnancies.

Choroid plexus papilloma expansion over 7 years in Aicardi syndrome

Choroid plexus papillomas have been reported in Aicardi syndrome. Management of these tumors is controversial because their natural progression in Aicardi syndrome has only been rarely documented. This report describes the progression of such a tumor over 7 years in a girl with Aicardi syndrome. A magnetic resonance imaging study at 2 months of age demonstrated a right ventricular mass that was consistent with a unilateral choroid plexus papilloma. The mass enlarged over the next 7 years without causing any clinically apparent symptoms, ventricular enlargement, hydrocephalus, or mass effect. The tumor was removed without change in behavior or development. The known cases of Aicardi syndrome associated with choroid plexus papillomas are reviewed. The heterogeneous nature of this lesion is highlighted.

Xeroderma pigmentosum: beyond skin cancer

Xeroderma pigmentosum (XP) is a rare, autosomal-recessive inherited disease that is found worldwide at a frequency of approximately 1:250,000. XP is caused by a deficiency in either nucleotide excision repair (NER) or postreplication repair (PRR), and is characterized by severe actinic changes leading to early onset of skin cancers, various ocular manifestations, and occasional neurological abnormalities. Diagnosis is usually made clinically and can be confirmed by unscheduled DNA synthesis. Early preventative care is the most important treatment modality. We present a review of the history, clinical manifestations, pathogenesis, diagnosis, and treatment of XP.

ATAXIN-1 Interacts with the Repressor Capicua in Its Native Complex to Cause SCA1 Neuropathology

Spinocerebellar ataxia type 1 (SCA1) is one of several neurodegenerative diseases caused by expansion of a polyglutamine tract in the disease protein, in this case, ATAXIN-1 (ATXN1). A key question in the field is whether neurotoxicity is mediated by aberrant, novel interactions with the expanded protein or whether its wild-type functions are augmented to a deleterious degree. We examined soluble protein complexes from mouse cerebellum and found that the majority of wild-type and expanded ATXN1 assembles into large stable complexes containing the transcriptional repressor Capicua. ATXN1 directly binds Capicua and modulates Capicua repressor activity in Drosophila and mammalian cells, and its loss decreases the steady-state level of Capicua. Interestingly, the S776A mutation, which abrogates the neurotoxicity of expanded ATXN1, substantially reduces the association of mutant ATXN1 with Capicua in vivo. These data provide insight into the function of ATXN1 and suggest that SCA1 neuropathology depends on native, not novel, protein interactions.

Confirmed congenital rubella syndrome--A case report

BACKGROUND

Congenital Rubella Syndrome (CRS) is defined clinically as an illness usually manifesting in infancy, resulting from rubella infection in utero with certain specific signs and symptoms. Confirmed CRS is a clinically consistent case which is laboratory confirmed. A report of a 3 month old male diagnosed with confirmed congenital rubella is here presented on account of its rarity and easy prevention with vaccination.

METHOD

The case notes of 3 month old male admitted with features consistent with CRS and managed for overwhelming septicaemia with heart failure and encephalitis and review of literature on the subject using manual library and Medline search.

RESULT

The infant's Rubella-specific immunoglobulin M (IgM) antibody demonstrated positive and the rubella antibody level was high at 11.6 IU/ml.

CONCLUSION

This is the first report of confirmed CRS in our centre. Though few cases are seen, the effects and defects on the child are severe and irreversible thus, vaccination with Measles-mump-rubella (MMR) vaccine is recommended as part of the National Programme on Immunization and for all females of child bearing age, who did not receive it in childhood.

Ocular manifestations of Fabry's disease: data from the Fabry Outcome Survey

BACKGROUND

Fabry's disease is an X-linked lysosomal storage disorder characterised by deficient activity of the enzyme alpha-galactosidase A.

AIM

To study eye abnormalities in patients with Fabry's disease in the Fabry Outcome Survey (FOS).

METHODS

This is the largest study of ocular manifestations in patients with Fabry's disease. In all, 173 of the 688 patients enrolled in FOS underwent a detailed ophthalmic examination, with a special focus on abnormalities of the cornea, lens, conjunctival and retinal vessels.

RESULTS

Cornea verticillata was reported in 76.9% of females and 73.1% of males; vessel tortuosity was observed in 21.9% of females and in 48.7% of males. Fabry cataract was recorded in 9.8% of females and in 23.1% of males. Cornea verticillata was therefore the most frequently reported ophthalmic abnormality in Fabry's disease in both hemizygotic males and heterozygotic females. Tortuous conjunctival and retinal vessels and Fabry cataract were more frequently found in males than in females. Vessel tortuosity was more frequently observed in patients with a higher severity score and greater impairment of renal and cardiac function, suggesting that it may be associated with a more severe disease. The youngest patient with ocular changes was 3 years old. The prevalence of tortuous vessels in males increased with age.

CONCLUSION

The presence of cornea verticillata is a useful aid in the diagnosis of Fabry's disease, as it is often present at the time of diagnosis. Vessel tortuosity may have some predictive value for systemic involvement.

The hypoplastic maxillary sinus and the orbital floor

PURPOSE OF REVIEW

Hypoplastic maxillary sinus is a relatively rare clinical problem that has a variable presentation. The purpose of this article is to review the recent literature with regard to evaluation and treatment.

RECENT FINDINGS

Most authors suggest that hypoplastic maxillary sinus results from the development of negative pressure resulting from an obstruction of maxillary sinus ventilation. Patients most frequently present with unilateral enophthalmos but some cases may be identified incidentally on imaging studies.

SUMMARY

Hypoplastic maxillary sinus is a rare clinical entity with variable presentation. Evaluation and management are tailored to each individual patient's degree of disease and symptoms.