Congenital Microphthalmos* *From the Kresge Eye Institute, Detroit, Michigan. This paper was awarded a first prize by the Detroit Ophthalmological Society

Bilateral severe microphthalmos with bilateral colobomatus orbitopalpebral cyst: accessibility of speciality eye-care and rehabilitation services in low and middle-income countries

A 12-year-old girl presented with an unusually large mass under the right lower eyelid and a smaller mass under the left lower lid since the last 6 months. The parents had noticed the absence of the right eyeball and a very small left eyeball and no vision in both eyes since birth but did not approach the healthcare system. The patient was diagnosed as a case of bilateral severe microphthalmos with colobomatous cyst with late presentation and was treated surgically. The parents were counselled for education and training of the child in schools for visually impaired. Early treatment and rehabilitation help patients lead a normal life in these cases. In rural areas, patients face challenges in getting access to the specialty eye-care services due to several barriers, including lack of availability and affordability. This case highlights the disparities in essential health services in low and middle-income countries.

Quantitative Trait Locus Analysis of SIX1-SIX6 With Retinal Nerve Fiber Layer Thickness in Individuals of European Descent

PURPOSE

To perform a quantitative trait locus (QTL) analysis and evaluate whether a locus between SIX1 and SIX6 is associated with retinal nerve fiber layer (RNFL) thickness in individuals of European descent.

DESIGN

Observational, multicenter, cross-sectional study.

METHODS

A total of 231 participants were recruited from the Diagnostic Innovations in Glaucoma Study and the African Descent and Glaucoma Evaluation Study. Association of rs10483727 in SIX1-SIX6 with global and sectoral RNFL thickness was performed. Quantitative trait analysis with the additive model of inheritance was analyzed using linear regression. Trend analysis was performed to evaluate the mean global and sectoral RNFL thickness with 3 genotypes of interest (T/T, C/T, C/C). All models were adjusted for age and sex.

RESULTS

Direction of association between T allele and RNFL thickness was consistent in the global and different sectoral RNFL regions. Each copy of the T risk allele in rs10483727 was associated with -0.16 μm thinner global RNFL thickness (β = -0.16, 95% confidence interval: -0.28 to -0.03; P = .01). Similar patterns were found for the sectoral regions, including inferior (P = .03), inferior-nasal (P = .017), superior-nasal (P = .0025), superior (P = .002) and superior-temporal (P = .008). The greatest differences were observed in the superior and inferior quadrants, supporting clinical observations for RNFL thinning in glaucoma. Thinner global RNFL was found in subjects with T/T genotypes compared to subjects with C/T and C/C genotypes (P = .044).

CONCLUSIONS

Each copy of the T risk allele has an additive effect and was associated with thinner global and sectoral RNFL. Findings from this QTL analysis further support a genetic contribution to glaucoma pathophysiology.

Familial acorea, microphthalmia and cataract syndrome

PURPOSE

To describe the clinical features of members of a family with acorea, microphthalmia and cataract syndrome. In addition, to perform linkage analysis on family members to determine possible candidate genes.

METHODS

Comprehensive ophthalmic examinations were performed on five affected members of a family consisting of a paternal grandmother, father and three children. In addition, DNA was extracted from nine family members (the five affected and four normal members) and used for genome-wide single nucleotide polymorphism genotyping and linkage analysis.

RESULTS

All of the affected patients had acorea or fibrous occlusion of the pupil, microphthalmia and cataracts in both eyes. They also had microcornea and iridocorneal dysgenesis. Examination of the crystalline lens was hindered by the abnormal iris surface, but cataracts were detected by ultrasound biomicroscopy. Surgical reconstruction of the pupil allowed a better view of the posterior pole of the eye, and ophthalmoscopy showed a normal retina and optic disc. No systemic abnormalities were observed. Linkage analysis did not reach significance but narrowed the location of possible candidate genes to chromosomes 1, 5, 8, 11 and 17.

CONCLUSIONS

This acorea, microphthalmia and cataract syndrome has not previously been reported. Genetic analyses indicate that this syndrome is probably due to an autosomal dominant mutation.

A new locus for congenital cataract, microcornea, microphthalmia, and atypical iris coloboma maps to chromosome 2

OBJECTIVE

To report a novel phenotype of autosomal dominant atypical congenital cataract associated with variable expression of microcornea, microphthalmia, and iris coloboma linked to chromosome 2. Molecular analysis of this phenotype may improve our understanding of anterior segment development.

DESIGN

Observational case study, genome linkage analysis, and gene mutation screening.

PARTICIPANTS

Three families, 1 Egyptian and 2 Belgians, with a total of 31 affected were studied.

METHODS

Twenty-one affected subjects and 9 first-degree relatives underwent complete ophthalmic examination. In the Egyptian family, exclusion of PAX6, CRYAA, and MAF genes was demonstrated by haplotype analysis using microsatellite markers on chromosomes 11, 16, and 21. Genome-wide linkage analysis was then performed using 385 microsatellite markers on this family. In the 2 Belgian families, the PAX6 gene was screened for mutations by direct sequencing of all exons.

MAIN OUTCOME MEASURES

Phenotype description, genome-wide linkage of the phenotype, linkage to the PAX6, CRYAA, and MAF genes, and mutation detection in the PAX6 gene.

RESULTS

Affected members of the 3 families had bilateral congenital cataracts inherited in an autosomal dominant pattern. A novel form of hexagonal nuclear cataract with cortical riders was expressed. Among affected subjects with available data, 95% had microcornea, 39% had microphthalmia, and 38% had iris coloboma. Seventy-five percent of the colobomata were atypical, showing a nasal superior location in 56%. A positive lod score of 4.86 was obtained at theta = 0 for D2S2309 on chromosome 2, a 4.9-Mb common haplotype flanked by D2S2309 and D2S2358 was obtained in the Egyptian family, and linkage to the PAX6, CRYAA, or MAF gene was excluded. In the 2 Belgian families, sequencing of the junctions and all coding exons of PAX6 did not reveal any molecular change.

CONCLUSIONS

We describe a novel phenotype that includes the combination of a novel form of congenital hexagonal cataract, with variably expressed microcornea, microphthalmia, and atypical iris coloboma, not caused by PAX6 and mapping to chromosome 2.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Microphthalmos: clinical and ultrasonographic findings

We analyzed ocular and ultrasonographic findings of microphthalmos and associated ocular and systemic pathologies in 27 microphthalmic eyes. A high incidence of consanguinous marriages (26%) was present among the parents of patients. Associated systemic abnormalities were growth retardation, congenital rubella, cleft lip and palate, facial hemangioma, inguinal hernia, clinodactyly, Hurler syndrome, Goltz-Gorlin syndrome and Hallermann-Streiff syndrome. A variety of ocular/systemic abnormalities were encountered. Early ultrasonographic diagnosis and description of other ocular and systemic pathologies are essential.

Posterior chamber intraocular lens implantation in pediatric cataract with microcornea and/or microphthalmos

Purpose

To report the results of secondary posterior chamber intraocular lens (PC-IOL) implantation in pediatric cataract eyes with microcornea and/or microphthalmos.

Methods

Retrospective studies were conducted by reviewing the charts of 26 eyes of 15 patients with secondary PC-IOL implantations for microcornea and/or microphthalmos associated with cataract in children between 1999 and 2002. The corneal diameter was 9.5 mm or less at the time of secondary PC-IOL implantation. Preoperative examinations were conducted for bilaterality, corneal diameter, eye abnormalities and systemic abnormalities. Postoperative results were evaluated in terms of visual developments, refractive changes, axial length measurements and the occurrence of complications. The follow-up period was at least one year after secondary PC-IOL implantation.

Results

Age at the first diagnosis for cataract with microcornea and/or microphthalmos was 2.7 months on average. Among 15 patients, 8 (53.3%) had a family history. All patients received an initial irrigation and aspiration, posterior capsulectomy, and anterior vitrectomy at 0.8 years (0.1-3.3 years) of age and a secondary PC-IOL implantation surgery at 6.7 years (1.6-17.2 years) of age on average. The postoperative follow-up period was 2.1 years (1.1-4.3 years) on average. The average power of the implanted PC-IOL was +21.2D. Postoperative complications were secondary glaucoma in two eyes, secondary pupillary membrane formation in two eyes. Best corrected visual acuities in 20 eyes in children capable of the vision test at the last follow-up were 20/60 or better in 11 eyes, 20/80 to 20/150 in eight eyes, and 20/200 or worse in one eye.

Conclusions

The secondary PC-IOL implantation in pediatric cataract with microcornea and/or microphthalmos is recommended as a means of improving vision, but must be conducted carefully to avoid possible complications.

Congenital microphthalmos with orbital cysts: distinct diagnostic features and management

PURPOSE

To review the clinical features and treatment strategies for microphthalmic globes with orbital cyst.

METHODS

: The clinical records of 23 patients treated for microphthalmos associated with orbital cysts were reviewed retrospectively.

RESULTS

Most cases of congenital microphthalmos with orbital cysts were first noted at birth, and all were confirmed by means of computed tomography and/or ultrasonography. Six of the 23 cases were bilateral. Sixty-seven percent of bilateral and 29% of unilateral cases also had other congenital malformations. Mild microphthalmos was noted in 3 orbits, moderate in 16 orbits, and severe in 10 orbits. On the basis of clinical findings, 8 orbits were treated with enucleation and cyst excision and 15 were treated with cyst excision only. Cyst aspiration was performed on 5 orbits; 2 required aspiration and subsequent cyst excision. Twenty-six orbits had good cosmesis and 2 had acceptable cosmesis. The mean follow-up interval was 5.15 years.

CONCLUSIONS

Management of microphthalmos with orbital cyst is a cosmetic issue. Cyst size, degree of microphthalmos, and general condition of the patient determine the best treatment approach.

Early sonographic detection of recurrent fetal eye anomalies

OBJECTIVE

To determine the possible association between congenital eye anomaly of a previous child in the family and current congenital eye anomaly.

METHODS

An early transvaginal anomaly scan at 14-16 gestational weeks was used to diagnose fetal eye anomalies in five cases in which at least one previous child in the family had the same congenital eye anomaly.

RESULTS

At least one cataract was detected in four of the five fetuses and bilateral anophthalmia in one. The congenital cataract in one case was part of multiple pterygium syndrome. Both of these extremely rare malformations are commonly associated with other fetal anomalies.

CONCLUSION

Our data suggest that a detailed targeted ultrasound survey with a special focus on the orbital region should be offered at the time of genetic counseling to couples with children with congenital eye anomalies.

Surgical management of congenital cataract associated with severe microphthalmos

PURPOSE

To report the results of cataract surgery in children with severe microphthalmos and congenital cataract.

SETTING

Seoul National University, Department of Ophthalmology, Seoul, Korea.

METHODS

Retrospective studies were conducted by reviewing the charts of 20 eyes of 11 patients with severe microcornea and microphthalmos or severe microcornea with a corneal diameter smaller than 9.0 mm. The patient pool was divided according to surgical method, specifically by incision site: an anterior group that had corneal limbal incisions and a posterior group treated via pars plicata incisions. Preoperative examinations included bilaterality, corneal diameter, axial length, and eye and systemic abnormalities. Postoperative results and complications of the 2 operative methods were compared.

RESULTS

All 11 patients had bilateral congenital cataract and microphthalmos. Except in 1 case, surgeries were done in patients ranging in age from 2 to 16 months. Mean follow-up was 2 years. Corneal diameter was smaller than 9.0 mm in all 20 eyes and smaller than 7.5 mm in 11 eyes. Ten eyes were categorized into the anterior group, and the other 10 eyes were placed in the posterior group. Postoperative complications included secondary membranes in 3 eyes in the posterior group and corneal opacity in 3 eyes in the anterior group.

CONCLUSION

The surgical management of children with congenital cataract and severe microphthalmos is recommended as a way to improve vision but must be performed carefully to avoid complications.

Infantile cataracts

Cataracts are one of the most treatable causes of visual impairment during infancy. Recent epidemiological studies have shown that they have a prevalence of 1.2 to 6.0 cases per 10,000 infants. The morphology of infantile cataracts can be helpful in establishing their etiology and prognosis. Early surgery and optical correction have resulted in an improved outcome for infants with either unilateral or bilateral cataracts. While contact lenses continue to be the standard means of optically correcting an infant's eyes after cataract surgery, intraocular lenses are gaining in popularity as an alternative means of optically correcting these eyes. Post-operative complications occur more commonly after infantile than adult cataract surgery and many of these complications do not develop until years later. As a result, it is critical that children be followed closely on a long term basis after infantile cataract surgery.

Systemic anomalies in 77 patients with congenital anophthalmos or microphthalmos

Congenital anophthalmos and microphthalmos are rare conditions which can have associated pathology in the second eye and/or systemic anomalies. A retrospective review of 77 patients with congenital anophthalmos or microphthalmos seen at Moorfields Eye Hospital over a 13 year period was performed. A detailed description of the ocular and systemic anomalies present in our series of patients is given, and the current understanding of the pathogenesis of congenital anophthalmos and microphthalmos is reviewed.

Prosthetic treatment of severe microphthalmos in infancy

Four infants with blind, severely microphthalmic eyes have been treated with cosmetic scleral shells. Through periodic refitting, this method has permitted the development of symmetrical ocular appearance without the need for surgery. We recommend that this treatment be initiated in early infancy in appropriate patients.

Microphthalmia-congenital anterior polar cataract. An autosomal dominant syndrome

A condition is described which is characterized by microphthalmia and congenital anterior polar cataract, transmitted in an autosomal dominant fashion.

Bilateral extreme microphthalmos

A case of bilateral extreme microphthalmos is reported. Autopsy of a one-day-old full-term female revealed multiple congenital anomalies which included occipital encephalocele, cleft palate, hips which could not be abducted, long fingers and toes, and cardiovascular malformations. Chromosomal analysis showed a normal 46 XX karyotype. Ocular findings in this case included clinical anophthalmos with bilateral fused eyelids, optic nerve aplasia, absent cornea and lens, and retinal dysplasia. The distinctions between anophthalmos and varying degrees of microphthalmos are discussed. The insult causing abnormal development in this case appears to have occurred during the first trimester of pregnancy. There were no prenatal or delivery complications. A genetic abnormality was considered since two older siblings have birth defects. Also discussed is the possibility of a combined genetic and environmental etiology.

Genetics in pediatric ophthalmology

Genetic factors are becoming increasingly important causes of both congenital and acquired eye disease in the pediatric age group. Referral to an ophthalmologist is important both for global genetic disorders potentially affecting the eye and for eye disorders that may be diagnostic for genetic disease.

Microphthalmos and colobomata among mentally retarded individuals

Among 993 visually impaired mentally retarded persons 86 had microphthalmos or colobomata. The aetiology was prenatal infections in 16 cases, 6 had chromosomal aberrations, syndromes previously described were present in 14, private syndromes in 3. Although the malformation association observed in 36 patients had been previously described, it was impossible to assess whether the individual cases were due to environmental or genetic causes, and in 11 cases the associations were apparently previously undescribed.

Genetics of microphthalmos

This is a survey of the genetics of microphthalmos and the heritable syndromes in which microphthalmos occurs. New syndromes are delineated such as the autosomal dominant anophthalmos-microphthalmos-coloboma syndrome, the autosomal dominant microphthalmos, microcephaly, lacunar retinal atrophy syndrome, the autosomal recessive anophthalmos-microphthalmos-coloboma syndrome, the autosomal recessive syndrome with anophthalmos or microphthalmos and genital malformations, and the autosomal recessive syndrome with microphthalmos, microcephaly and retinal falciform folds. Nanophthalmos is described as a poorly defined phenotype and rejected as a genotype. Several other genetic entities with microphthalmos are reviewed and recent descriptions are surveyed.

Prognosis for education of children with bilateral congenital microphthalmus

Retrospective study of 34 patients with bilateral microphthalmus and follow-up of 30 of these revealed mental retardation of seven, an incidence equal to or less than reported by others. Of greater import is the number of highly educated or extremely good students, a finding not previously reported. Familial incidence of microphthalmus was low (4 probable but unproved cases). It seems that in counseling parents of children with microphthalmus we should be optimistic about the future achievement of these children. Support should be provided during their learning years, and we must promote better acceptance by the community, particularly in regard to employment.

Colobomatous microphthalmia, heart disease, hearing loss, and mental retardation--a syndrome

A syndrome consisting of colobomatous microphthalmia, heart disease, abnormalities of the external ear with associated hearing loss, and mental retardation is described. Nine children and one adult were evaluated. There is not race or sex predilection. The syndrome can be heritable, as shown by a mother and daughter who were among the patients. In addition to the four major components enumerated, multiple other anomalies may be associated. In some cases, the syndrome may occur incompletely. Whenever two or more of the four components are recognized, the other systems usually affected should be investigated.

Anophthalmos in an infant with multiple congenital anomalies

A full-term, 2,828-g male infant who lived five weeks had histologically proven, bilateral, congenital anophthalmos. The infant had multiple congenital anomalies including esophageal atresia, choanal stenosis, tetralogy of Fallot, persistent left superior vena cava, arhinencephaly, retardation of myelination in the brain, cerebellar sclerosis, and dysplasias, as well as other developmental anomalies of the central nervous system. There was no family history of anophthalmos, and, in view of the arhinencephaly, we diagnosed sporadic secondary anophthalmos.