Phenotypic spectrum of FGF10-related disorders: a systematic review

FGF10, as an FGFR2b-specific ligand, plays a crucial role during cell proliferation, multi-organ development, and tissue injury repair. The developmental importance of FGF10 has been emphasized by the identification of FGF10 abnormalities in human congenital disorders affecting different organs and systems. Single-nucleotide variants in FGF10 or FGF10-involving copy-number variant deletions have been reported in families with lacrimo-auriculo-dento-digital syndrome, aplasia of the lacrimal and salivary glands, or lethal lung developmental disorders. Abnormalities involving FGF10 have also been implicated in cleft lip and palate, myopia, or congenital heart disease. However, the exact developmental role of FGF10 and large phenotypic heterogeneity associated with FGF10 disruption remain incompletely understood. Here, we review human and animal studies and summarize the data on FGF10 mechanism of action, expression, multi-organ function, as well as its variants and their usefulness for clinicians and researchers.

Update on the Long-Term Outcomes Following the Management of Incomplete Punctal Canalization

PURPOSE

To study the clinical profile, associated lacrimal disorders, and long-term outcomes following a membranotomy, in patients with incomplete punctal canalization (IPC).

METHODS

Retrospective interventional study was performed of all the patients diagnosed with IPC during the study period over 5 years from January 2015 to December 2020. The diagnosis of IPC was made based on the earlier published guidelines. A combination of rapid and slow taper Nettleship's punctal dilators were used for an effective membranotomy, followed by further assessment of the lacrimal drainage passage. Appropriate interventions for associated lacrimal disorders were performed. Data collected on chart reviews include demographics, clinical presentation, laterality, type of IPC, associated lacrimal anomalies, management modalities, and long-term outcomes.

RESULTS

Ninety-eight puncta of 62 eyes of 46 patients with IPC were examined in the clinic. Incomplete punctal canalization-external membrane variant was seen in 62% (61/98) and internal membrane variant in 38% (37/98). Seventy-eight puncta (78/98, 79.5%) in 39 patients underwent membranotomy using Nettleship's punctal dilator. Associated lacrimal drainage pathway deformities were seen in 31% of patients (12/39). Three puncta had mini-monoka insertion for associated canalicular stenosis and canalicular obstruction. Five patients with associated congenital nasolacrimal duct obstruction underwent probing, of which 3 patients needed dacryocystorhinostomy for complex congenital nasolacrimal duct obstruction. Associated punctal agenesis was noted in 3 patients involving the other punctum of the same eye. Canalicular wall hypoplasia involving 3 walls of the canaliculus was seen in 1 patient. At a mean follow up of 28 months, the anatomical and functional outcomes were noted in 100% and 97.4%, respectively.

CONCLUSIONS

The long-term outcomes of membranotomy for IPC are excellent. Associated congenital lacrimal drainage anomalies are common with IPC.

Congenital canaliculops with punctal agenesis: is there a possibility to establish patency?

Canaliculops is a non-inflammatory dilatation of the canaliculus which can be secondary to trauma, punctal agenesis, herpetic infections or chronic drug use. This condition can affect either canaliculi and has shown female preponderance. Treatment described so far has consisted of cyst marsupialization with no literature on the post-operative epiphora in these cases. We describe two cases of canaliculops with punctal agenesis where we have tried to establish lacrimal patency.

Lacrimal drainage system anomalies in microphthalmia anophthalmia coloboma complex

Purpose: To study the prevalence and types of lacrimal drainage system (LDS) anomalies inchildren with congenital microphthalmia anophthalmia coloboma (MAC) complex.Methods: This is a prospective, consecutive, non-comparative, case series of LDS anomalies in 31 children presenting with MAC complex. Previously untreated children with MAC complex, enrolled for socket surface and volume expansion during the study period from January 2017 to April 2018 were included.Results: Thirty-one patients with MAC complex were evaluated for LDS anomalies. Incidence of LDS anomalies in children presenting with MAC complex was 68% (42 of 62 lacrimal systems evaluated). Mean age of the patients at the time of examination under anaesthesia was 27 ± 25 (median 15 months, range 3-108 months). Proximal bicanalicular block (BCB) was the commonest LDS anomaly, noted in 15 (48%) cases. In patients with unilateral ocular disease (n = 20), LDS was affected in 14 (70%) patients and in 9 (45%) patients ipsilateral side LDS was affected. In patients with bilateral ocular disease (n = 11), LDS was affected in 7 (64%) patients. Three patients with unilateral anophthalmos (25%) had an ipsilateral upper canalicular block and contralateral nasolacrimal duct obstruction, of which one patient had a single canalicular wall hypoplasia along with CNLDO. No patient had punctal anomalies.Conclusions: LDS anomalies are seen in nearly two-thirds (68%) of children with MAC complex. The lacrimal drainage system anomaly is not limited to the side of the MAC complex. Commonest LDS anomaly is proximal bicanalicular blocks while punctal anomalies are unusual.

[New type of sutured titanium wire combined with titanium nail internal fixation for correction of serious old medial canthus deformity]

Objective

To evaluate the effectiveness of a new type of sutured titanium wire combined with titanium nail internal fixation in correction of serious old medial canthus deformity.

Methods

Between March 2012 and June 2015, 18 patients with unilateral serious old medial canthus deformity were treated. There were 14 males and 4 females. The patient's age ranged from 23 to 62 years (mean, 42 years). The causes of deformity included accident injury in 10 cases, boxing injury in 4 cases, sharp device scratching in 3 cases, and animal bite in 1 case. All patients had been treated with suture or steel wire fixation in other hospitals to correct the medial canthus deformity and the deformity recurred. The interval between this operation and the first operation was 6 months to 2 years (mean, 16 months). The nasal root or medial canthus skin scar incision was used as the operative approach, and the adhesion of the medial canthus ligament to the adjacent tissues was fully loosened, then the tail end of the new type sutured titanium wire was fixed to the residual end of the medial canthus ligament. After passing through the scar tissue, the needle end of wire was fixed on the titanium nail in the bone wall of anterior lacrimal crest. The position and shape of the medial canthus angle was determined by adjusting the tightness of titanium wire.

Results

All incisions healed by first intention. All patients were followed up 6-12 months (mean, 10 months). In 16 cases, the medial canthus deformity was obviously corrected, and the appearances of bilateral eyes were basically symmetrical, without exposure of titanium nail and titanium wire. The medial canthus was retreated at 2 mm after 6 months in 2 cases, who were satisfied with their appearance without reoperation.

Conclusion

Application of the new type of suture titanium wire combined with titanium nail in the correction of serious old medial canthus deformity can achieve good effectiveness with the low recurrence rate.

Isolated Bilateral Lacrimal Gland Agenesis

A 5-year-old boy presented to the ophthalmology department complaining of absent tearing while crying. Slit-lamp examination showed decreased tear margin film with normal punctae. Orbit magnetic resonance imaging was done and showed bilateral absent lacrimal glands. This is the third case of isolated bilateral lacrimal gland agenesis in the literature. [J Pediatr Ophthalmol Strabismus. 2016;53:e35-e38.].

Bilateral congenital agenesis of lacrimal glands in a Tunisian family

BACKGROUND

Chronic corneal ulcers still pose etiological and therapeutic challenge. They are serious complications and often associated with poor functional prognosis.

AIM

We report the case of a patient with bilateral and chronic corneal ulcer revealing a rare   familial   form   of   bilateral   agenesis   of   the   lacrimal   gland.

CASES REPORT

A 39-year-old man was referred to our department for bilateralchronic and sterile ulcer. The tear break-up time was less than one second and the schirmer test detected no wetting in 5 minutes. He mentioned that lacrimation had been totally absent even when crying as was the case of his brother and his sister. Orbital echography showed absence of lacrimal gland. Orbital magnetic resonance imaging revealed absence of both lacrimal glands. Our patients were treated with permanent topical artificial tears. We performed also permanent occlusion of lower lachrymal poncti to preserve basic tear flow.

CONCLUSION

Congenital lacrimal gland agenesis is rare. We report, to ourknowledge, the first case of Tunisian family with three patients suffering from bilateral lacrimal gland agenesis and the first documented familiarly cases diagnosed in adulthood.

Unilateral Congenital Lacrimal Gland Agenesis With Contralateral Lacrimal Gland Hypoplasia

Congenital alacrima is a form of primary lacrimal deficiency characterized by aplasia or hypoplasia of the lacrimal gland. The puncta and salivary glands may also be aplastic. The case of a 5-year-old girl with congenital alacrima secondary to lacrimal gland agenesis and hypoplasia without punctal or salivary gland involvement and without other systemic comorbidities is reported.

[Radiographic observation of nasolacrimal canal in congenital nasolacrimal canal agenesis]

OBJECTIVE

To explore the radiographic characteristics of nasolacrimal canals in congenital nasolacrimal canal agenesis.

METHODS

Retrospective case series study. The images of Computed Tomography of 18 children with unilateral congenital nasolacrimal canal agenesis who were treated in Beijing Children's Hospital from January 2009 to June 2013 were studied. The common features of abnormal lacrimal canals were analyzed. The heights of bilateral lacrimal canals, anterioposterior and transverse diameters at the original level of lacrimal canal were measured. The traverse diameters, anteroposterior diameters, heights of bony nasolacrimal duct between affected side and normal side were compared using paired t tests.

RESULTS

The initial segment of abnormal nasolacrimal canal showed no obvious abnormalities, but it became significant stenosis or even atresia at the middle and terminal segments. The transverse (4.72 ± 0.79) mm and anterioposterior diameters (5.45 ± 1.07) mm of affected sides were larger than the values of normal sides (3.42 ± 0.67) mm, (4.35 ± 1.01) mm at the original level of nasolacrimal canal with statistically significance (t = 5.665, P = 0.000; t = 6.610, P = 0.000). However, the height of nasolacrimal canal of normal sides were larger than the affected sides (t = 5.931, P = 0.000).

CONCLUSIONS

Atresia position of congenital nasolacrimal canal agenesis always located in the terminal segment. High pressure in the nasolacrimal duct caused by bony obstruction leaded to the enlargement of nasolacrimal canal in affected side.

[The application of pedicle orbital fat flap for the correction of lacrimal groove and palpebromalar groove deformity in the middle-aged and old people]

OBJECTIVE

To explore the effective techniques for correction of lacrimal groove and palpebromalar groove deformity in the middle-aged and old people.

METHOD

The lacrimal groove and palpebromalar groove deformity was corrected by the techniques of transcutaneous orbital fat releasing and pedicle orbital fat flap filling. From 1996 to 2011, 426 patients, aged from 35 to 72 (average, 48), were treated by the techniques. Among them, 54 patients had underwent the surgical treatment before this operation. 362 patients were followed up for 3-24 months.

RESULTS

Completely correction was achieved in 283 patients, obvious improvement in 79 patients. The result was not satisfied in 2 patients with severe deformity who had surgical treatment before.

CONCLUSION

The lacrimal groove and palpebromalar groove deformity can be effectively corrected by transcutaneous orbital fat releasing and pedicle orbital fat flap in the middle-aged and old people.

[Congenital dacryocystocele: presentation and treatment]

OBJECTIVE

To report the presentation, complications, and treatment strategies for infants with congenital dacryocystocele.

METHOD

We performed a retrospective chart review of all patients presenting with dacryocystoceles to Beijing Children's Hospital between 2007 and 2011.

RESULTS

Thirty-one patients (33 eyes) were identified, presenting at a median age of 10 days of life. Twenty-four (72.72%) patients presented with cellulitis or dacryocystitis and required systemic antibiotics. Two (6.45%) patients presented with respiratory compromise. Resolution occurred with conservative treatment for 6 eyes, but 27 (81.82%) required surgical intervention. All 27 eyes received probing, and 20 (74.07%) were successful. The other 7 eyes required marsupialization of an intranasal cyst.

CONCLUSIONS

Although congenital dacryocystoceles may resolve with conservative measures, many become infected and require systemic antibiotic treatment, and most require surgical intervention. Referral in the early neonatal period can aid in timely intervention before complications such as infection occur.

Comparison of two techniques using hyaluronic acid to correct the tear trough deformity

BACKGROUND

Hyaluronic acid (HA) can be used to correct volume loss associated with periorbital aging.

OBJECTIVE

To report and compare the efficacy and safety of HA used to treat tear trough deformities with two different injection techniques.

MATERIALS AND METHODS

This is a retrospective, single-center study of 81 patients comparing the two injection techniques used for the treatment of tear trough deformities from 2003 to 2011. Hyaluronic acid was administered either in a single depot in the nasojugal groove and massaged into position or in multiple small aliquots along the inferior orbital rim and massaged into position. Patient satisfaction and the incidence of adverse reactions were evaluated.

RESULTS

Of the 194 patients treated during the study period, 81 (42%) were successfully contacted. The overall patient satisfaction with the correction was similar for both techniques. Two patients treated with a single depot of HA were later given hyaluronidase, but otherwise, there was no statistically significant difference in the incidence and severity of side effects.

CONCLUSIONS

We describe and compare an alternative technique for the correction of tear trough deformity using a single deposition of HA in the nasojugal groove with favorable outcomes.

Unilateral lacrimal fistula in a patient with uterus didelphys and renal agenesis

A 30-year-old female patient presented to our clinic because of lacrimation from an orifice close to the left lower eyelid. Ocular examinations and analyses revealed uterus didelphys and unilateral renal agenesis associated with a left lacrimal fistula. The patient underwent fistulectomy and external dacryocystorhinostomy. We decided to report on this patient owing to the unusual concurrent systemic abnormalities.

Results of endoscopic assisted probing for congenital nasolacrimal duct obstruction in older children

PURPOSE

To evaluate the results of lacrimal probing with the use of nasal endoscopy and identify the anatomical anomalies responsible for the symptoms in older children.

METHODS

Fifty-two eyes of 40 children with congenital nasolacrimal duct obstruction underwent primary probing of the lacrimal duct under general anaesthetic in conjunction with nasal endoscopy. Patients followed up for at least 6 months. Cure was defined as complete resolution of symptoms or minimal symptoms brought on by cold or wind.

RESULTS

The age range was 12-126 months. In 30/52 (57.7%) eyes the symptoms were attributed to a single mechanical obstruction. Seven eyes had canalicular stenosis. Three eyes had upper nasolacrimal duct obstruction. Nine eyes had narrow duct and nine eyes had atresia of the distal end of the duct. Two eyes had only intranasal abnormalities. In 16/52 (30.76%) eyes a combination of anomalies was responsible for the symptoms. Nine eyes had canalicular stenosis in association with: either a membrane at the valve of Hasner in four, or a narrow duct in three, or intranasal anomalies in two. Two eyes had punctual stenosis and narrow duct. Two eyes had narrow duct and tight inferior turbinate. Three eyes had abnormal openings in association with stenotic ducts. Six (11.54%) eyes had functional blockage. With the use of endonasal endoscopy, intranasal anomalies identified in 12 eyes and treated in nine. One eye had large inferior conchae. One eye had inferior concha adherent to lateral nasal wall. One eye had redundant nasal mucosa. Three eyes had tight inferior turbinate. Three had abnormal openings. In three eyes the probe went submucosally. The overall success rate was 84.6% (44/52 eyes). Eight eyes remained unchanged. Endoscopically treated cases contributed to the overall success by 17.31%.

CONCLUSION

Multiple anatomical anomalies within the lacrimal system and abnormalities of the nose are quite common in older children. Lacrimal probing remains the primary treatment and nasal endoscopy is a useful adjunct to probing increasing the success rate of the procedure.

Congenital aberrant tearing: a re-look

PURPOSE

Congenital aberrant tearing is characterized by tearing when eating ("crocodile tears"), lack of emotional tearing, or both. Most reported cases are associated with Duane syndrome. In our previous studies we observed aberrant tearing in individuals with thalidomide embryopathy and Möbius sequence. This report summarizes the literature on the subject and adds 3 new studies that give information on this unusual condition.

METHODS

Twenty-eight individuals with Möbius sequence were interviewed about tearing symptoms at a support group meeting in Italy. In Sweden 30 adults primarily from the original thalidomide series were reexamined. In this latter study, a Schirmer test was done at baseline and repeated 5 minutes after eating. Twenty families in Brazil who have children with Möbius sequence were questioned about tearing symptoms and exposure to misoprostol during pregnancy.

RESULTS

In the 28 Italian individuals, either "crocodile tears" or lack of emotional tearing was noted in 7 cases. In the thalidomide study, 10 of 30 patients had tearing when eating and 7 had no emotional tearing. Low Schirmer scores or increased tearing after eating was noted in a few asymptomatic individuals. Among the 20 Brazilian children with Möbius sequence, 10 had some tearing abnormality.

CONCLUSION

Congenital anomalous lacrimation is rare but usually associated with Duane syndrome or abduction deficits, as in Möbius sequence and, less frequently, facial nerve palsy. Studies implicate an early insult in development at 4 to 6 weeks. At that time the facial nerve, sixth nerve, and lacrimal nucleus are in close proximity in the embryo.

Severe, unilateral, unresponsive keratoconjunctivitis sicca in 16 juvenile Yorkshire Terriers

OBJECTIVE

To present ophthalmic findings, clinical data, and treatment outcomes of 16 juvenile Yorkshire Terriers with severe unilateral keratoconjunctivitis sicca.

RESULTS

Each of the 16 dogs exhibited extreme unilateral dryness associated with blepharospasm, mucoid discharge, and corneal vascularization. Ages of affected dogs at presentation ranged from 5 months to 4 years. Mean Schirmer tear test (STT) result for affected eyes was 1 mm/min. Topical application of 0.2% cyclosporine to the affected eye was not associated with improvement in STT values in any dog. Clinical signs subjectively improved with topical application of 20% chondroitin sulfate ophthalmic solution in some dogs, and transposition of the parotid duct was performed in three dogs. Histopathologic examination in one dog failed to show evidence of orbital lacrimal gland tissue. Clinical signs, age of presentation, disease severity, and lack of response to treatment are consistent with breed-related unilateral aplasia or hypoplasia of the lacrimal gland.

CONCLUSION

Lacrimal gland aplasia or hypoplasia should be considered in young dogs with severe unilateral ocular dryness, especially female Yorkshire Terriers.

Atypical synophthalmos with arhinencephaly unilateralis

This article describes a rare case of a 4-month-old infant with atypical synophthalmos with ipsilateral arhinencephaly unilateralis, ethmoid sinus, and lacrimal apparatus and brain abnormalities--diagnosed on the basis of the clinical picture and imaging findings.

Lacrimo-auriculo-dento-digital syndrome is caused by reduced activity of the fibroblast growth factor 10 (FGF10)-FGF receptor 2 signaling pathway

Lacrimo-auriculo-dento-digital (LADD) syndrome is characterized by abnormalities in lacrimal and salivary glands, in teeth, and in the distal limbs. Genetic studies have implicated heterozygous mutations in fibroblast growth factor 10 (FGF10) and in FGF receptor 2 (FGFR2) in LADD syndrome. However, it is not clear whether LADD syndrome mutations (LADD mutations) are gain- or loss-of-function mutations. In order to reveal the molecular mechanism underlying LADD syndrome, we have compared the biological properties of FGF10 LADD and FGFR2 LADD mutants to the activities of their normal counterparts. These experiments show that the biological activities of three different FGF10 LADD mutants are severely impaired by different mechanisms. Moreover, haploinsufficiency caused by defective FGF10 mutants leads to LADD syndrome. We also demonstrate that the tyrosine kinase activities of FGFR2 LADD mutants expressed in transfected cells are strongly compromised. Since tyrosine kinase activity is stimulated by ligand-induced receptor dimerization, FGFR2 LADD mutants may also exert a dominant inhibitory effect on signaling via wild-type FGFR2 expressed in the same cell. These experiments underscore the importance of signal strength in mediating biological responses and that relatively small changes in receptor signaling may influence the outcome of developmental processes in cells or organs that do not possess redundant signaling pathway.

[Anhidrotic ectodermal dysplasia: "congenital ameibomia"]

Anhidrotic ectodermal dysplasia is a congenital, generally X-linked dermatosis that associates facial dysmorphy, short stature, and severe blepharitis. The anomalies of the skin are epidermic abnormalities; reduction of the glands of the derm, particularly the sweat glands, explaining the hypohidrosis; onychodysplasia; trichodysplasia; and abnormal dentition. The ophthalmologic manifestations are palpebral anomalies with a reduction in or an absence of Meibomian glands, dysfunction of the Moll and Zeis glands, leading to chronic squamous blepharitis and lacrimal punctal atresia. These anomalies result in severe attacks of the ocular surface, developing during the second decade, which are often invalidating and require a rigorous follow-up to avoid corneal complications.

FGF10 missense mutations in aplasia of lacrimal and salivary glands (ALSG)

Aplasia of lacrimal and salivary glands (ALSG) is an autosomal dominant congenital anomaly characterized by aplasia, atresia or hypoplasia of the lacrimal and salivary systems. Affected individuals present with irritable eyes and dryness of the mouth with variable expressivity. Mutations in FGF10 were recently described in ALSG and in lacrimo-auriculo-dento-digital (LADD) syndrome which are overlapping clinical entities. We present here two families with ALSG associated with missense mutations (R80S and G138E, respectively) affecting highly conserved residues in FGF10. The clinical features of these patients further broaden the knowledge of FGF10-related phenotypes.

Bilateral congenital lacrimal sac fistulae in a patient with ectrodactyly-ectodermal dysplasia-clefting syndrome

We describe a case of bilateral congenital lacrimal sac fistulas, associated with ectrodactyly-ectodermal dysplasia-clefting syndrome. The embryologic basis for this condition is discussed, as well as the epidemiology, typical presentation, and possible treatment modalities. After we excised the fistulas and intubated the nasolacrimal ducts in this patient, he experienced improvement in symptoms by report.

Bilateral corneal perforation in an infant with congenital alacrima

A 9-month-old infant had bilateral corneal opacity with erosion in the inferior corneas. Clinical examination suggested the infant had congenital alacrima. After 1 week, both corneas perforated with collapsed anterior chambers. Therapeutic soft contact lenses with ofloxacin ointment 4 times daily were successful, and the perforations sealed within 1 week.

Familial absence of lacrimal puncta associated with preauricular sinuses

Previously reported cases of lacrimal outflow dysgenesis have frequently been associated with developmental anomalies or systemic syndromes, raising potential red flags in affected children. We report an unusual case of familial punctal atresia with apparent genetic linkage to bilateral preauricular sinuses without any such comorbid syndromic features.

LADD syndrome is caused by FGF10 mutations

Lacrimo-auriculo-dento-digital syndrome [LADD (MIM 149730)] is an autosomal-dominant multiple congenital anomaly disorder characterized by aplasia, atresia or hypoplasia of the lacrimal and salivary systems, cup-shaped ears, hearing loss, and dental and digital anomalies. Loss of function mutations in FGF10 were recently described in aplasia of the lacrimal and salivary glands [ALSG (MIM 180920; MIM 103420)] (Entesarian et al., Nat Genet 2005: 37: 125-127, Milunsky et al., American College of Medical Genetics Annual Meeting, Dallas, TX, 2005: A100). Due to the significant phenotypic overlap between LADD syndrome and ALSG and the variable expressivity of both the disorders, we hypothesized that FGF10 mutations could also result in LADD syndrome. A de novo missense mutation was found in exon 3 of FGF10 in a 3-year-old female (Family 1) with LADD syndrome. This missense mutation, resulting in a non-conservative amino acid change, was confirmed by restriction enzyme digestion and was not found in 500 control chromosomes. A nonsense mutation was also found in exon 2 of FGF10 (Family 2) in a 19-year-old mother with ALSG and her 2-year-old daughter with LADD syndrome. Previous studies of FGF10 mutant mice have demonstrated abnormalities consistent with ALSG and LADD syndrome. We conclude that ALSG and LADD syndrome may represent variable presentations of the same clinical spectrum caused by FGF10 mutations.

FGF signalling in craniofacial development and developmental disorders

The Fgf signalling pathway is highly conserved in evolution and plays crucial roles in development. In the craniofacial region, it is involved in almost all structure development from early patterning to growth regulation. In craniofacial skeletogenesis, the Fgf signal pathway plays important roles in suture and synchondrosis regulation. Mutations of FGF receptors relate to syndromatic and non-syndromatic craniosynostosis. The Fgf10/Fgfr2b signal loop is critical for palatogenesis and submandibular gland formation. Perturbation of the Fgf signal is a possible mechanism of palatal cleft. Fgf10 haploinsufficiency has been identified as the cause of autosomal dominant aplasia of lacrimal and salivary glands. The Fgf signal is also a key regulator of tooth formation: in the absence of Fgfr2b tooth development is arrested at the bud stage. Fgfr4 has recently been identified as the key signal mediator in myogenesis. In this review, these aspects are discussed in detail with a focus on the most recent advances.

A case of major salivary gland agenesis

Major salivary gland agenesis is a rare disorder and only a few instances of the condition have been reported. The number of absent salivary glands and the degree of associated xerostomia vary between individuals. Salivary gland agenesis can cause profound xerostomia in children and there may be oral and upper respiratory tract sequelae, such as dental caries, candidiasis, ascending sialadenitis, laryngitis and pharyngitis. Salivary gland aplasia may be associated with other ectodermal defects, particularly abnormalities of the lacrimal apparatus. We report on the first observation of major salivary gland agenesis in South Korea. A child with xerostomia should be appropriately investigated and diagnosed, and careful attention should be paid to the prevention and treatment of sequelae.

Bilateral lacrimal sac mucocele with punctal and canalicular atresia

Congenital absence of lacrimal puncta may be an isolated finding or associated with other developmental abnormality. Nasolacrirnal ducts can be absent thus predisposing to the formation of a congenital lacrimal mucocele. Punctal and canalicular agenesis is very rare. Four percent of new patients attending the lacrimal clinic at Moorfields Eye Hospital, London, UK. from 1981 to 1990 inclusive were diagnosed to have this condition. We describe a case of bilateral congenital absence of lacrimal puncta with lacrimal mucocele. Combined surgery was carried out by Ophthalmologist and Otolaryngologist with successful results.

Two cases of lacrimal gland agenesis in the same family — clinicoradiologic findings and management

BACKGROUND

Lacrimal gland agenesis is extremely rare. This condition is occasionally associated with salivary gland agenesis and abnormalities in the lacrimal drainage system, particularly occlusions of the lacrimal puncta and canaliculi. The detailed presentation of clinicoradiologic findings and treatment modality has not been previously reported.

METHODS

A 6-year-old boy was presented to our department complaining of severe foreign-body sensations in both eyes. Punctate epithelial erosions and mucous filaments were noted in both eyes. His tear break-up time (TBUT) was less than 1 second, and a Schirmer's test (both eyes) detected less than 1 mm of wetting in 5 minutes. His mother had similar complaints dating back to childhood.

RESULTS

Orbital computed tomography (CT) scan and magnetic resonance imaging (MRI) revealed the absence of both lacrimal glands and all major salivary glands. After the insertion of a lacrimal punctal plug, punctate epithelial erosions and mucous filaments decreased remarkably within 2 weeks. MRI scans of the patient's mother confirmed the absence of both lacrimal glands and salivary glands. She had been using artificial tears for a long time.

INTERPRETATION

The absence of lacrimal glands can be confirmed by clinicoradiologic findings, and the punctal plug may be an effective tool for the treatment of patients who retain a patent lacrimal drainage system.

The role of integrated imaging techniques for prenatal prediction of phenotype in two cases of facial anomalies

OBJECTIVES

Fetal face malformations represent one of the most challenging prenatal diagnoses mainly because of the wide range of morphological features involved. We tested an approach based on a combination of conventional two-dimensional ultrasound with the more recent three-dimensional technique plus magnetic resonance imaging, in order to improve parents' understanding of fetal face anomalies, thereby facilitating parent counselling.

METHODS

Two cases of fetal facial anomaly were studied using these combined techniques; one had severe micrognathia and malformation of the ears with preauricular tags, while the other had bilateral dacryocystocele and severe hypertelorism.

RESULTS

The images generated by three-dimensional ultrasound enabled the parents to visualize their child immediately and helped them to adjust to the diagnosis of facial defects and its clinical consequences.

CONCLUSIONS

An approach based on combined use of different imaging techniques was found useful in both cases.

CT findings of head and neck anomalies in lacrimo-auriculo-dento-digital (LADD) syndrome

We present computed tomography (CT) findings of a boy with lacrimo-auriculo-dento-digital (LADD) syndrome. Bilateral lacrimal glands were not detected and CT imaging of this abnormality in LADD syndrome has not been reported before. Despite suggestions from previous reports of multiple temporal bone abnormalities resulting in hearing losses in these patients, only minor temporal bone abnormalities were seen in our deaf-mute patient. Dysplasia of salivary glands was noted. CT findings of head and neck abnormalities in LADD syndrome are discussed.

Mutations in the gene encoding fibroblast growth factor 10 are associated with aplasia of lacrimal and salivary glands

Autosomal dominant aplasia of lacrimal and salivary glands (ALSG; OMIM 180920 and OMIM 103420) is a rare condition characterized by irritable eyes and dryness of the mouth. We mapped ALSG to 5p13.2-5q13.1, which coincides with the gene fibroblast growth factor 10 (FGF10). In two extended pedigrees, we identified heterozygous mutations in FGF10 in all individuals with ALSG. Fgf10(+/-) mice have a phenotype similar to ALSG, providing a model for this disorder. We suggest that haploinsufficiency for FGF10 during a crucial stage of development results in ALSG.

Lacrimo-Auriculo-Dento-Digital Syndrome

Lacrimo-auriculo-dento-digital (LADD) syndrome, also known as Levy-Hollister syndrome, is characterized by pronounced dysplasias in various organ systems. The resulting disturbances affect primarily the lacrimal glands, the inner and outer ear, the salivary glands, and the osseous framework. Although the degree to which the different organs are involved varies considerably, dental anomalies are regularly reported. An autosomal-dominant trait has been recognized for this syndrome, but the majority of cases described in the literature concerned sporadic new mutations. We report on this unusual and relatively unknown syndrome with reference to a 13-year-old girl suffering from LADD syndrome presenting symptoms of severe xerostomia and various craniofacial malformations, hearing loss, enamel dysplasia, microdontia, and hypodontia.

Congenital Alacrima in Pierre Robin Sequence

PURPOSE

To report the presence of congenital alacrima in a patient with Pierre Robin (PR) sequence.

METHODS

A 6-month-old child with diagnosed PR sequence presented to us with dysfunctional lacrimation present since birth. The child subsequently developed bilateral corneal ulcers. This unusual presentation and its management are described in detail, and other ocular associations of the PR sequence are discussed.

RESULTS

Continuous tear supplementation and appropriate treatment with antibiotics controlled the microbial infection. However, the long-term prognosis for visual rehabilitation remained poor in this patient because of the presence of central corneal opacities, persistent dry eye, which would preclude future optical keratoplasty, and possible sensory deprivation amblyopia.

CONCLUSIONS

Alacrima can cause significant ocular morbidity, because persistent ocular surface dryness can be very difficult to manage. Lifelong tear supplementation may be necessary. The association or coexistence of congenital alacrima and the Pierre Robin sequence has not been described before this report.

Vertical facial distraction in the treatment of arhinia

Arhinia is a rare congenital malformation characterized by lack of the formation of external and internal nasal structures. Restricted midfacial growth is secondary to the loss of the midfacial growth centers. Staged reconstruction of the nasal passage and external nose is required. Vertical distraction osteogenesis is a beneficial step in the overall reconstructive program. This provides for additional bone and soft tissue for both improved aesthetic facial proportions and later surgical interventions.

Proboscis lateralis: a report of two cases

Proboscis Lateralis (PL) is one of the congenital anomalies of the nose which presents as obvious deformity. This is a report of two cases of the rare anomaly PL. One presented with right PL and the second presented with left PL. In this rare anomaly, the nasal cavity on one side is completely normal while on the affected side, the nasal cavity is replaced by a tube of skin and soft tissue attached to the inner canthus of the eye. This anomaly occurs sporadic as an isolated defect or in association with other anomalies. It is usually associated with failure of the paranasal sinuses and the nasolacrimal duct development. Embryologically, this anomaly is a result of imperfect fusion of the lateral nasal wall and maxillary processes (Int. J. Pediatr. Otorhinolaryngol. 23 (1992) 275).

Congenital reduplication of the lacrimal punctum and canaliculus in a patient with dry eye

A healthy 60-year-old woman presented with bilateral dry eye syndrome that was more pronounced in the right eye than in the left eye. Two patent independent supernumerary puncta and canaliculi were found in the right upper eyelid. This condition may explain the more severe dryness in her right eye. Successful punctum occlusion was accompanied by marked resolution of symptoms in both eyes.

Bilateral congenital dacryocystocele as a cause of respiratory distress in a newborn

Newborns with respiratory distress and nasal obstruction must be examined for congenital dacryocystocele. This disease is caused by a stenosis in the proximal and distal area of the nasolacrimal duct and leads to a cystic dilatation of this duct. A case of a newborn with bilateral dacryocystocele and dyspnoea is presented. The otorhinolaryngologic as well as the paediatric examination could only reveal in the rhinoscopic examination a tumor of the left nasal cavity that partly obstructed the endonasal space. No other pathologic findings were detected. To clarify the origin and the localization of the tumor as well as to exclude an intracranial relation, a magnetic resonance imaging of the middle face and the frontal skull base was performed. After probe and rinsing of the lacrimal ducts the symptoms improved rapidly. In newborns with nasal obstruction a bilateral rhinoscopy of the lower nasal meatus is required to exclude the existence of a dacryocystocele.