Foveomacular vitelliform dystrophy, adult type. A clinicopathologic study including electron microscopic observations

Adult-onset foveomacular vitelliform dystrophy: a study by optical coherence tomography

PURPOSE

To evaluate the morphology of adult-onset foveomacular vitelliform dystrophy (AFVD) using optical coherence tomography (OCT) and to correlate the OCT findings with those of biomicroscopy and fluorescein angiography (FA).

DESIGN

Prospective observational case series.

METHODS

A complete ophthalmologic examination, including visual acuity, fundus biomicroscopy, FA, and OCT was performed in 21 eyes of 14 consecutive patients with AFVD.

RESULTS

Mean age at presentation was 64 years (range, 39 to 84 years), and best-corrected visual acuity ranged from 20/25 to 20/400 (median 20/50). Sixteen of 21 eyes (11 patients) exhibited late staining of lesions on FA. In these 16 eyes, OCT revealed that AFVD material consists of a hyperreflective structure located between the photoreceptor and the retinal pigment epithelium layers. The retinal pigment epithelium layer was linear and was not elevated, unlike what is observed in retinal pigment epithelium detachment. Five other eyes (x4 patients) without late staining in FA showed, by OCT, a hyperreflective area at the level of the retinal pigment epithelium band, with no material visible between the photoreceptor and retinal pigment epithelium layers. In all 21 eyes, the retina overlying the hyperreflective structure was raised by the pseudovitelliform material and was markedly thinned.

CONCLUSIONS

Optical coherence tomography is a noninvasive useful tool that provides new information on the morphology of AFVD. It demonstrates, better than biomicroscopy, the location of the yellowish material under the sensory retina but above the retinal pigment epithelium, corresponding angiographically to the late staining. The foveal thinning found by OCT in all cases probably explains the progressive visual loss and possible evolution toward a full-thickness macular hole.

Optical coherence tomography findings in adult-onset foveomacular vitelliform dystrophy

PURPOSE

The purpose of this article is to analyze cross-sectional images of a subretinal macular lesion, using optical coherence tomography (OCT) in eyes with adult-onset foveomacular vitelliform dystrophy (AOFVD), to compare thickness of the neurosensory retina over the lesion with best-corrected visual acuity (BCVA) of each eye, and to compare OCT tomograms of AOFVD patients with OCT of Best disease.

DESIGN

Observational case series.

METHODS

This is a retrospective study which took place in a clinical practice. Forty-three patients (72 eyes) with AOFVD and 12 patients (24 eyes) with Best's disease were studied. The observation procedures used were biomicroscopic fundus examination, fluorescein angiography (FA), indocyanine green angiography (ICGA), and optical coherence tomography (OCT). The main outcome measures were a description of the typical picture of AOFVD in OCT tomograms, the relationship between the neurosensory retinal thickness over the lesion, the BCVA expressed in decimal terms, and a comparison with description of OCT in Best disease.

RESULTS

Of the 43 patients affected by AOFVD, 29 had bilateral macular lesions. Fluorescein angiography showed a central hypofluorescent spot surrounded by an irregular hyperfluorescent ring in 65 of the 72 eyes. Indocyanine green angiography demonstrated a central nonfluorescent spot and a hyperfluorescent area surrounding the central spot in 22 of 27 eyes examined. In all 72 eyes of 43 patients, OCT showed a well-defined central region of thickening in the reflective band representing the retinal pigment epithelium (RPE). The relationship between the thickness of neurosensory retina over the lesion and BCVA was significant (P =.001, r(2) = 0.61). Optical coherence tomography in all 24 eyes with Best disease showed a well-defined central serous retinal detachment.

CONCLUSION

In the 72 eyes with AOFVD, FA and ICGA presented different features. Instead, OCT tomograms showed a well-defined subretinal thickening of the RPE in all the eyes. The lack of difference in OCT patterns between cases with or without the hypofluorescent spot on angiography was useful for confirming the diagnosis of AOFVD. Moreover, a reduced visual acuity was evident in patients with a thinner neurosensory retinal layer over AOFVD lesion. Finally, OCT images were also useful for distinguishing AOFVD from Best disease.

Splice site mutation in the peripherin/RDS gene associated with pattern dystrophy of the retina

PURPOSE

To report the phenotype and genotype of a splice site mutation at intron 2 of the peripherin/RDS gene in four half-siblings with pattern dystrophy of the retina.

DESIGN

Experimental study.

METHODS

In four siblings with a common mother and three separate fathers, complete ophthalmic examination, pedigree, electrophysiologic testing, and fluorescein angiography studies were obtained. Genomic DNA from serum lymphocytes was isolated and used as a template for primers specific for the cone homeobox gene (CRX), rhodopsin (RHO), and peripherin/RDS genes to conduct single stranded conformational analysis and cycle sequencing.

RESULTS

The pedigree of four affected siblings suggested probable autosomal dominance transmission of pattern dystrophy. In the four siblings, best corrected visual acuity ranged from 20/20 to 20/80 by Snellen chart. Clinical findings included discrete, localized degenerative changes of the macular retinal pigment epithelium in all patients, with subclassification foveal. One patient exhibited pigment clumping within the atrophic areas. Another patient exhibited yellow flecks diffusely in the macula. Fluorescein angiographic findings included central hypofluorescence with a surrounding rim of hyperfluorescence that corresponded to the observed fundus lesions and window defects. There was a range of electroretinography (ERG) and electrooculography (EOG) findings. One patient demonstrated both cone and rod dysfunction on ERG testing and another demonstrated decreased rod function. EOG testing was normal in two patients and mildly diminished in one patient. DNA sequencing identified a point mutation in intron 2 of the peripherin/RDS gene, consisting of an A to T change at 1068+3, present in all four affected patients.

CONCLUSIONS

Four siblings with pattern dystrophy of the retina presented a splice site mutation in the peripherin/RDS gene.

Pattern dystrophies of the retinal pigment epithelium

We describe a family that shows autosomal dominant pattern dystrophy of the retinal pigment epithelium. There were 10 affected family members encompassing three generations. The various manifestations of these dystrophies, their inheritance characteristics, affects on vision function and their pathogenesis are discussed.

Adult-onset foveomacular vitelliform dystrophy and indocyanine green videoangiography

BACKGROUND

Adult-onset foveomacular vitelliform dystrophy (AOFVD) represents a heterogeneous group of disorders with different clinical, angiographic, and histopathological features. The most common form is characterized by a yellow, round to oval subretinal macular lesion with or without central pigmented spot.

METHODS

Eight patients affected by typical AOFVD underwent fluorescein angiography and indocyanine green videoangiography (ICGV).

RESULTS

Fluorescein angiography showed a central hypofluorescent spot surrounded by an irregular hyperfluorescent ring. ICGV demonstrated a foveal nonfluorescent spot, visible during the entire examination, and a hyperfluorescent area surrounding the central spot, which became evident soon after the beginning of the examination.

CONCLUSIONS

In light of previous histopathological studies, the central nonfluorescent spot may be interpreted as a masking effect of a pigment clump, whereas the hyper-fluorescent area may represent dye pooling or staining of the subretinal pigment epithelial material.

Pattern dystrophies of the retinal pigment epithelium

Pattern dystrophies of the retinal pigment epithelium are infrequent fundus abnormalities arranged in various patterns of dots, lines and branches. The basic lesion appears to be yellow deposits of abnormal lipofuscin accumulated within degenerated retinal pigment epithelium cells. Examinations were carried out on two families who had developed different patterned alterations in the retinal pigment epithelium. The proband of family 1 had diffuse changes associated with equatorial folds. One sister had a macular alteration. A daughter was normal; a son had bilateral atrophy of the temporal retinal pigment epithelium. The proband of family 2 had bilateral, symmetrical retinal pigment epithelium lesions that simulated fundus flavimaculatus. His first daughter had a central lesion in her right eye. The second daughter, a peripapillary crescent of hyperpigmentation in her right eye, and circumpapillary chorioretinal atrophy associated with foveolar abnormalities in the left. This report provides further evidence that variable types of pattern dystrophy can occur within a single family pedigree and support the current opinion that all forms of pattern dystrophies are variants of a single pathogenic mechanism.

Distribution of fundus autofluorescence with a scanning laser ophthalmoscope

BACKGROUND

Variation of fluorescence derived from lipofuscin in the retinal pigment epithelium has been recorded with age and in retinal diseases. Studies have been based largely on in vitro observations on eye bank eyes which has placed severe limitations on the data available.

METHODS

A technique is described whereby in vivo imaging of autofluorescence of the fundus was achieved using a scanning laser ophthalmoscope.

RESULTS

The optical characteristics, distribution, and variation with disease imply that the fluorescence is derived from lipofuscin in the pigment epithelium. Autofluorescence is shown to be abnormally high in certain inherited diseases, and low in the presence of retinal atrophy.

CONCLUSION

This technique may be useful both in clinical practice and research. It may allow the detection of the abnormal phenotype in genetically determined disease at a time when other techniques may not. Longitudinal studies of age related macular disease would permit correlation between changes in the pigment epithelium and Bruch's membrane to be established.

Lipofuscinosis of the cornea. A clinicopathologic study of three cases

BACKGROUND

Lipofuscin pigments are the indigestible residue of lysosomal activity usually associated with normal aging. Abnormal amounts of lipofuscin also are associated with certain disease processes. The rarity of lipofuscin in the cornea and the similarities between its staining properties and those of intracellular micro-organisms caused great diagnostic problems in three cases. The correct diagnosis of corneal lipofuscinosis was made after extensive histochemical, autofluorescent, and ultrastructural studies.

METHODS

Clinical histories of three patients are correlated with morphologic and histochemical findings on five corneal buttons with lipofuscinosis.

RESULTS

The histopathologic features of one cornea with chronic keratitis and three corneas from two patients with bilateral opacities of undetermined origin were mostly similar. Large amounts of lipofuscin pigment were found within macrophages and stromal keratocytes. Other pathologic findings were nonspecific, including phagocytosis of degenerated collagen fibrils, scarring, and neovascularization of the stroma.

CONCLUSION

The lipofuscin deposits are probably the consequence of a corneal degenerative process and not its cause, although their pathogenesis remains unclear. Familiarity with the morphologic appearance of corneal lipofuscinosis and its staining and autofluorescent properties is important because the small, 1- to 3-microns deposits may be mistaken for intracellular micro-organisms.

Phenotypic similarities between Stargardt's flavimaculatus and pattern dystrophies

Some heredomacular diseases share ophthalmoscopic and morphologic similarities despite being nosologically distinct. In part, this may arise from pathologic reaction patterns such as lipopigment accumulation and drusen deposition which are common to a variety of disorders of the photoreceptor--retinal pigment epithelium--Bruch's membrane complex. Two of these disorders, Stargardt's flavimaculatus and the pattern dystrophies of the retinal pigment epithelium may be especially difficult to differentiate clinically since they are characterised by both a similar ophthalmoscopic appearance and considerable inter and intrafamilial variation in their expression. Stargardt's flavimaculatus may, however, be distinguished from the retinal pigment epithelial pattern dystrophies by certain clinical and morphological features that are outlined below.

Autosomal-dominant fundus flavimaculatus. Clinicopathologic correlation

The authors report the first clinicopathologic study of autosomal-dominant fundus flavimaculatus with late-onset atrophic macular degeneration in a 62-year-old man. Results of histopathologic examination disclosed the retinal pigment epithelium (RPE) to be distended by a periodic acid-Schiff (PAS)-positive, acid mucopolysaccharide-negative material. Transmission electron microscopy showed marked accumulation of lipofuscin and melanolipofuscin granules within the RPE. The different modes of genetic transmission and ultrastructural heterogeneity suggest that fundus flavimaculatus is a clinical syndrome representing several genetically and mechanistically distinct disorders whose common end-stage is a topographically similar accumulation of lipofuscin.

Adult vitelliform macular degeneration: a clinical spectrum

Adult vitelliform macular degeneration (adult Best's disease) has a spectrum of clinical appearances which may include focal macular pigment clumps as well as the more typical small, yellow lesions. We surveyed 81 patients with this diagnosis retrospectively. Ages ranged from 36 to 87 years, with an average age of 67 years. Males and females were almost equally represented. Median visual acuity at presentation was 6/12 for eyes with yellow lesions, and 6/9 for eyes with pigment clumps. Of 17 cases followed for an average of 3.6 years, there was a decrease in visual acuity of two lines or more in five cases. A significant proportion of patients also had other manifestations of age-related macular degeneration. Adult vitelliform macular degeneration probably falls within the spectrum of age-related macular degeneration.

Patterned dystrophies of the retinal pigment epithelium. A review

Pigmentations and depigmentations, accompanied or not by yellow subretinal lipofuscin accumulations, are the ophthalmologically visible manifestations of dystrophies of the retinal pigment epithelium. The pigmentations may or may not become confluent and form concentric, butterfly-shaped or reticular configurations. Different patterns of pigment migration may occur in a family and even in one individual. Hence these dystrophies are called pattern(ed) dystrophies of the retinal pigment epithelium. The visual functions are relatively well-preserved, although severe visual impairment is not excluded. The pattern(ed) dystrophies are inherited as an autosomal dominant, an autosomal recessive or an X-linked recessive trait. The author suggests that some cases diagnosed as atypical pigmentary dystrophies with near-normal visual functions probably are dystrophies of the retinal pigment epithelium.

Macular disease resembling adult foveomacular vitelliform dystrophy in older adults

Fifty-three eyes of 31 patients over age 50 with macular disease were reviewed. Clinical appearance of the macula was of two types: a yellow slightly elevated lesion (29 eyes) and a pigmented flat lesion with surrounding atrophy (24 eyes). Drusen were found in 60% of affected eyes. No familial tendencies were documented. A reduced electro-oculogram (EOG) was present in approximately 50% of all eyes tested. Fluorescein angiographic findings and differential diagnosis are described. Visual prognosis was markedly different for the two groups: 69% of eyes with yellow elevated lesions lost two or more lines of visual acuity and 48% went on to visual acuity equal to or less than 20/200, whereas 33% of eyes with pigmented flat lesions lost two or more lines of visual acuity and 8% went on to visual acuity equal to or less than 20/200.