Ocular manifestations in the Marfan syndrome and homocystinuria

Risk Factors for Retinal Detachment in Marfan Syndrome After Pediatric Lens Removal

PURPOSE

To determine retinal detachment (RD) risk factors after lens removal surgery in children with Marfan syndrome (MS).

DESIGN

Retrospective, case control study.

METHODS

This was an institutional case series including children (age <18 years) with MS who underwent lens removal surgery. Clinical and surgical characteristics were extracted from the children's electronic files: age, axial length (AL), gender, number of surgeries received, intraocular lens (IOL) implantation at the first surgery, complete removal of the capsular bag, and final best-corrected visual acuity. Risk factors associated with RD occurrence were identified.

RESULTS

Among 158 eyes included (85 children), 35 eyes (22.2%) developed RD during follow-up. Bilateral detachment occurred in 11 patients (45.8%). Age at the time of the lens removal surgery was not different between groups. Children in the RD group had a higher AL (P < .001), longer follow-up, IOL implantation, and capsular residue. Multivariate analysis identified capsular residue (odds ratio, 16.8; 95% CI, 1.9-148.8; P = .01) and AL (odds ratio, 1.3; 95% CI, 1.01-1.7; P = .03) as predictors for RD.

CONCLUSIONS

Children with MS and increased AL were more likely to develop an RD after lens surgery. When considering lens removal surgery in a pediatric population presenting with MS, a complete capsular removal seemed to be the safer option regarding RD risk.

Comparison of intraocular lens tilt after capsular sutured scleral fixation with capsular segments versus uneventful cataract surgery

PURPOSE

To evaluate and compare intraocular lens (IOL) tilt between uneventful phacoemulsification with in-the-bag IOL implantation and sutured scleral fixation (SSF) of the lens bag with a capsular tension segment (type 6 D / Morcher) using a Sheimpflug camera.

SETTING

Clinical Practice, Hospital. Barcelona and A Coruña, Spain.

DESIGN

Retrospective, comparative multicenter study.

METHODS

IOL tilt was compared between patients who underwent sutured scleral fixation with a capsular tension segment in a single eye (SSF group, n = 15) with patients who underwent uneventful IOL implantation (control group, n = 12) that were matched by biometric measurements. Post-operative refractive accuracy of biometric formulas by means of mean absolute error (MAE) was also reported. All patients underwent a general ophthalmic evaluation, anterior segment photography, and postoperative optical biometry (Zeiss IOLMaster® 500). In addition, IOL tilt was measured with a Scheimpflug camera (Pentacam R, Oculus Optikgerate Gmbh).

RESULTS

Mean vertical tilt was similar in both groups (2.20+/-2.47° SSF vs 1.97 +/- 1.79° control; p = 0.836) but mean horizontal tilt tended to higher values in the SSF series (2.09 +/- 2.74° vs 0.94 +/- 1.17°; p = 0.139). Considering post-operative refractive error in diopters by MAE calculations, there was an underestimation of IOL power in the SSF group which was only statistically significant for Barrett Universal II (1.07 vs 0.32; p = 0.028) and Hill-RBF (0.95 vs 0.26; p = 0.024) formulas, but not for SRK/T (0.99 vs 0.42; p = 0.285) and Kane (0.96 vs 0.33; p = 0.083).

CONCLUSION

Sutured scleral fixation of capsular tension segments in the presence of zonular instability does not seem to induce clinically significant IOL tilt compared to uneventful cataract extraction cases.

Long-Term Postoperative Outcomes Following Cionni Ring and In-the-Bag Intraocular Lens Implantation in Eyes With Subluxated Lenses

PURPOSE

Evaluate long-term outcomes following Cionni modified capsule tension ring (MCTR) and in-the-bag intraocular lens (IOL) implantation in subluxated lenses.

DESIGN

Retrospective case series.

METHODS

Forty-one eyes of 31 patients from Raghudeep Eye Hospital, India, with subluxated lenses who had completed a minimum of 5 years' postoperative follow-up were included. Lens extraction, capsular bag fixation with MCTR using 9-0 polypropylene suture, and in-the-bag IOL implantation were performed in all eyes. Corrected distance visual acuity (CDVA), IOL centration, posterior capsule opacification, glaucoma, and retinal complications were documented at final follow-up.

RESULTS

The mean age of the cohort was 20.48 ± 16.46 (SD) years. Twenty-four eyes (58%) were below 15 years of age at the time of surgery. Marfan syndrome accounted for 37% cases. Mean follow-up was 9.89 ± 3.81 (SD) years. Thirty-two eyes (74%) had a CDVA of ≥0.3 logMAR at final follow-up. IOL decentration was noted in 7 eyes (17%), requiring a secondary surgery. The mean duration from primary surgery to resurgery was 8.79 years. Seventeen eyes (41%) required a laser capsulotomy, 88% of which were pediatric eyes. Retinal detachment occurred in 4 eyes (10%), 3 of which had Marfan syndrome.

CONCLUSION

Capsular bag fixation with an MCTR using 9-0 polypropylene and in-the-bag IOL implantation had good long-term visual outcomes with an acceptable rate of serious postoperative complications in eyes with subluxated lenses. This approach allows preservation of the natural compartments of the eye and placement of an IOL in its most physiological position. However, considering a 17% rate of IOL decentration requiring surgical intervention, long-term stability with nonbiodegradable suture materials such as polytetrafluoroethylene as well as decentration rates following sutured or sutureless scleral fixation should be compared.

Unique Features of Cardiovascular Involvement and Progression in Children with Marfan Syndrome Justify Dedicated Multidisciplinary Care

Marfan syndrome (MIM: # 154700; MFS) is an autosomal dominant disease representing the most common form of heritable connective tissue disorder. The condition presents variable multiorgan expression, typically involving a triad of cardiovascular, eye, and skeletal manifestations. Other multisystemic features are often underdiagnosed. Moreover, the disease is characterized by age related penetrance. Diagnosis and management of MFS in the adult population are well-described in literature. Few studies are focused on MFS in the pediatric population, making the clinical approach (cardiac and multiorgan) to these cases challenging both in terms of diagnosis and serial follow-up. In this review, we provide an overview of MFS manifestations in children, with extensive revision of major organ involvement (cardiovascular ocular and skeletal). We attempt to shed light on minor aspects of MFS that can have a significant progressive impact on the health of affected children. MFS is an example of a syndrome where an early personalized approach to address a dynamic, genetically determined condition can make a difference in outcome. Applying an early multidisciplinary clinical approach to MFS cases can prevent acute and chronic complications, offer tailored management, and improve the quality of life of patients.

Genetic mutation and aqueous humor metabolites alterations in a family with Marfan syndrome

This study used four generations of a Chinese family to reveal the genetic etiology and ocular manifestation pathogenesis of Marfan syndrome (MFS) through whole genome sequencing (WGS) and metabolomics analysis. In the study, we explored the pathogenic gene variant and aqueous humor (AH) metabolites alterations of MFS. Using WGS, a novel heterozygous variant (NM_000138: c.G4192A, p.D1398 N) in the fibrilin-1 (FBN1) gene was identified. This variant was co-segregated with the phenotype and considered "deleterious" and highly conserved during evolution. The p.D1398 N variant is located in a cbEGF-like domain and predicted to lead to a new splice site, which might result in structural and functional changes to the FBN1 protein. FBN1 is highly expressed in the mouse cornea, conjunctiva and lens capsule, which highlights the important role of FBN1 in eyeball development. AH metabolomics analysis identified eight differentially expressed metabolites, including 3-hydroxyphenylacetic acid, 4-pyridoxic acid, aminoadipic acid, azelaic acid, chlordiazepoxide, niacinamide, ribose, 1,5-bisphosphate and se-methylselenocysteine, associated with relevant metabolic pathways likely involved in the pathogenesis of ocular symptoms in MFS. Our analysis extends the existing spectrum of disease-causing mutations and reveals metabolites information related to the ophthalmic features of MFS. This may provide a new sight and a basis for the diagnosis and mechanism of MFS.

Incidence and de novo mutation rate of Marfan syndrome and risk of ectopia lentis

PURPOSE

To investigate the population-based incidence and de novo mutation rate of Marfan syndrome and risk of ectopia lentis.

METHODS

Patients newly diagnosed with Marfan syndrome in Olmsted County, Minnesota, from January 1, 1976, through December 31, 2005, were identified through medical records review. Outcome measures were Marfan incidence, de novo mutation rate, risk of ectopia lentis.

RESULTS

Marfan syndrome was identified in 17 patients during the 30-year period, yielding an incidence of 0.52 per 100,000 people/year (95% CI, 0.27-0.77). Mean age at diagnosis was 24.4 years (range, 1.7 year to 51.3 years). Nine patients (53%) were female. Of the 17, 5 (29%) were new mutations, with a calculated mutation rate of 3.8 ± 1.7 × 10-5. Four (24%) were diagnosed with ectopia lentis, including 3 at the time of their Marfan diagnosis. Of the 14 patients at risk for developing ectopia lentis after being diagnosed with Marfan syndrome, 1 (7%) developed it during a mean follow-up of 9 years (range, 0-6.4). Twelve (71%) were diagnosed with dilated ascending aorta during a mean follow-up of 13.2 years (range, 6.7 months to 28.9 years).

CONCLUSIONS

Incidence and de novo mutation rate of Marfan syndrome in this population-based cohort was higher than prior reports. Ectopia lentis, whose prevalence in North America has not been reported previously, occurred in approximately one-fourth of study patients and more commonly around the time of initial Marfan diagnosis.

Outcomes of Iris-Claw IOL Implantation in Patients with Marfan’s Syndrome in Jordan

Objective

The management of ocular complications of Marfan’s syndrome, especially ectopia lentis, is challenging. In this study, we present the effectiveness and the safety of iris-claw intraocular lens (IOL) implantation along with lensectomy for those patients. Also, we compare the practice of implanting these IOLs either in the anterior chamber of retropupillary.

Methods

Retrospectively, we included all patients with Marfan’s syndrome who underwent lensectomy with iris-claw IOL implantation as a result of ectopia lentis. The patients were categorized into two groups: anterior chamber iris claw IOL and retropupillary iris-claw IOL. The clinical and demographic data, the visual outcome and postoperative complications were compared.

Results

Eighteen eyes of 10 patients were included in the study. The mean age of the patients was 19.1 years. Six patients were males. The iris-claw IOL was implanted anteriorly in 13 eyes. The visual outcome was comparable between both groups and most patients achieved improvement in the visual acuity. In addition, the postoperative complications developed similarly in both groups. However, all cases of IOL disenclavation (6 cases) developed in the anterior group. It is revealed that the age of the patient was the most significant factor affecting the occurrence of IOL disenclavation.

Conclusion

Iris-claw IOL (either anteriorly or retropupillary) is an effective and relatively safe method in treating ectopia lentis in patients with Marfan’s syndrome. In younger patients, anterior iris-claw IOL is safer than retropupillary iris-claw IOL as the risk of disenclavation is higher in younger patients.

Homocystinuria and ocular complications - A review

Homocystinuria is a rare metabolic inborn disorder caused due to dysfunctional cystathionine β-synthase (CBS) enzyme activity, thus resulting in elevated levels of methionine and homocysteine in the blood and urine. The timely recognition of this rare metabolic disorder and prompt methionine-restricted diet are crucial in lessening the systemic consequences. The recalcitrant cases have a higher risk for cardiovascular diseases, neurodegenerative diseases, neural tube defects, and other severe clinical complications. This review aims to present the ophthalmic spectrum of homocystinuria and its molecular basis, the disease management, as well as the current and potential treatment approaches with a greater emphasis on preventive strategies.

Intercalary staphyloma after strabismus surgery in a patient with Marfan syndrome: A case report

RATIONALE

A few cases of intercalary staphyloma have been reported in patients with Marfan syndrome, but we believe that this is the first case of intercalary staphyloma in Marfan syndrome developing after strabismus surgery.

PATIENT CONCERNS

A 9-year-old girl diagnosed with Marfan syndrome visited a strabismus clinic for treatment of esotropia. Both eyes were aphakic and had 60 prism diopter esotropia at distance and 55 prism diopter esotropia at near. There were no corneal, conjunctival, or scleral abnormalities. Six millimeters of recession was performed on both medial rectus muscles via an inferonasal fornix approach under general anesthesia. 5 days after surgery, a dark gray protruding lesion was observed on the upper nasal side of the left eye.

DIAGNOSES

Intraocular ultrasonography showed no bleeding, retinal detachment, or other abnormal findings. Computed tomography showed a conical protrusion of the scleral wall which was diagnosed as intercalary staphyloma.

INTERVENTIONS

To reduce risk of progression of the staphyloma in the left eye and to reduce risk of development of a new staphyloma, intraocular pressure lowering eye drops were administered.

OUTCOMES

We just observed it without any intervention except the intraocular pressures lowering eye drops. It remained stable for 12 months.

LESSONS

Clinicians need to be alert to the possibility of this serious complication in Marfan syndrome patients after minor surgical trauma, which can occur during uneventful strabismus surgery.

Phacoemulsification Combined With Supra-Capsular and Scleral-Fixated Intraocular Lens Implantation in Microspherophakia: A Retrospective Comparative Study

Background

Microspherophakia (MSP) is a rare ocular condition, the lens surgery of which is complicated by both insufficient zonules and undersized capsule.

Methods

This study included MSP eyes managed with phacoemulsification combined with supra-capsular and scleral-fixated intraocular lens implantation (SCSF-IOL) and made the comparison with those treated by transscleral-fixated modified capsular tension ring and in-the-bag intraocular lens implantation (MCTR-IOL).

Results

A total of 20 MSP patients underwent SCSF-IOL, and 17 patients received MCTR-IOL. The postoperative best corrected visual acuity was significantly improved in both groups (P &lt; 0.001), but no difference was found between the groups (P = 0.326). The IOL tilt was also comparable (P = 0.216). Prophylactic Nd:YAG laser posterior capsulotomy was performed 1 week to 1 month after the SCSF-IOL procedure. In the SCSF-IOL group, two eyes (10.00%) needed repeated laser treatment and one eye (5.00%) had a decentered capsule opening. Posterior capsule opacification was the most common complication (6, 35.29%) in the MCTR group. No IOL dislocation, secondary glaucoma, or retinal detachment was observed during follow-up.

Conclusions

SCSF-IOL is a viable option for managing MSP and is comparable with the MCTR-IOL. Nd:YAG laser posterior capsulotomy was necessary to prevent residual capsule complications after the SCSF-IOL procedure.

Incidence of retinal detachment after lens surgery in children and young adults with nontraumatic ectopia lentis

PURPOSE

To determine the incidence of retinal detachment after lens surgery in children and young adults with nontraumatic ectopia lentis.

SETTING

Population-based claims data.

DESIGN

Population-based retrospective cohort study.

METHODS

Patients with nontraumatic ectopia lentis aged 30 years or younger who had undergone lens surgery with or without intraocular lens (IOL) implantation and had 1 year or greater continuous enrollment after lens surgery were included in the Optum deidentified Clinformatics Data Mart Database (2003 to 2019) and IBM MarketScan Databases (2007 to 2016). Both databases were assessed for sex, age, etiology of ectopia lentis, IOL implantation, and postoperative retinal detachment separately. Univariate and multivariate analyses were conducted to identify the risk factors for postoperative retinal detachment.

RESULTS

Among a total of 298 eyes (210 patients), IOL implantation was coupled with lens surgery in 151 eyes (49.8%) that underwent lens surgery for nontraumatic ectopia lentis. The median follow-up was 32 months in aphakic eyes and 29 months in pseudophakic eyes. Patients undergoing IOL implantation were older at the time of lens surgery (median age: no IOL, 6 years; IOL, 16 years; P < .001). Retinal detachment developed in 13 patients (14 eyes [4.7%]) 14 eyes (4.7%). Older age was the baseline characteristic that correlated most closely with the risk for retinal detachment (P = .05).

CONCLUSIONS

The rate of retinal detachment was similar with or without IOL implantation after lens surgery for nontraumatic ectopia lentis in children and young adults.

Sutureless Scleral-Fixated Intraocular Lens Implantation in the Treatment of Congenital Lens Subluxation Related to Marfan Syndrome

PURPOSE

To evaluate the efficacy and safety of bimanual capsulorhexis combined with sutureless scleral-fixated intraocular lens (IOL) implantation in children diagnosed as having Marfan syndrome.

METHODS

The study included 14 eyes with subluxated lenses of 7 children who were diagnosed as having Marfan syndrome and underwent bimanual capsulorhexis combined with sutureless scleral-fixated IOL implantation by the same surgeon between 2015 and 2019 at the University of Health Sciences, Kartal Dr. Lütfi Kirdar City Hospital's Eye Department.

RESULTS

The mean preoperative and postoperative uncorrected visual acuity was 1.47 ± 0.41 and 0.42 ± 0.15 logarithm of the minimum angle of resolution (logMAR), respectively (P = .001). The preoperative best corrected visual acuity (BCVA) ranged from 1.30 to 0.40 logMAR with a mean value of 0.81 ± 0.30 logMAR. Postoperatively, all patients had an increase in the BCVA with a mean value of 0.20 ± 0.11 logMAR, which was statistically significant (P = .001). The mean preoperative and postoperative spherical equivalent was -9.69 ± 4.59 and -0.27 ± 1.21 diopters, respectively.

CONCLUSIONS

Despite the small number of patients in this study, good visual results and a low complication rate were obtained in patients with ectopic lens. The long-term IOL status in patients who have undergone sutureless scleral-fixated IOL implantation will make it possible to better evaluate the safety and applicability of the technique. [J Pediatr Ophthalmol Strabismus. 2021;58(6):401-406.].

Management of the subluxated crystalline lens: A review

Cataract surgery for the subluxated crystalline lens is challenging. A thorough preoperative evaluation is important to determine the appropriate surgical approach for lens removal and the subsequent technique of intraocular lens placement. Important considerations include the extent and location of zonular weakness, and whether the zonular deficiency is caused by a static or progressive disease. The capsular bag should be preserved where possible. Creating a good-sized and centred continuous curvilinear capsulorhexis is crucial to facilitate the use of capsular retractors and capsular tension devices, which provide capsular stability. Nucleus sculpting and rotation should be minimised to reduce zonular stress. Being cognisant of the possible intraoperative complications that may occur at each stage of the surgery and knowing how to reduce the risk of these complications occurring will enable surgeons to perform safe cataract surgery in these complex cases.

Three-Year Outcomes of Cionni-Modified Capsular Tension Ring Implantation in Children Under 8 Years Old With Ectopia Lentis

PURPOSE

This study evaluated visual outcomes and complications at 3 years post-implantation of a Cionni-modified capsular tension ring (MCTR) with an intraocular lens (IOL) in ectopia lentis patients ≤8 years old.

DESIGN

Prospective clinical cohort study.

METHODS

Included were 101 eyes from 57 patients <8 years of age, who underwent surgery for nontraumatic ectopia lentis between November 2015 and December 2016. Exclusion criteria were planned IOL fixation in the ciliary sulcus, severe intraoperative complications, and incomplete follow-up. All eyes received in-the-bag implantation of a posterior IOL and Cionni-MCTR. Posterior capsulectomy and anterior vitrectomy were performed through the pars plana in 23 eyes of children <5 years of age. Patients were examined at 1 day, and 1, 6, and 12 months, and at 2 and 3 years postoperatively. Outcome; measurements included best-corrected visual acuity (BCVA), intraocular pressure (IOP), IOL centration, and posterior capsule opacification (PCO).

RESULTS

In all eyes, BCVA improved significantly after surgery, especially during the first 12 months (P < .05). Three years post-operatively, 44 eyes had BCVA 0.9 or better. Prophylactic Nd:YAG laser capsulotomy was performed 3 months post-surgery in 24 eyes; 34 eyes underwent this; procedure 6 months post-surgery because of PCO. A second surgery was; warranted in 4 eyes because of severe IOL decentration and combined anterior capsule contraction. No severe postoperative complications, such as retinal detachment or endophthalmitis, occurred.

CONCLUSIONS

Implantation of in-the-bag IOL with Cionni MCTR is effective for visual rehabilitation in young children with ectopia lentis. A close follow-up of these patients is necessary to monitor IOL centration and stability.

Marfan syndrome and the eye clinic: from diagnosis to management

Marfan syndrome (MFS) is an autosomal dominantly inherited disorder affecting the cardiovascular, ocular and musculoskeletal systems. Frequently, clinical suspicion and subsequent diagnosis begins in the ophthalmology clinic. Importantly, the ophthalmologist has a responsibility to cater not only to the eye, but also to be involved in a holistic approach for these patients. In this review, we discuss how MFS may present to an eye clinic, including clinical features, ocular morbidity, genetic diagnosis and management. Although this condition is ideally managed by a multidisciplinary team, our focus will be on MFS and the eye, including other conditions which may present with similar phenotypes. The ophthalmologist's role as the potential first contact for a patient with suspected MFS is crucial in making the proper investigations and referral, with the knowledge that not all ectopia lentis cases are MFS and vice versa. Management of ocular conditions in MFS may range from simple observation to surgical intervention; current options will be discussed.

Ocular manifestations in classic homocystinuria

BACKGROUND

Classic homocystinuria (HCU), or cystathionine beta-synthase (CBS) deficiency, is a rare inborn error of methionine metabolism. Main clinical features may include skeletal and vascular manifestations, developmental delay, intellectual disability and eye disorders.

MATERIAL AND METHODS

This is an observational and retrospective study aiming at describing eye abnormalities presented by a cohort of late-diagnosed HCU patients. Data regarding ophthalmological evaluation included visual acuity, refraction, biomicroscopy, Perkins tonometry, fundus examination, retinography, biometry, ocular ultrasound, optical coherence tomography, anterior segment photography and topography.

RESULTS

Ten patients with HCU (20 eyes) were included. The most frequent findings were ectopia lentis(n = 20) and myopia (n = 9). Biometry, ultrasound, OCT and topography findings were available for four patients. One patient had keratoconus; one had abnormal retinal pigmentation; and two had lens surgery scars with irregular astigmatism.

CONCLUSIONS

Eye abnormalities are very frequent in late-diagnosed HCU patients. The presence of ectopia lentis should always raise the diagnostic hypothesis of HCU.

Cystathionine β-synthase Deficiency Impairs Vision in the Fruit Fly, Drosophila melanogaster

PURPOSE

Deficiency in Cystathionine β-synthase (CBS) leads to an abnormal accumulation of homocysteine and results in classical homocystinuria, a multi-systemic disorder that affects connective tissue, muscles, the central nervous system, and the eyes. However, the genetic players and mechanisms underlying vision alterations in patients with homocystinuria are little understood.

MATERIALS AND METHODS

The fruit fly, Drosophila melanogaster, is a useful system to investigate the genetic basis of several human diseases, but no study to date has used Drosophila as model of homocystinuria. Here, we use Drosophila genetic tools to down-regulate CBS expression and evaluate its behavioral response to light.

RESULTS

We show that CBS-deficient flies do not display the normal stereotypical behavior of attraction towards a luminous source, known as phototaxis. This behavior cannot be attributed to a motor or olfactory deficiency, but it is most likely related to a lower visual acuity. CBS-deficient flies are overall smaller, but smaller eyes do not explain their lack of phototactic response.

CONCLUSIONS

The vision phenotype of CBS knock-down flies is consistent with severe myopia in homocystinuria patients. We propose to use Drosophila as a model to investigate ocular manifestations underlying homocystinuria.

<p>Ocular Manifestations and Biometrics in Marfan’s Syndrome from Eastern Nepal</p>

Purpose

To evaluate the ocular characteristics of Marfan’s syndrome (MFS) fulfilling the revised Ghent-2 nosology in Eastern Nepal.

Materials and Methods

A hospital-based observational and cross-sectional study was conducted. Ocular manifestations and biometrics were incorporated. Patients were subdivided into adults (16 years or older) and children (5–15 years). Ocular biometric parameters consisted of values of refractive error, keratometry readings, anterior chamber depth (ACD), central corneal thickness (CCT), lens thickness (LT) and axial length (AL).

Results

A total of 34 eyes of 17 patients with MFS were included, where 32 eyes were phakic. Mean age of the study participants was 14.5 ± 9.1 years. The mean best corrected visual acuity (BCVA) of phakic eyes was 0.99 ± 0.82 LogMAR. Myopia greater than −3 diopters (D) was present in 28/34 (82.35%) eyes. The average spherical equivalent was −12.34 ± 8.85 D. Ectopia lentis (EL) was present in 24/32 (75%) eyes where superonasal was the most common subluxation in 10/24 (41.7%) eyes. AL was longer in adults 26.54 ± 4.42 mm compared to 25.21 ± 1.93 mm in children. Likewise, LT in adults was 4.9 ± 0.70 mm and 4.40 ± 0.59 mm in pediatric participants. Flat corneas were noted in both the groups with an average of 41.53 ± 2.21 D. The mean CCT and ACD were 524.62 ± 21.74 μm and 3.64 ± 0.80 mm, respectively. There was a negative association between the AL and the average corneal curvature (K_med, correlation coefficient −0.11, p=0.54).

Conclusion

Myopia is the foremost ocular involvement with significant visual disability in MFS. Though, AL and corneal curvature are not included in the revised Ghent-2 nosology, we strongly recommend these parameters to be considered during ophthalmic evaluation in suspected and diagnosed cases of MFS in the absence of genetic testing.

Bimanual irrigation-aspiration for ectopia lentis and use of a small incision for 4-point scleral-sutured foldable intraocular lens and anterior vitrectomy in patients with Marfan syndrome

Purpose:

This study evaluated bimanual intracapsular irrigation-aspiration for ectopia lentis with use of a small incision for 4-point scleral fixation of a foldable posterior-chamber intraocular lens (IOL) and anterior vitrectomy in patients with Marfan syndrome.

Methods:

We performed a retrospective study of 18 eyes from 10 patients with Marfan syndrome who underwent surgical intervention for ectopia lentis at our clinic between July 2012 and September 2018. In this study, intraoperative and postoperative complications, uncorrected visual acuity, best-corrected visual acuity, spherical equivalent, intraocular pressure, and endothelial cell density were evaluated.

Results:

No intraoperative complications were reported. In all cases, early postoperative evaluation revealed a clear cornea, round pupil, and well-centered IOL. Mean logMAR uncorrected visual acuity improved from 1.09 preoperatively to 0.56 postoperatively (P < 0.05). Mean logMAR best-corrected visual acuity improved from 0.45 preoperatively to 0.17 postoperatively (P < 0.05). Aside from transient ocular hypertension, no postoperative complications were reported.

Conclusion:

The combined surgical technique presented above yields excellent visual outcomes with an extremely low incidence of complications. This approach is simple, safe, and effective in the treatment of ectopia lentis in patients with Marfan syndrome.

Ocular abnormalities and complications in anterior megalophthalmos: a case series

OBJECTIVES

To describe the clinical and Scheimpflug imaging features in cases of anterior megalophthalmos (AM).

METHODS

Retrospective record review was performed for patients with AM who presented between June 2017 and May 2018. Clinical history, slit lamp examination, Scheimpflug imaging indices (Pentacam-HR, Oculus, GmbH), dilated fundus examination and treatment records were reviewed.

RESULTS

The study included eight eyes of four male patients (mean age 6.5 years, range 4-10 years). Corrected distance visual acuity ranged from finger counting to 20/80. The mean horizontal corneal diameter, central corneal thickness, steep keratometry, flat keratometry, anterior chamber (AC) angle, AC depth, maximum pupil diameter and axial length were 13.8 ± 0.5 mm, 538.7 ± 68.9 µm, 42.8 ± 1.6 D, 41.4 ± 0.9D, 47.0 ± 4.2 degree, 3.8 ± 0.3 mm, 3.9 ± 0.1 mm, and 24.9 ± 0.9 mm, respectively. Posterior dislocation of crystalline lens, vitreous degeneration and rhegmatogenous retinal detachment (consequent of retinal dialysis/atrophic hole/lattice with hole) were noted in seven, eight and five eyes, respectively. Pigment dispersion glaucoma was noted in both eyes of one patient, which was managed with topical anti-glaucoma medication. Vitrectomy with silicone oil tamponade was successful in retinal reattachment in all three eyes that underwent surgery.

CONCLUSION

Scheimpflug imaging helps in demonstrating the corneal and anterior segment pathological changes in AM. The disease extends to involve the zonules, vitreous and retina as well. Ophthalmologists should be able to identify this disorder, recognise and manage the associations and complications.

Management Strategies of Ocular Abnormalities in Patients with Marfan Syndrome: Current Perspective

Marfan syndrome is an autosomal dominant genetic connective tissue disorder that results from mutations in the fibrillin-1 gene located on chromosome band 15q15-21. Fibrillin, a glycoprotein, is widely expressed throughout the body and contributes to the elasticity and force-bearing capacity of connective tissue. In the eye, fibrillin is a key constituent of the ciliary zonules, which suspend the crystalline lens in place. The zonular defect leads to ectopia lentis, which is a hallmark of Marfan ocular abnormalities and occurs in 60% to 80% of cases. Other less common ocular features of Marfan syndrome are increased axial length, astigmatism, and flat cornea. Visual function in Marfan syndrome could be affected in several ways: ectopia lentis, refractive error, amblyopia, retinal detachment, cataract, and glaucoma. Management of a subluxated lens starts with the correction of refractive error with eyeglasses in mild cases. In more severe cases, especially when the lens bisects the pupil, complete correction of refractive error is impossible without removing the subluxated lens. The best method for visual rehabilitation after lens extraction is still debated. Aphakic Artisan lens implantation at the time of subluxated lens removal results in good visual outcomes with an acceptable safety profile. Studies with longer term follow-up and larger sample populations are needed to evaluate the safety of this procedure in patients with Marfan syndrome.

Surgical indications, outcomes, and complications with the use of a modified capsular tension ring during cataract surgery

PURPOSE

To determine the surgical indications, outcomes, and complications with the use of modified capsular tension rings (CTRs) during cataract surgery.

SETTING

Ivey Eye Institute, Western University, London, Ontario, Canada.

DESIGN

Systematic review.

METHODS

A systematic review of databases was conducted for studies related to the use of modified CTRs during cataract surgery that were published between 1992 and 2015. Primary research papers on human participants published in English were screened. The surgical indications, outcomes, and complications of modified CTR use during cataract surgery were compiled and analyzed.

RESULTS

The search identified 6035 records from published and gray literature. After screening, 10 studies involving 320 eyes were included in the systematic review. The most common surgical indications for modified CTR use were Marfan syndrome (40.3%), idiopathic zonular insufficiency (27.2%), and previous ocular trauma (22.8%). The weighted average of indicated zonular insufficiency was 173 degrees, with 75.4% of eyes achieving visual acuity better than 20/40 postoperatively. The use of modified CTRs resulted in a reduction in intraocular lens (IOL) decentration and tilt. Vitrectomy during surgery was required in 19.8% of eyes. The rate of posterior capsule opacification (PCO) was 41.1%. Intraocular pressure (IOP) elevation, suture breakage, and uveitis were the most common postoperative complications.

CONCLUSIONS

The use of modified CTRs during cataract surgery was associated with causes of large and progressive zonular insufficiency. Use of the CTR produced good postoperative visual outcome and reduced IOL decentration and/or tilt. The most common complications were PCO, IOP elevation, and suture breakage.

FINANCIAL DISCLOSURE

None of the authors has a financial or proprietary interest in any material or method mentioned.

Retinal detachments in the pediatric population

In this review, we present a concise summary of the more commonly seen types of retinal detachments (RDs) that one can encounter in pediatric patients. A spectrum of diseases from rhegmatogenous RD in Stickler syndrome, Marfan syndrome, and choroidal coloboma to exudative RD in Coats disease, to tractional RD in persistent fetal vasculature, and combined RDs in familial exudative vitreoretinopathy are described with the management pearls for each.

Gastrointestinal Symptoms in Marfan Syndrome and Hypermobile Ehlers-Danlos Syndrome

Objective

Marfan syndrome (MS) is a multisystem disorder caused by a mutation in FBN1 gene. It shares some phenotypic features with hypermobile Ehlers-Danlos syndrome (EDS) such as joint hypermobility. EDS is a group of inherited heterogenous multisystem disorders characterized by skin hyperextensibility, atrophic scarring, joint hypermobility, and generalized tissue fragility. Hypermobile EDS (hEDS) is thought to be the most common type. Recent studies have suggested an association between connective tissue hypermobility and functional gastrointestinal disorders (FGDs). The aim of this study is to determine the prevalence of gastrointestinal symptoms in patients with Marfan syndrome and hypermobile EDS.

Method

Patients with a diagnosis of either MS or hEDS attending cardiology or rheumatology outpatients at our hospital were asked to complete SF36 RAND and Rome IV Diagnostic questionnaires. Questionnaires were also completed by patients who are members of Marfan Association UK. The same questionnaires were also completed by age- and gender-matched controls attending fracture clinic without existing diagnoses of MS or hEDS.

Results

Data were collected from 45 MS patients (12 males and 33 females, age range 19-41 years, mean 28 years) and 45 hEDS patients (6 males and 39 females, age range 18-32 years, mean 24 years). None had a previous organic gastrointestinal diagnosis. The control group was matched for age and sex (18 males and 72 females, age range 18-45, mean 29 years). Both MS and hEDS groups showed a higher prevalence of abdominal symptoms compared to the control group; however, the hEDS group not only showed a higher prevalence but more frequent and severe symptoms meeting Rome IV criteria for diagnosis of FGIDs. Nearly half of the hEDS patients met the criteria for more than one FGID. The hEDS group also scored lower on quality of life (QOL) scores in comparison to either of the other groups with a mean score of 48.6 as compared to 54.2 in the Marfan group and 78.6 in the control group.

Conclusion

FGIDs are reported in both Marfan syndrome and hypermobile Ehlers-Danlos syndrome but appear to be more common and severe in hEDS. These patients score lower on quality of life scores as well despite hypermobility being a common feature of both conditions. Further work is needed to understand the impact of connective tissue disorders on gastrointestinal symptoms.

American Journal of Ophthalmology Contributions to Ophthalmic Genetics

PURPOSE

To review the contributions to ophthalmic genetics through the American Journal of Ophthalmology (AJO).

DESIGN

Perspective.

METHODS

A literature search to retrieve original articles, letters, editorials, and published lectures from 1966 to 2017, providing a 50-year review. Titles were excluded that gave no reference to genetics or that presented findings related to a nongenetic ocular condition.

RESULTS

From a search of the Scopus database, 719 articles were ascertained. Of these, 115 were excluded because the title did not reference a genetic condition or have a focus on genetic factors; 4 were excluded because they described animal phenotypes (1966-1967); and 4 were excluded owing to having received no citations up to and including 2015. The highest number of citations was 283 times for a single article on familial aggregation in age-related macular degeneration. The Web of Science database yielded 771 articles; of these, 118 were excluded owing to not reporting human genetic studies; 55 received no citations. The highest number of citations was 307 for a single article, a 1991 paper on Leber hereditary optic neuropathy.

CONCLUSIONS

The Journal's contributions to our understanding of the heritability of human ocular traits have been broad and deep, with international reach. The development of new techniques fostered new concepts and new approaches to rapidly expand the number of known single gene disorders with a defined molecular genetic cause. Reports on Mendelian and complex traits in the AJO abound, along with 6 Edward Jackson Memorial Lectures on retinal dystrophies, Leber congenital amaurosis, age-related macular degeneration, and glaucoma.

Ocular manifestations of Marfan syndrome in children and adolescents

PURPOSE:

To study ocular manifestations of Marfan syndrome in children and adolescents.

METHODS:

Retrospective comparative cohort study on consecutive patients up to age 17 years, presenting to the interdisciplinary Marfan clinic of Charité-University Medicine Berlin over a period of 4 years.

RESULTS:

A total of 52 Marfan syndrome patients and 73 controls were enrolled. In Marfan syndrome eyes, the cornea was flatter (mean keratometry, 40.86 ± 2.13 vs 42.55 ± 1.55 diopters in control eyes, p < .001) and corneal astigmatism was greater (1.50 ± 1.22 vs 0.88 ± 0.49 diopters in control eyes, p < .001). The central cornea was thinner in Marfan syndrome eyes (537.35 ± 40.64 vs 552.95 ± 38.57 μm, p = 0.007) and Marfan syndrome eyes were more myopic than control eyes (spherical equivalent, -2.77 ± 4.77 vs -0.64 ± 1.92 diopters, p < .001). Visual acuity was reduced (logMAR 0.11 ± 0.17 vs 0.04 ± 0.26, p = 0.014) and intraocular pressure was lower in Marfan syndrome eyes. Iris transillumination defects were more common in Marfan syndrome eyes (19.6% vs 4.3% in control eyes, odds ratio for Marfan syndrome in the presence of iris transillumination defects = 7.2). Ectopia lentis was only found in Marfan syndrome eyes (25 Marfan syndrome patients, 49% with available data, bilateral in 68%).

CONCLUSION:

Iris transillumination defects and ectopia lentis are characteristic ocular findings in children and adolescents with Marfan syndrome. Myopia is more common and corneal curvature, central corneal thickness, and visual acuity are reduced in Marfan syndrome eyes. Children with Marfan syndrome need regular comprehensive eye examinations to identify potential complications.

Bilateral Retinal Detachment in Marfan's Syndrome

Purpose

Bilateral retinal detachment (RD) in Marfan's syndrome (MS) has a typical preoperative, operative, and post-operative course. This study describes symmetry of retinal tears and bilateral RD surgery in five MS patients over a period of 15 years.

Methods

Six eyes with uncomplicated RD were operated on using the scleral buckling procedure, and four eyes with complicated RD were operated using a pars plana vitrectomy (PPV) and inner retinal tamponade with silicon oil.

Results

Complete retinal reattachment was achieved in seven eyes. Partial anatomical success with attached macula was achieved in one eye. The surgery failed in two eyes. Final visual acuity was between 0.66 and 0.33 in three eyes, and between 0.25 and 0.1 in five; two eyes had no light perception.

Conclusions

The course of the bilateral retinal disease highly correlated with the symmetry of retinal defects.

Ocular Manifestations of Pediatric Systemic Diseases

Ocular manifestations that occur directly or indirectly as result of a pathologic process that involves other parts of the body, in a pediatric population, will be discussed here. While a myriad number of systemic conditions have ocular manifestations, its importance cannot be undermined because it has implications for both diagnosis and treatment. Often, the eye findings can give a clue to the systemic diagnosis and at other times, not managing the eye manifestations can lead to irreversible blindness although the systemic condition was treated well. So, it is important for all clinicians dealing with pediatric population to be aware of ocular manifestations of the common systemic conditions. The authors discuss the ocular manifestations of the following systemic conditions: Genetic and chromosomal anomalies, phakomatoses, metabolic disorders, infectious diseases, craniofacial anomalies, muscular disorders, inflammatory disorders and miscellaneous.

Ocular findings in Loeys-Dietz syndrome

Background

Loeys-Dietz syndrome (LDS), an autosomal-dominant connective tissue disorder, is characterised by systemic manifestations including arterial aneurysm and craniofacial dysmorphologies. Although ocular involvement in LDS has been reported, detailed information on those manifestations is lacking.

Methods

Retrospective chart review of patients with diagnosed LDS and comparison with age-matched control patients.

Results

Mean age was 37.8±14.6 years (patients with LDS) and 38.4±13.5 years (controls). Patients with LDS less frequently had iris transillumination, cataract and glaucoma compared with controls. Scleral and retinal vascular abnormalities were not found in any of the LDS eyes. Ectopia lentis was found in one patient with LDS. The eyes of patients with LDS tended to be more myopic (spherical equivalent, −2.47±2.70 dioptres (dpt) vs −1.30±2.96dpt (controls); P=0.08) and longer (24.6±1.7mm vs 24.1±1.5mm (controls); P=0.10). Central corneal thickness was significantly reduced in LDS eyes (521±48µm vs 542±37µm (controls); P=0.02). Corneal curvature (43.06±1.90dpt (LDS) versus 43.00±1.37dpt (controls); P=0.72) and interpupillary distance (65.0±6.0mm (LDS) vs 64.3±4.8mm (controls); P=0.66) did not differ significantly between both groups. Visual acuity was similar between both groups (0.03±0.09logarithm of the minimum angle of resolution (logMAR) for LDS eyes and 0.05±0.17logMAR for control eyes, P=0.47).

Conclusions

Ocular features of LDS include decreased central corneal thickness and mild myopia. Ectopia lentis may be slightly more common than in controls but appears less common than in Marfan syndrome. Hypertelorism, scleral and retinal vascular abnormalities were not features of LDS.

Biometric and structural ocular manifestations of Marfan syndrome

Background

To study biometric and structural ocular manifestations of Marfan syndrome (MFS).

Methods

Observational, retrospective, comparative cohort study in a tertiary referral center on 285 MFS patients and 267 controls. Structural and biometric ocular characteristic were compared.

Results

MFS eyes were longer (axial length 24.25 ± 1.74 mm versus 23.89 ± 1.31 mm, p < 0.001) and had a flatter cornea than control eyes (mean keratometry 41.78 ± 1.80 diopters (D) versus 43.05 ± 1.51 D, p < 0.001). Corneal astigmatism was greater and the central cornea was thinner in MFS eyes (530.14 ± 41.31 μm versus 547.02 ± 39.18 μm, p < 0.001). MFS eyes were more myopic than control eyes (spherical equivalent -2.16 ± 3.75 D versus -1.17 ± 2.58 D, p < 0.001). Visual acuity was reduced (0.13 ± 0.25 logMAR versus 0.05 ± 0.18 logMAR, p < 0.001) and intraocular pressure was lower in MFS eyes (14.6 ± 3.4 mmHg versus 15.1 ± 3.2 mmHg, p = 0.01). Iris transillumination defects (ITD) were significantly more common in MFS eyes (odds ratio for MFS in the presence of ITD, 3.7). Ectopia lentis (EL) was only present in MFS eyes (33.4%). History of retinal detachment was significantly more common in MFS eyes. Glaucoma was equally common in both groups.

Conclusions

ITD and EL are most characteristic findings in MFS. ITD and corneal curvature should be studied as diagnostic criteria for MFS. Visual acuity is reduced in MFS. MFS patients need regular eye exams to identify serious ocular complications.

[Morphological features of clinical manifestations of particular congenital lens and vitreous anomalies]

The review covers general clinical features of particular congenital anomalies of the human eye associated with its abnormal embryonic development. Principal literature sources on evaluation of congenital changes in the vitreous body and identification of its 'underdevelopment' in certain types of congenital cataracts have been studied. The said changes were analyzed with account to general pathology of the human body as well as local morphological manifestations. Covered is the time period from the end of the XIX century to the present. According to the authors, their analysis helps justify the use of digital three-dimensional ultrasound examination for intravital evaluation of congenital changes in the lens and vitreous.

Biometry Characteristics in Adults and Children With Marfan Syndrome: From the Marfan Eye Consortium of Chicago

PURPOSE

To report on the biometric findings of adults and children with Marfan syndrome (MFS) recruited from 2 annual National Marfan Foundation conferences (2012 and 2015).

DESIGN

Cross-sectional study.

METHODS

Subjects diagnosed with MFS by Ghent 2 nosology were included for analysis. Subjects were divided into "adults" (≥16 years of age) and "children" (5-15 years of age). Biometric data included values for refractive error, axial length (AL), corneal curvature, anterior chamber depth, lens thickness, and central corneal thickness.

RESULTS

Of the 117 subjects evaluated, 74 (35 adults, 32 children, and 7 children <5 years of age) had a definite diagnosis of MFS and were included in the study. The AL was longer (25.25 ± 0.32 mm vs 24.24 ± 0.33 mm, P = .03) and the lens was thicker (3.94 ± 0.09 mm vs 3.62 ± 0.10 mm, P = .03) in adults. Both groups had flat corneas (average keratometry [K_med] of 41.59 ± 0.35 diopters [D] in adults vs 40.89 ± 0.36 D in children, P = .17). A negative correlation was found between AL and K_med (-0.33, P < .001). The corneas of patients with MFS with ectopia lentis (EL) were significantly flatter and with higher degree of corneal astigmatism compared to patients without EL (K_med of 40.68 ± 0.31 D vs 41.75 ± 0.28 D, P < .01 and corneal astigmatism of 1.68 ± 0.16 D vs 1.13 ± 0.14 D, P = .01).

CONCLUSIONS

Children with established MFS have flat corneas at least to the same degree as adults. Corneas of patients with MFS with EL are flatter and have a higher degree of corneal astigmatism. We strongly suggest that corneal parameters should be measured if MFS is suspected, especially in children that may not yet have developed EL.

A novel FBN1 missense mutation (p.C102Y) associated with ectopia lentis syndrome in a Chinese family

AIM

To characterize the disease-causing mutations in a Chinese family with ectopia lentis syndrome (ELS).

METHODS

Patients and their family members were given complete physical, ophthalmic, and cardiovascular examinations. Genomic DNA samples were extracted from the peripheral blood of the pedigree members and 100 healthy controls. Mutation screening was performed in the fibrillin-1 (FBN1) gene by bi-directional sequencing of the amplified products. The mutation was analyzed using two bioinformatics methods.

RESULTS

A novel heterozygous c.305G>A mutation in exon 3 of FBN1 was detected. As a result of this change, a highly conserved cysteine residue was replaced by a tyrosine residue (p.C102Y). Another mutation was found in the same exon (c.303T>C), which did not change the amino acid sequence. Both mutations were discovered in each affected individual, but not in the unaffected family members, or in 100 ethnically matched controls. A bioinformatics analysis predicted that mutation p.C102Y would affect protein function.

CONCLUSION

In the first epidermal growth factor-like module, we identified a novel FBN1 mutation (p.C102Y), which caused ELS in the family. Our study presented a unique phenotype, including some distinct ophthalmic findings, such as hypoplasia of the iris and anisometropia. Our results expanded the mutation spectrum of FBN1 and enriched the overall knowledge of genotype-phenotype correlations due to FBN1 mutations.

Pediatric Glaucoma: A Literature's Review and Analysis of Surgical Results

The purpose of this paper is to review the surgical options available for the management of pediatric glaucoma, to evaluate their advantages and disadvantages together with their long-term efficacy, all with the intent to give guidelines to physicians on which elements are to be considered when taking a surgical decision. Currently there is a range of surgical procedures that are being used for the management of pediatric glaucoma. Within these, some are completely new approaches, while others are improvements of the more traditional procedures. Throughout this vast range of surgical options, angle surgery remains the first choice in mild cases and both goniotomy and trabeculotomy have good success rates. Trabeculectomy with or without mitomycin C (MMC) is preferred in refractory cases, in aphakic eyes, and in older children. GDIs have a good success rate in aphakic eyes. Nonpenetrating deep sclerectomy is still rarely used; nevertheless the results of ongoing studies are encouraging. The different clinical situations should always be weighed against the risks associated with the procedures for the individual patients. Glaucomatous progression can occur many years after its stabilization and at any time during the follow-up period; for this reason life-long assessment is necessary.

Rare Diseases Leading to Childhood Glaucoma: Epidemiology, Pathophysiogenesis, and Management

Noteworthy heterogeneity exists in the rare diseases associated with childhood glaucoma. Primary congenital glaucoma is mostly sporadic; however, 10% to 40% of cases are familial. CYP1B1 gene mutations seem to account for 87% of familial cases and 27% of sporadic cases. Childhood glaucoma is classified in primary and secondary congenital glaucoma, further divided as glaucoma arising in dysgenesis associated with neural crest anomalies, phakomatoses, metabolic disorders, mitotic diseases, congenital disorders, and acquired conditions. Neural crest alterations lead to the wide spectrum of iridocorneal trabeculodysgenesis. Systemic diseases associated with childhood glaucoma include the heterogenous group of phakomatoses where glaucoma is frequently encountered in the Sturge-Weber syndrome and its variants, in phakomatosis pigmentovascularis associated with oculodermal melanocytosis, and more rarely in neurofibromatosis type 1. Childhood glaucoma is also described in systemic disorders of mitotic and metabolic activity. Acquired secondary glaucoma has been associated with uveitis, trauma, drugs, and neoplastic diseases. A database research revealed reports of childhood glaucoma in rare diseases, which do not include glaucoma in their manifestation. These are otopalatodigital syndrome, complete androgen insensitivity, pseudotrisomy 13, Brachmann-de Lange syndrome, acrofrontofacionasal dysostosis, caudal regression syndrome, and Wolf-Hirschhorn syndrome.

Ocular disease in the cobalamin C defect: a review of the literature and a suggested framework for clinical surveillance

The association between combined methylmalonic acidemia and homocystinuria of cblC type (cobalamin C defect, cblC) and ocular disease is now well recognized, and is a significant component of morbidity and disability associated with the condition. In this review, through collation of historically reported cases of early- and late-onset cblC and previously unreported cases, we have attempted to characterize the epidemiology, clinical features, and pathomechanisms of individual ocular features of cblC. These data suggest that maculopathy and nystagmus with abnormal vision are extremely common and affect the majority of children with early-onset cblC, usually before school age; strabismus and optic atrophy are also seen at relatively high frequency. The timing of progression of macular disease may coincide with a critical period of postnatal foveal development. Maculopathy and retinal disease may be subclinical and show only partial correlation with the extent of visual deficits, and visual deterioration may be relentlessly progressive in spite of aggressive treatment of biochemical abnormalities. In later-onset forms of the disease, visual loss and ocular complications appear to be infrequent. Finally, we discuss investigational strategies in diagnosing and characterizing eye disease in individuals with cblC, explore possible therapeutic avenues that may attenuate progression and severity of eye disease, and propose a clinical surveillance guideline for monitoring progression of ocular disease in children and adults with cblC.

Ocular findings in 87 adults with Ghent-1 verified Marfan syndrome

PURPOSE

To study ocular characteristics in 87 patients with verified Marfan syndrome (MFS) based on the Ghent criteria from 1996 (Ghent-1).

METHODS

The position of the lens was noted by observing the eye in different gaze directions in maximal mydriasis during slit lamp examination. Ectopia lentis (EL) was classified as subluxated (dislocation slightly backwards) or luxated (vertical or horizontal displacement). Corneal curvature, axial length (AL), corneal diameter, central corneal thickness, anterior chamber depth, lens thickness, condition of the iris, intraocular pressure, spherical equivalent and visual acuity were also investigated.

RESULTS

EL was found in 108 eyes (62.1%). Of the 68 phakic eyes with EL, 43 (63.2%) had subluxation. Mean AL was 24.80 ± 2.57 mm, and the AL was above 23.5 mm in 65.3%. Mean keratometry (K) in phakic eyes was 41.79 ± 1.70 diopters (D), and the K value was <41.5D in 46.8%. Iris hypoplasia was found in 3.4%. Myopia above 3D occurred in 38.4% of the phakic eyes. Mean binocular logMAR was 0.10 ± 0.32. Only five patients (5.7%) had a logMAR more than 0.5. These 5 patients had EL, and 4 of them were amblyopic.

CONCLUSION

In this strictly defined MFS group fulfilling the Ghent-1 criteria, the prevalence of EL was 62.1%. In many cases, the dislocation of the lens was subtle. On average, the corneas were flattened and the globe length was increased. Only a few patients were visually impaired. Children with MFS should have a thorough follow up to avoid amblyopia.

Scleral-fixated capsular tension rings and segments for ectopia lentis in children

PURPOSE

To report the short-term outcomes and complications of implantation of scleral-fixated capsular tension rings and/or capsular tension segments with intraocular lenses (IOL) in pediatric patients with ectopia lentis.

DESIGN

Retrospective, observational case series.

METHODS

Thirteen consecutive pediatric patients (19 eyes) underwent placement of in-the-bag IOL with either a Cionni modified capsular tension ring or a capsular tension segment in conjunction with a conventional capsular tension ring between January 1, 2009 and March 30, 2013 by 3 anterior segment surgeons at a single academic center. The scleral fixation suture was 9-0 polypropylene in 16 eyes and CV-8 Gore-Tex (expanded polytetrafluoroethylene) in 3 eyes. Outcome measures included change in corrected distance visual acuity (CDVA) and complications.

RESULTS

The mean age was 10.2 years ± 4.8 (SD) and the median follow-up, 23.4 months. A Cionni modified capsular tension ring was implanted in 5 eyes and a capsular tension segment with an unsutured capsular tension ring was implanted in 12 eyes. In 2 eyes, capsular tension segment alone was placed. The mean CDVA at the final follow-up (0.10 ± 0.11 logMAR, 18 eyes) was significantly better than preoperatively (0.58 ± 0.26 logMAR, 15 eyes) (P < .001). The CDVA at the final follow-up was 20/40 or better in 18 eyes (94.7%). All IOLs were well centered. Posterior capsule opacification developed in 11 eyes (57.9%), 9 eyes (47.4%) required neodymium-yttrium-aluminum-garnet capsulotomy, and 3 eyes (15.8%) required pars plana vitrectomy and posterior capsulotomy. Other complications included broken suture (5.3%) (9-0 polypropylene at CTR eyelet, repaired with CV-8 Gore-Tex), conjunctival dehiscence (5.3%), suture exposure (5.3%) (trans-scleral 9-0 polypropylene), and vitreous strand at inferior paracentesis (5.3%).

CONCLUSIONS

Implantation of in-the-bag IOL with either a Cionni modified capsular tension ring or a capsular tension segment in conjunction with a conventional capsular tension ring appears to be a safe and effective technique for visual rehabilitation in pediatric ectopia lentis.

Ophthalmic presentation in the emergency department: a case report of a girl with "shimmering eyes"

BACKGROUND

Ophthalmic complaints are commonplace in the emergency department (ED) and are often initial presentations of a systemic illness. We present a 2-year-old girl presenting to the ED with ataxia and "shimmering" eyes.

CASE REPORT

The patient was diagnosed with opsoclonus-myoclonus syndrome (OMS) involving involuntary, multi-vectorial (mostly horizontal), conjugate fast eye movements without intersaccadic intervals. The ophthalmic presentation led to a paraneoplastic work-up, which revealed an abdominal mass measuring 5.3 × 3.3 × 4.3 cm, suggestive of neuroblastoma. The patient's opsoclonus improved after a 5-day course of dexamethasone and intravenous immunoglobulin. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case illustrates the importance of recognizing pathognomonic ophthalmic complaints in the ED. We present an overview of classic ophthalmic presentations associated with systemic illnesses.

Surgical management of lens subluxation in Marfan syndrome

PURPOSE

To review the literature on the surgical management, describe a simplified surgical technique, and to report the postoperative clinical course of ectopia lentis removal in patients with Marfan syndrome.

METHODS

The medical records of patients with a clinical diagnosis of Marfan syndrome and clinically significant lens subluxation were retrospectively reviewed. Patients underwent lens extraction by a single surgeon via a simplified anterior segment approach. The pre- and postoperative best-corrected visual acuity, biometric measurements, intraocular pressure, and incidence of surgery-related complications were reviewed.

RESULTS

A total of 42 eyes of 22 patients were included. Mean postoperative follow-up was 4.9 ± 2.9 years (range, 1-10 years). Average age at surgery was 10.2 ± 9.2 years (range, 2-37 years), with 18 patients (36 eyes) ≤ 18 years of age. The average preoperative best-corrected visual acuity was 20/80, and the average postoperative best-corrected visual acuity at last follow-up was 20/25, with an average improvement of 6 lines on the Snellen chart. All eyes had a best-corrected visual acuity > 20/30 at last follow-up with aphakic correction. One eye of 1 patient developed a retinal detachment following blunt trauma. No other intra- or postoperative complications were reported.

CONCLUSIONS

Anterior lensectomy and limited vitrectomy with aphakic correction is safe and provides a consistent visual outcome in patients with lens subluxation secondary to Marfan syndrome. This is especially important in pediatric patients, in whom long-term follow-up for iris- and scleral-fixated intraocular lenses is limited.