The eye in the CHARGE association

Choroidal neovascular membrane associated with optic nerve coloboma in a patient with CHARGE association

PURPOSE

To report a patient with CHARGE association (coloboma, heart disease, choanal atresia, growth retardation, genital hypoplasia, and ear abnormalities) who developed a choroidal neovascular membrane in association with an optic nerve coloboma.

DESIGN

Interventional/observational case report.

METHOD

A 21-month-old boy with CHARGE association developed a grayish choroidal neovascular membrane associated with lipid exudation, subretinal fluid, and retinal hemorrhage at the temporal edge of his right optic nerve coloboma.

RESULTS

The patient underwent transpupillary diode laser of the choroidal neovascular membrane. Five months later, it and the serous retinal detachment had resolved.

CONCLUSIONS

Patients with CHARGE association may develop choroidal neovascular membrane with serous retinal detachments in association with optic nerve colobomas. These neovascular membranes may be treated successfully with transpupillary diode laser.

CHARGE syndrome: a window of opportunity for audiologic intervention

OBJECTIVE

To detail the clinical features of 22 new patients with a syndrome characterized by ocular coloboma, heart defects, atretic choanae, retarded growth or development, genital hypoplasia, and ear anomalies or hearing loss (CHARGE) seen in a tertiary academic medical center; compare auditory brainstem response (ABR) thresholds and behavioral hearing test results; identify a "window of opportunity" for audiologic intervention; review the literature regarding hearing results in CHARGE syndrome; and review the relationship between facial palsy and sensorineural hearing loss.

METHODS

Clinical data were gathered to examine 1) the variety of hearing results, 2) the average age at the time of hearing loss identification in 22 children with CHARGE using electrophysiologic and behavioral test methods, 3) the usefulness of the ABR as an early indicator of hearing sensitivity for a select group composed of children from the present study and from an earlier report from the same institution, and 4) the value of congenital facial paralysis as a predictor of sensorineural hearing loss in CHARGE children seen in the authors' institution since 1983.

RESULTS

All children had 4 or more acronymic features, including colobomatous defects or choanal atresia. Ear anomalies/hearing loss occurred at least as frequently as other primary features. A total of 81% of patients had hearing loss; in this subset, 1 child had a mild degree of loss, and the remaining children had moderate or greater losses. The average age at which ABR confirmed hearing status was 3.8 months, whereas for behavioral testing, that age was 24.7 months, a statistically significant difference. In a select group of 16 children, no statistical differences existed when comparing threshold results of early electrophysiologic testing with behavioral test findings obtained at a later date. Contingency analysis suggests that congenital facial paralysis and sensorineural hearing loss are related.

CONCLUSIONS

Hearing loss is prevalent in children with CHARGE syndrome. Within a wide range of results exists a propensity for moderate or greater hearing loss in children with sensorineural or mixed impairments. Congenital facial palsy seems to be a valid statistical predictor of sensorineural hearing loss and can be a useful device in audiologic decision making. A "window of opportunity" for audiologic intervention exists in the first few months of life. Primary care providers are encouraged to recognize the need for immediate, early audiologic referral of their patients suspected to have CHARGE. Evaluation of hearing sensitivity during infancy and, when appropriate, provision of amplification are important components in the process of auditory habilitation. These efforts are in keeping with various professional guidelines that call for early detection of hearing loss and subsequent prompt intervention to minimize effects on infant development.

CHARGE Association in newborns: a registry-based study

The CHARGE Association is a nonrandom occurrence of congenital malformations that has been described in clinical series. Reported patients have been selected on the basis of certain prior criteria. In this article, we try to identify a congenital malformation pattern corresponding to the CHARGE Association, using statistical methods and analyzing 5,260 infants with multiple malformations collected from four large registries of congenital malformations. Care was taken to identify a number of confounding characteristics that can influence the ascertainment and registration of specific congenital malformations. We have identified a cluster of malformations that generally agreed with the current clinical definition of the CHARGE Association and have added some further malformations (e.g., facial clefts). We demonstrate that others (e.g. , esophageal atresia) are probably not part of the pattern. Heart defects (H in the acronym) seems to be less helpful in identifying infants with the association. We suggest a method to select infants who probably represent the CHARGE Association for analyses of possible risk factors.

CHARGE association-related ocular pathology in a newborn with partial trisomy 19q and partial monosomy 21q, from a maternal translocation (19;21) (q13.1;q22.3)

We report a novel case of partial trisomy 19q and concomitant partial monosomy 21q, segregated from a maternal translocation (19;21) (q13.1;q22.3), identified by spectral karyotyping. Clinical examination revealed dysmorphic features of the face and limbs, cleft palate, bilateral colobomas with associated bilateral colobomatous optic nerve cysts, hearing loss, and a cardiac anomaly. At autopsy, the dysmorphic features and cleft palate were confirmed. The ocular histopathology is described in detail and the cardiac anomaly was further specified. The combination of phenotype features is diagnostic of the CHARGE (coloboma, heart malformation, atresia choanae, retarded growth and development, and/or CNS anomalies, genital hypoplasia, ear anomalies and/or deafness) association. This case also has some phenotypic features in common with previous cases of partial trisomy 19q. The importance of a complete autopsy in cases with multiple congenital anomalies and/or genetic abnormalities is emphasized. This will allow optimal genetic counseling and contribute to our understanding of developmental biology.

Ocular malformations and developmental genes

New insights into the pathogenesis of ocular malformations came with the discovery of transcription factors that determine the fate of cells in the developing eye. Several malformations have been matched to individual developmental genes that share conserved DNA sequences such as the homeobox. These disease/gene matches include the oculorenal syndrome and PAX2; aniridia and PAX6; Rieger syndrome and RIEG1/PITX2; cyclopia and Sonic hedgehog; cone-rod dystrophy, Leber's congenital amaurosis and CRX; and recessive septooptic dysplasia and HESX1. Gene mapping and mutation analysis have allowed a more accurate and meaningful classification of genetically heterogeneous diseases such as the anterior segment dysgenesis syndromes. This paper reviews current information on the genetics of ocular malformations.

CHARGE syndrome: report of 47 cases and review

The acronym CHARGE refers to a syndrome of unknown cause. Here we report on 47 CHARGE patients evaluated for the frequency of major anomalies, namely coloboma (79%), heart malformation (85%), choanal atresia (57%), growth and/or mental retardation (100%), genital anomalies (34%), ear anomalies (91%), and/or deafness (62%). In addition, we comment on anomalies observed very frequently in neonates and infants with the CHARGE syndrome, including, minor facial anomalies, neonatal brain stem dysfunction with cranial nerve palsy, and, mostly, internal ear anomalies such as semicircular canal hypoplasia that were found in each patient that could be tested. We propose several criteria for poor survival including male gender, central nervous system and/or oesophageal malformations, and bilateral choanal atresia. No predictive factor regarding developmental prognosis could be identified in our series. A significantly higher mean paternal age at conception together with concordance in monozygotic twins and the existence of rare familial cases support the role of genetic factors such as de novo mutation of a dominant gene or subtle sub-microscopic chromosome rearrangement. Finally, the combination of malformations in CHARGE syndrome strongly supports the view that this multiple congenital anomalies/mental retardation syndrome is a polytopic developmental field defect involving the neural tube and the neural crests cells.

CHARGE association: histopathological report of two cases and a review

BACKGROUND

The CHARGE association (C = coloboma, H = heart disease, A = atresia or stenosis of the choanae, R = retarded growth and development or CNS anomalies, G = genital hypoplasia, and E = ear anomalies or deafness) is a rare, recently well-recognized clinical study. The ophthalmic abnormalities have been described in numerous reports, but the ocular histopathologic findings have not been presented in detail.

METHODS

We conducted gross and microscopic studies of eyes of two patients with the CHARGE association obtained postmortem.

RESULTS

The eyes in one case had a small, symmetrical, inferior nasal coloboma of the choroid. In the other case, extensive inferior nasal colobomas of the iris, ciliary body, and choroid with retinal dysplasia, ectopic retinal/glial tissue in the sclera and hypoplasia of the optic nerve head were present.

CONCLUSION

We document the histopathological features of eyes of two subjects with the CHARGE association. The abnormalities of these eyes were typical ocular colobomas presumably resulting from the failure of complete closure of the optic fissure.

CHARGE association: an update and review for the primary pediatrician

CHARGE association is a nonrandom pattern of congenital anomalies that occurs together more frequently than one would expect on the basis of chance. This common multiple anomaly condition has an estimated prevalence of 1:10,000. The number of children diagnosed with CHARGE association is increasing, owing presumably to greater awareness of this condition and advances in the care of complex, chronically ill children, resulting in improved survival and outcome. This review of CHARGE association presents diagnostic criteria that may define a concise, recognizable syndrome with a single pathogenetic basis. This review also summarizes our current understanding of the management for this complex and chronic multiple congenital anomaly condition and discusses the pathogenetic basis for this condition.

CHARGE association with congenital glaucoma due to maldevelopment of the anterior chamber angle

PURPOSE

We examined the clinicopathologic features of a male infant with the CHARGE association and bilateral congenital glaucoma.

METHODS

Trabeculectomy specimens were obtained from the anterior chamber angle and examined by light and electron microscopy.

RESULTS

Histopathologic examination of the trabeculectomy specimens showed immature development of the trabecular meshwork that was covered by the ciliary muscles. There were few intertrabecular spaces because the meshwork was almost completely filled with cells and extracellular substances. Deposition of a granular and/or homogeneous substance was observed in the subendothelial area of Schlemm's canal.

CONCLUSIONS

Our patient exhibited features typical of the CHARGE association, but also had congenital glaucoma. We hypothesize that these clinical findings are all mediated by a neurocristopathic mechanism. Our findings suggest that the CHARGE association may predispose to anterior chamber angle maldevelopment, which can lead to congenital glaucoma.

Vestibular areflexia as a cause of delayed motor skill development in children with the CHARGE association

Six cases of the CHARGE association are described that were encountered consecutively at an institute for the deaf. Five of them showed external ear anomalies and according to expectations all of them showed some degree of hearing impairment: two had moderate mixed hearing loss; three had severe to profound sensorineural hearing loss; and one was completely deaf. In addition, they all had vestibular areflexia and the five cases examined with computer tomography of the petrosal bones showed aplasia of the semicircular canals. One case with poor visual acuity also showed subnormal optokinetic responses and horizontal pendular nystagmus during visual fixation. All these children were initially diagnosed as having severe psychomotor retardation, because of their failure to acquire speech and their delayed motor skill development. Given the fact that (mild) mental retardation was found in only one case, the delayed development could at least in part have been caused by vestibular areflexia. The vestibular findings support previously reported temporal bone findings that indicate dysplasia or aplasia of the superior part of the labyrinth. Early detection of the full extent of (multiple) sensory deficits is necessary in children with the CHARGE association who have similar abnormalities, because aggressive intervention and special educational support are likely to be of great benefit to sensorimotor development.

Congenital optic disk anomalies

Over the past decade, a wealth of information has accumulated pertaining to the diagnosis and management of patients with congenital optic disk anomalies. As new examples of each entity have been detailed, the diagnostic criteria for each anomaly have become more clearly defined. The advent of sophisticated noninvasive neuroimaging techniques has further refined our ability to accurately detect and categorize the associated CNS anomalies that complicate many of these conditions. In light of recent findings, this review will critically examine many of the well-entrenched concepts pertaining to the diagnosis, evaluation, and treatment of patients with congenital optic disk anomalies. In so doing, it will attempt to dispel some longstanding misconceptions that pervade the literature and obscure our understanding of the pathogenesis, neuroradiological associations, and systemic implications of each anomaly.

Cranial nerve abnormalities in CHARGE association

Many children with the CHARGE association have facial paralysis and feeding and swallowing difficulties. Indeed, facial paralysis and pharyngeal incoordination may be important diagnostic indicators of CHARGE association [Davenport et al., 1986a; Mitchell et al., 1985]. We describe an individual with dysfunction of multiple cranial nerves (Möbius sequence) and CHARGE association, a previously unrecognized combination. Our review of 150 patients from the literature and 13 patients from this center with CHARGE association documented that dysfunction of cranial nerves is frequent in CHARGE association, and that often cranial nerve abnormalities are multiple. Such multiple cranial nerve abnormalities may be the primary underlying cause for the facial paralysis, feeding difficulties and sensorineural hearing loss seen in many individuals with CHARGE association.

The systemic and genetic significance of congenital optic disc anomalies

Optic disc anomalies have great significance as a clue to associated systemic problems and as a marker of inherited disease. Optic nerve hypoplasia and colobomas of the optic disc are the main visually significant disorders; however, the Morning Glory disc anomaly and Aicardi's syndrome may also be associated with visual impairment.