Ocular pathology in congenital heart disease

Evaluation of retinal and peripapillary vessel density and subfoveal choroidal thickness changes in patients undergoing cardiopulmonary bypass: An OCTA study

PURPOSE

We aimed to investigate hemodynamic changes in the retina, peripapillary area, and choroid in patients undergoing coronary artery bypass grafting (CABG).

METHODS

This prospective case series included 35 eyes of 35 patients. Vessel density (VD) of superficial capillary plexus, deep capillary plexus, radial peripapillary capillary, foveal avascular zone area, and subfoveal choroidal thickness changes were evaluated using optical coherence tomography angiography (OCTA) 1 day before and 2 weeks after surgery. The correlation of these parameters with aortic cross-clamp (ACC) duration and cardiopulmonary bypass (CPB) duration was evaluated.

RESULTS

There were no differences in the OCTA measurements of the patients after CABG compared to before surgery (P > 0.05). Inside-disc VD showed a negative correlation with both ACC (P = 0.036) and CPB duration (P = 0.048); peripapillary inferior hernia showed a negative correlation with both ACC (P = 0.042) and CPB duration (P = 0.027). Another negative correlation was observed between mean peripapillary VD and CPB duration (P = 0.039).

CONCLUSION

The CPB procedure had no permanent effect on retinal choroid and optic disc blood flow postoperatively. Prolonged ACC and CPB times seem to be important in terms of optic nerve blood flow. Clinicians should be alert for postoperative ocular complications after long surgeries.

Association of Cardiovascular Disease with Retinopathy of Prematurity

PURPOSE

To determine the associations of presence and types of cardiovascular diseases (CVDs) with development of retinopathy of prematurity (ROP) in premature infants undergoing ROP examinations.

STUDY DESIGN

We performed secondary analyses of data from the multi-center Postnatal Growth and ROP Validation Study (GROP-2). CVD was categorized based on pulmonary blood flow (PBF), systemic blood flow (SBF), pulmonary hypertension (PPHN), or dysrhythmia. Adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were calculated from multivariable logistic regression models that included any ROP or severe ROP as outcome variable and any CVD or type of CVD as independent variable, with adjustment of covariates including birth weight (BW), gestational age (GA), and days on supplemental oxygen in the first month of postnatal life.

RESULT

Among 3980 infants, 528 (13.3%) had CVD (304 had increased PBF, 101 had decreased PBF, and 49 had PPHN), 1643 (40.4%) developed ROP, and 503 (12.6%) developed severe ROP. In multivariable analyses, presence of CVD was not significantly associated with increased risk of any ROP (aOR = 1.15, 95% CI: 0.90-1.46, p = .26) or severe ROP (aOR = 0.98, 95% CI: 0.72-1.34, p = .92). However, there were trends associating CVD resulting in increased PBF with a higher risk of ROP (aOR = 1.32, 95% CI: 0.97-1.80, p = .08) and PPHN with a higher risk of severe ROP (aOR = 2.04, 95% CI: 0.96-4.35, p = .07). When adjusting only for BW and GA, these associations were significant (aOR = 1.47, 95% CI: 1.09-1.99, and aOR = 2.35, 95% CI: 1.19-4.65, respectively).

CONCLUSION

CVD with increased PBF likely increases the risk of ROP. PPHN likely increases the risk of severe ROP.

Rare presentation of central retinal vein occlusion sparing the superotemporal quadrant in a patient with congenital cardiovascular disease

A young Asian man with a diagnosis of complex congenital heart disease and visceral situs inversus presented to the eye casualty with a recent onset of blurred vision in his left eye. Funduscopic examination of the left eye showed the presence of intraretinal haemorrhages in the inferior and superonasal quadrants, sparing the superotemporal arcade. Optical coherence tomography showed presence of macular oedema and fundus fluorescein angiography confirmed the diagnosis of central retinal vein occlusion sparing the superotemporal branch. Intravitreal antivascular endothelial growth factor treatment was administered, with favourable anatomic and functional outcomes. The presentation of an incomplete central retinal vein occlusion is extremely unusual, especially in a patient with significant cardiac malformation. With the current advances in interventional cardiac procedures, more patients are having longer lifespan and are presenting to ophthalmologists with ocular consequences of circulatory disorders, emphasising the need for multidisciplinary management.

Eyelash trichomegaly: a systematic review of acquired and congenital aetiologies of lengthened lashes

Long eyelashes have been popularized and many commercially available products exist to achieve eyelash growth as a desired cosmetic effect. Eyelash trichomegaly may be induced by medications, procedures, or be related to medical conditions; however, the exact mechanisms that govern eyelash growth are not well elucidated. This study aims to identify and summarize aetiologies associated with eyelash trichomegaly. We report a systematic review of 148 clinical trials, prospective and retrospective studies, and case reports describing all evidence-based potential aetiologies of eyelash trichomegaly obtained from the Medline/PubMed and Cochrane Library through January 2021. Inclusion criteria were defined as (i) human studies involving congenital and acquired diseases in which eyelash trichomegaly is a characteristic or (ii) assessment of trichomegaly as an adverse or desired effect of a medication or procedure. Exclusion criteria included: animal studies, articles not available in English, outcomes unrelated to eyelash trichomegaly, and secondary review articles. Pharmacologic agents associated with eyelash trichomegaly included prostaglandin analogues (15-keto fluprostenol isopropyl ester, bimatoprost, latanoprost, and travoprost), epidermal growth factor receptor inhibitors (cetuximab, erlotinib, and panitumumab), interferon-alpha, and calcineurin inhibitors (tacrolimus and cyclosporine). Surgical procedures of the eyelid, as well as allergic rhinitis, atopic dermatitis, HIV, ichthyosis vulgaris (IV), uveitis, and vernal keratoconjunctivitis were also associated with increased eyelash growth. Congenital disorders associated with lengthened eyelashes included Cantú syndrome, CHOPS syndrome, Coffin-Siris syndrome, congenital heart disease, Cornelia de Lange syndrome, Costello syndrome, familial trichomegaly, Floating Harbor syndrome, Hermansky-Pudlak syndrome, Kabuki-Makeup syndrome, KBG syndrome, Oliver-McFarlane syndrome, Rubinstein-Taybi syndrome, and Smith-Magenis syndrome. While the most common cause of eyelash trichomegaly is topical bimatoprost use, better understanding of pathways implicated in eyelash trichomegaly may lead to the discovery of additional medications to stimulate eyelash growth and create avenues for future therapeutic interventions.

Disability Among Young Adults With Congenital Heart Defects: Congenital Heart Survey to Recognize Outcomes, Needs, and Well-Being 2016-2019

Background

Disabilities have implications for health, well‐being, and health care, yet limited information is available on the percentage of adults with congenital heart defects (CHD) living with disabilities. We evaluated the prevalence of disability and associated characteristics among the 2016–2019 CH STRONG (Congenital Heart Survey to Recognize Outcomes, Needs, and Well‐Being) population‐based sample of 19‐ to 38‐year‐olds with CHD from 3 US locations.

Methods and Results

Prevalence of disability types (hearing, vision, cognition, mobility, self‐care, living independently) were compared with similarly aged adults from the general population as estimated by the American Community Survey and standardized to the CH STRONG eligible population to reduce nonresponse bias and confounding. Health‐related quality of life (HRQOL) was measured via Patient‐Reported Outcomes Measurement Information System Global Health Scale T‐scores standardized to US 18‐ to 34‐year‐olds. Separate multivariable regression models assessed associations between disability and HRQOL. Of 1478 participants, 40% reported disabilities, with cognition most prevalent (29%). Of those reporting disability, 45% ever received disability benefits and 46% were unemployed. Prevalence of disability types were 5 to 8 times higher in adults with CHD than the general population. Those with ≥1 disability had greater odds of being female, and of having non‐Hispanic Black maternal race and ethnicity, severe CHD, recent cardiac care, and noncardiac congenital anomalies. On average, adults with CHD and cognition, mobility, and self‐care disabilities had impaired mental HRQOL and those with any disability type had impaired physical HRQOL.

Conclusions

Two of 5 adults with CHD may have disabilities, which are associated with impaired HRQOL. These results may inform healthcare needs and services for this growing population.

Neuro-Ophthalmological Manifestations in Children with Down Syndrome: Current Perspectives

Down syndrome, caused by an extra copy of all or part of chromosome 21, is the most prevalent intellectual disability of genetic origin. Among numerous comorbidities which are part of the phenotype of individuals with Down syndrome, ocular problems appear to be highly prevalent. Neuro-ophthalmological manifestations, such as ocular alignment and motility disturbances, amblyopia, hypoaccommodation or optic nerve abnormalities, and other organic ocular anomalies frequently reported in Down syndrome, may lead to an overall decrease in visual acuity. Although numerous studies have reported ocular anomalies related to Down syndrome, it remains challenging to determine the impact of each anomaly upon the decreased visual acuity, as most such individuals have more than one ocular problem. Even in children with Down syndrome and no apparent ocular defect, visual acuity has been found to be reduced compared with typically developing children. Pediatric ophthalmological examination is a critical component of a multidisciplinary approach to prevent and treat ocular complications and improve the visual outcome in children with Down syndrome. This narrative review aims to provide a better understanding of the neuro-ophthalmological manifestations and discuss the current ophthalmological management in children with Down syndrome.

Clinical and genetic findings in patients with congenital cataract and heart diseases

Background

Congenital cataract (CC) and congenital heart disease (CHD) are significant birth defects. In clinical practice, the concurrence of CC and CHD is frequently observed in patients. Additionally, some monogenic diseases, copy number variation (CNV) syndromes, and diseases associated with intrauterine infection involve both cataract and heart defects. However, little is known about the association between CC and CHD. Here, we characterised the demographic, clinical, and genetic features of patients with CC and heart defects.

Methods

Medical records for 334 hospitalised patients diagnosed with CC were reviewed. Demographic and clinical features of patients with CC with and without CHD were compared. Clinical and genomic information for patients with ‘cataract’ and ‘cardiac defects’ were reviewed from Database of Chromosomal Imbalance and Phenotype in Humans using Ensembl Resources (DECIPHER). Microarray-based comparative genomic hybridisation and whole-exome sequencing were performed in 10 trio families with CC and CHD to detect de novo genomic alterations, including copy number variants and single nucleotide changes.

Results

In a retrospective analysis of 334 patients with CC over the past 10 years at our hospital, we observed a high proportion of patients (41.13%) with CHD (including innocent CHD, which reported as left-to-right shunt in echocardiography test). The CC with CHD group had higher incidences of preterm birth and Down’s syndrome than the CC without CHD group. Atrial septal defect was the most frequent heart defect. A total of 44 cases with cataracts and heart diseases were retrieved from Database of Chromosomal Imbalance and Phenotype in Humans using Ensembl Resources (DECIPHER). In total, 52 genomic alterations were reported, 44% of which were de novo germline variants. In the 10 trio families with CC and CHD, we found de novo CNVs responsible for two well-known chromosomal disorders and identified a novel pathogenic mutation in GJA8 responsible for CC.

Conclusions

We observed significant associations between CHD and CC in our 10-year patient cohort. Based on the cohort and data from DECIPHER, developmental syndromes in some patients were due to genetic defects, thus explaining the concurrence of CC and CHD. Additionally, we detected de novo mutations as an independent cause of cataracts. Our findings suggest that developmental syndromes in patients with CC deserve more attention in clinical practice by ophthalmologists.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-021-01873-7.

Retinal microvasculature impairment in patients with congenital heart disease investigated by optical coherence tomography angiography

Importance

A high prevalence of retinal abnormalities have been reported in congenital heart disease (CHD), but quantitative analysis of retinal vasculature is scarce. Optical coherence tomography angiography (OCTA) is a noninvasive method to quantitatively assess the retinal microvasculature.

Background

To investigate the retinal microvasculature changes in CHD patients by using OCTA.

Design

Cross‐sectional study.

Participants

A total of 158 participants including 57 cyanotic CHD (CCHD) patients, 60 acyanotic CHD (ACHD) patients and 41 control subjects were included.

Methods

All participants underwent a comprehensive ophthalmologic examination, including refraction measurement, intraocular pressure measurement and OCTA.

Main Outcome Measures

Vessel density (VD) was measured within the radial peripapillary capillary (RPC), superficial capillary plexus (SCP) and deep capillary plexus (DCP) of the macula.

Results

CCHD patients had significantly lower VD in the RPC, SCP and DCP (all P < .01) compared to control subjects, and significantly lower VD in the RPC and DCP (both P < .05) compared to ACHD patients. Besides, among the CHD group, VD in the RPC was positively correlated with oxygen saturation (whole image, ρ = 0.45; peripapillary, ρ = 0.48) and negatively correlated with haematocrit (whole image, ρ = 0.55; peripapillary, ρ = 0.55) (all P < .001).

Conclusions and Relevance

Retinal VD might be a surrogate to reflect the effect of chronic systemic hypoxemia in CHD patients. OCTA could be a convenient and noninvasive tool to evaluate the retinal structure and function in CHD patients.

Investigating Ganglion Cell Complex Thickness in Children with Chronic Heart Failure due to Dilated Cardiomyopathy

PURPOSE

To assess ganglion cell complex (GCC) thickness in children with chronic heart failure (CHF) due to dilated cardiomyopathy (DCM) using optical coherence tomography (OCT).

METHODS

Sixty eyes of 30 patients with chronic heart failure (CHF) due to dilated cardiomyopathy (DCM) and 60 eyes of 30 age- and sex-matched healthy volunteers (control group) were enrolled. The mean age of the patients and controls was 9.9 ± 3.57 (range 5-17) years and 10.08 ± 3.41 (range 4-16) years, respectively. All patients underwent a complete ophthalmic assessment and OCT imaging using RTVue XR Avanti (Optovue). The following OCT-based parameters were analysed: average ganglion cell complex thickness (avgGCC), superior ganglion cell complex thickness (supGCC), inferior ganglion cell complex thickness (infGCC), global loss of volume (GLV) and focal loss of volume (FLV).

RESULTS

There were no significant differences in avgGCC (98.13 μm vs. 99.96 μm, p = 0.21), supGCC (97.17 μm vs. 99.29 μm, p = 0.13), infGCC (99.03 μm vs. 100.71 μm, p = 0.25), FVL (0.49% vs. 0.4%, p = 0.25) and GVL (2.1% vs. 1.3%, p = 0.09) between patients with chronic heart failure due to dilated cardiomyopathy and healthy children. There was no correlation between avgGCC, supGCC, infGCC, FLV, GLV and ocular biometry, refractive errors or age. There was no correlation between avgGCC, supGCC, infGCC, FLV, GLV and NT-proBNP or LVEF. There were no significant differences in the studied parameters between the sexes. There were no significant differences in the studied parameters between the left and right eye.

CONCLUSION

Our study seems to be the first to analyse ganglion cell complex in paediatric patients with dilated cardiomyopathy. We have demonstrated no changes in the ganglion cell complex thickness parameters in children with chronic heart failure due dilated cardiomyopathy, as compared to their healthy peers.

Incidence of congenital heart diseases in Chinese children with non-syndromic congenital blepharoptosis: a prospective observational study of 1053 patients

BACKGROUND

Congenital blepharoptosis (CBP) may be part of a large spectrum of birth defects presenting with other ocular or systemic conditions. Therefore, the aim of the study was to investigate the incidence of congenital heart diseases (CHD) in CBP children not associated with specific syndromes.

METHODS

A total of 1053 Chinese children diagnosed with non-syndromic CBP were consecutively enrolled and their cardiac structure was evaluated by echocardiography.

RESULTS

Forty children were identified with CHD. Twenty-four children had one type of structural malformation (simple CHD). Sixteen children had two or more types of structural malformation (complex CHD). CHD and complex CHD were more prevalent in patients with severe or bilateral ptosis. Multivariate analysis revealed that presence of severe ptosis and bilateral ptosis was independently associated with CHD occurrence.

CONCLUSIONS

We found an increased frequency of CHD in CBP children, suggesting a clinical need for routine echocardiography evaluation in CBP, especially in children with severe or bilateral ptosis.

Ocular Alterations Associated with Primary Congenital Heart Disease - A Cross-sectional Study

OBJECTIVE

The objective of the study was to asses ocular findings' prevalence in children with primary congenital heart disease (CHD).

PATIENTS AND METHODS

This is a prospective cross-sectional study of children with CHD treated at a specialized center in the South of Brazil between 2013 and 2015. They underwent a complete ocular examination, including measurement of visual acuity, refraction test, external motility, anterior and posterior biomicroscopy, and binocular indirect fundoscopy with retinal photographs. Two experienced examiners independently assessed fundus findings: one at the time of examination and image capture, while the other assessed only the captured images.

RESULTS

Of a total of 146 children examined, 124 were included in this analysis (16% loss). Seventy children were male (55.5%). The average age was 9.3 years (minimum 1 month and maximum 15 years). Caucasians race were 81.2%, African Descendants race were 11.1%, and others were 7.7%. About 57.1% had already had heart surgery. About 14.8% had visual acuity below 0.6 and 2.8% below 0.1. Strabismus was found in 7.4% and cataracts in 1.7%. Retinal alterations were recognized in 13.5%, of which 4.8% were related to vascular narrowing or dilation and/or abnormal arteriovenous crossing; 7.14% were related to increased vascular tortuosity, while 1.6% were related to active toxoplasmic chorioretinitis lesions. Concomitant abnormalities in ocular motility, biomicroscopy, or ophthalmoscopy were detected in 24% of the cases.

CONCLUSION

Children under the age of 15 years old with primary CHD have a high prevalence of ocular alterations, with external ocular and retinal manifestations, with higher occurrence rate among cyanotic cases. This leads us to strongly recommend the performance of a complete ophthalmological examination in such cases.

Diffuse enlargement of cerebral vasculature in an adult patient operated for cyanotic congenital heart disease

A 24-year-old female patient diagnosed with cyanotic CHD had undergone a correction procedure at the age of eight. She had a normal motor and mental development until the age of 23. Later she had functional and cognitive decline following heart failure. Brain MRI showed enlargement of the cerebral arterial and venous system. The changes of central nervous system vasculature occurring in operated cyanotic CHD are not well known. Thanks to advances in this field, more cyanotic CHD patients reach adulthood nowadays and clinicians need to be familiar with the neurological conditions and potential neuroradiological changes.

Window to the circulatory system: Ocular manifestations of cardiovascular diseases

The changes in the cardiovascular system are associated with ocular manifestations, often as a consequence of pathological alteration in the ocular vasculature. The ease of visualization of these retinal changes makes the eye a window to the cardiovascular system. Certain congenital cardiac defects lead to changes in the retinal vascularity due to increased tortuosity and dilatation. In adults, the arterial dissection of internal carotid and vertebral arteries present as amaurosis fugax with or without oculo-sympathetic palsy. The patients with untreated infective endocarditis present with Roth spots, retinitis, embolic retinopathy, or sub-retinal abscesses. Hypoperfusive, hypertensive, or "mixed" retinopathy is a hallmark sign in patients of untreated infective endocarditis. Giant cell arteritis can present with ischemic ocular symptoms that may precipitate in irreversible vision loss. Systemic vascular manifestations such as coronary artery disease may manifest in a wide range of symptoms from amaurosis fugax to vision loss depending upon the size and location of retinal emboli. Rare cardio-oncological pathologies such as myxomas result in vision loss secondary to central retinal artery occlusion. A high clinical suspicion in patients with history of cardiovascular diseases can help in early diagnosis and management of impending, adverse cardiovascular and cerebrovascular events. In this review, we comprehensively discuss the spectrum of cardiac and vascular diseases with ocular manifestations as well as highlight the typical ocular presentations associated with these pathologies.

Bilateral nongranulomatous uveitis with transposition of the great arteries: A rare case report

In this case report, we describe for the first time an association between transposition of the great arteries (TGAs), a congenital heart disease, and uveitis. We hope that this atypical finding in a patient with TGA will add to the clinical spectrum of ophthalmic conditions that can be seen with TGA. A 16-year-old boy, diagnosed and operated for TGA, presented with redness and pain in the left eye. The patient underwent complete ophthalmological and systemic examination. Detailed blood workup was done to rule out other causes of uveitis. A working diagnosis of bilateral nongranulomatous uveitis in status postopen-heart surgery was made, and the patient was successfully treated. Thus, uveitis can develop in patients with TGA, and prompt treatment can restore vision in these patients.

Dilated and tortuous retinal vessels as a sign of Cantu syndrome

When encountering patients with markedly dilated and tortuous retinal vessels, Wyburn-Mason syndrome (WMS) or racemous angiomatosis (phacomatosis) is commonly thought of as the archetypal entity that can produce these findings. We describe a patient with Cantu syndrome with phenotypical findings identical to those seen in patients with WMS and want to highlight this as another entity that can present with tortuous and dilated retinal vessels.

Abnormalities of the Optic Nerve in Down Syndrome and Associations With Visual Acuity

Background: Various ocular anomalies are present in the vast majority of individuals with Down syndrome; however, we know little about optic nerve abnormalities. The aim of this cross-sectional comparative study was to describe optic disc morphology in patients with Down syndrome and to determine if the differences found are potentially related to visual acuity.

Subjects/methods: Assessable fundus images were obtained in 50 children with Down syndrome and 52 children without Down syndrome. Morphological analysis of the optic nerve was performed, including the disc-to-macula distance (DM) to disc diameter (DD) ratio (DM/DD), the cup-to-disc ratio and optic disc ovality. Data relating to ophthalmological status were retrospectively analyzed to evaluate the possible causes of reduced visual acuity.

Results: DM/DD was significantly larger (p = 0.0036) and the cup-to-disc ratio was significantly smaller (p = 0.018) in children with Down syndrome, compared to controls. The optic discs were also more frequently torted (p = 0.034), tilted (p = 0.0049) and oval (p = 0.026). Furthermore, crescents (p = 0.0002), peripapillary atrophy (p = 0.0009), and pigment anomalies (p < 0.0001) were also more prevalent in children with Down syndrome than in those without. Visual acuity was significantly lower in children with Down syndrome compared to controls with similar refraction problems and strabismus prevalence (p < 0.0001). The mean DM/DD and the presence of a crescent was not directly related to visual acuity (r = 0.39, p = 0.31), (r = 0.35, p = 0.12) respectively. Visual acuity was diminished in 80% of children with Down syndrome and the smallest discs and in 84% of those with tilted discs. However, other causes may contribute to the diminished visual acuity in these cases.

Conclusion: The optic nerve head in children with Down syndrome is affected by various anatomical and developmental abnormalities. Unrelated to refraction (spherical equivalent), the optic discs appear smaller and more frequently mal-inserted in Down syndrome. Optic disc hypoplasia, as well as severe tilting, may reduce vision but they do not represent major contributors to the decrease of vision in such children. As these children often have multiple ocular and neurosensory problems, it remains challenging to relate visual acuity problems with a specific abnormality. Smaller discs may lead to optic disc drusen formation in children with Down syndrome.

The eye in CHD

In recent years, there has been a rise in the number patients with CHD surviving into adulthood. Many have complications related to their CHD or its treatments, outside the heart, including ocular abnormalities. The objective of this review is to highlight the ocular abnormalities that occur in adults with CHD, either from their condition or related to the common drugs prescribed to manage it. In particular, we reviewed the effects of cyanosis, coarctation of the aorta, endocarditis, and the side effects of Sildenafil and Amiodarone. A change in the retinal vasculature is a common observation with cyanosis or coarctation of the aorta. Occlusion of the retinal vessels may also be observed in cyanotic patients, as well as those with infectious endocarditis. Sildenafil has established ocular side effects; here they are explored in the context of therapy for pulmonary hypertension. Similarly, Amiodarone has established ocular risks, which are summarised. The high prevalence of ocular consequences in adult CHD patients reinforces the need for knowledge of the risks involved and for frequent ophthalmological screening where appropriate.

Retinal vascular changes in preterm infants: heart and lung diseases and plus disease

PURPOSE

To report the retinal vascular features of preterm infants with congenital heart disease (CHD), lung disease (pulmonary hypertension [PH] and bronchopulmonary dysplasia [BPD]), and ROP with plus disease to determine whether these disease entities are distinguishable on the basis of retinal vessel morphology.

METHODS

The medical records of preterm infants with CHD, lung disease, and ROP with plus disease were reviewed retrospectively. Qualitative vascular findings were validated using computer-based software to analyze 25 representative images, each corresponding to one infant's eye. The images were organized into five groups, based on clinical information. Vessel diameter (d) and tortuosity index (TI) were measured.

RESULTS

A total of 106 infants (mean gestational age, 30.5 ± 2.22 weeks) were initially included. Ophthalmologic evaluation of preterm infants with CHD and lung diseases showed vascular tortuosity without vasodilation at the posterior pole as well as in the periphery. Quantitative analysis showed that venular diameter was significantly increased in the plus disease group (P = 0.0022) compared to other groups. There was significantly less tortuosity in both arterioles and venules in BPD (P < 0.001, P = 0.0453) compared with plus group.

CONCLUSIONS

The patterns of retinal vascular tortuosity observed in preterm infants may be unique to different systemic congestive conditions and could have therapeutic implications.

Prevalence of ophthalmological abnormalities in children and adolescents with CHD: systematic review and meta-analysis of observational studies

BACKGROUND

CHDs form a complex and heterogeneous group of clinical entities, with high morbidity and mortality. With the advancement of surgical and invasive techniques and clinical treatment, the survival of these patients has increased significantly, and there are reports of a high prevalence of ocular abnormalities in this group. The objective of this study was to estimate the prevalence of ocular findings in children and adolescents diagnosed with CHD.

METHODS

A systematic search was conducted in the following databases: MEDLINE (via PubMed), EMBASE, and Cochrane CENTRAL, in addition to a manual search on studies published on the patient, from inception until August, 2014. Observational studies assessing the prevalence of ocular abnormalities in children and adolescents with CHDs were included.

RESULTS

Of the 2413 articles identified, eight were included, comprising a total of 1061 patients. Among them, the lowest and highest prevalences observed were 6.3 and 65%, respectively. The weighted average prevalence of ocular abnormalities was 32.5% (CI95% 19.3-49.3). Strabismus, cataracts, and retinopathy were the most frequently observed alterations.

CONCLUSION

The prevalence of ocular abnormalities in children and adolescents with CHDs was 32.5%, demonstrating that ocular consequences are not uncommon in this population and may have relevant clinical impact. These results reinforce the need for ophthalmological evaluation of patients with CHDs.

Haploinsufficiency of BAZ1B contributes to Williams syndrome through transcriptional dysregulation of neurodevelopmental pathways

Williams syndrome (WS) is a neurodevelopmental disorder caused by a genomic deletion of ∼28 genes that results in a cognitive and behavioral profile marked by overall intellectual impairment with relative strength in expressive language and hypersocial behavior. Advancements in protocols for neuron differentiation from induced pluripotent stem cells allowed us to elucidate the molecular circuitry underpinning the ontogeny of WS. In patient-derived stem cells and neurons, we determined the expression profile of the Williams-Beuren syndrome critical region-deleted genes and the genome-wide transcriptional consequences of the hemizygous genomic microdeletion at chromosome 7q11.23. Derived neurons displayed disease-relevant hallmarks and indicated novel aberrant pathways in WS neurons including over-activated Wnt signaling accompanying an incomplete neurogenic commitment. We show that haploinsufficiency of the ATP-dependent chromatin remodeler, BAZ1B, which is deleted in WS, significantly contributes to this differentiation defect. Chromatin-immunoprecipitation (ChIP-seq) revealed BAZ1B target gene functions are enriched for neurogenesis, neuron differentiation and disease-relevant phenotypes. BAZ1B haploinsufficiency caused widespread gene expression changes in neural progenitor cells, and together with BAZ1B ChIP-seq target genes, explained 42% of the transcriptional dysregulation in WS neurons. BAZ1B contributes to regulating the balance between neural precursor self-renewal and differentiation and the differentiation defect caused by BAZ1B haploinsufficiency can be rescued by mitigating over-active Wnt signaling in neural stem cells. Altogether, these results reveal a pivotal role for BAZ1B in neurodevelopment and implicate its haploinsufficiency as a likely contributor to the neurological phenotypes in WS.

Macular and peripapillary retinal nerve fibre layer thickness in patients with cyanotic congenital heart disease

PURPOSE

To evaluate macular and retinal nerve fibre layer (RNFL) measurements in patients with cyanotic congenital heart disease (cCHD) using spectral domain optical coherence tomography (OCT).

PATIENTS AND METHODS

Thirty patients with cCHD (18 females and 12 males, mean age 10.9 years) and 60 healthy controls (35 females and 25 males, mean age 11.2 years) underwent complete ophthalmologic examination and OCT measurements of macular and peripapillary RNFL thickness.

RESULTS

Patients with cCHD had significantly thinner measurements in all macular subfields compared with healthy controls (P<0.001). There was no significant difference in peripapillary RNFL thickness between the two groups, with the exception of the upper quadrant, for which thickness measurements were higher in patients with cCHD (P=0.021).

CONCLUSIONS

Patients with cCHD showed a significant decrease in macular thickness and a thickened superior quadrant RNFL thickness when compared with healthy controls. This may represent the damage caused by the effect of hypoxia.

Unusual retinal abnormalities in sisters with tetralogy of Fallot

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease and can occur in the setting of chromosomal aberrations or multisystem malformation syndromes. We report unusual focal bilateral retinal defects in sisters with TOF.

Congenital eyelid ptosis: onset and prevalence of amblyopia, associations with systemic disorders, and treatment outcomes

OBJECTIVES

To determine the age at onset of amblyopia, the response to occlusion therapy, and the association with systemic disorders in children with congenital eyelid ptosis.

STUDY DESIGN

Retrospective chart review of children seen at Seattle Children's Hospital with moderate or severe congenital ptosis. Assessments were longitudinal visual acuity development using objective methods, definition of ptosis severity by eyelid margin to pupillary light reflex distance (margin reflex distance [MRD]), age at amblyopia diagnosis, correlation between amblyopia and MRD, and associated systemic disorders.

RESULTS

Eighty-four children with moderate-to-severe congenital ptosis met inclusion criteria; the mean longitudinal follow-up was 49.1 months. Fifteen (18%) of these children had amblyopia, of which 9 had deprivation amblyopia (mean age 17.3 months ± 11.2) and 6 had anisometropic or strabismic amblyopia (mean age 60 months ± 11.8). Eleven (73%) of the children with amblyopia were successfully treated with occlusion therapy. Amblyopia was not correlated with MRD. A systemic disorder was identified in 29 (35%) of the children, the most common being genetic, chromosomal, or neurologic conditions. Patients with systemic disorders and developmental delay have significantly lower visual acuity bilaterally compared with patients without systemic disorders (P ≤ .003).

CONCLUSIONS

Using longitudinal and objective visual acuity assessments, the incidence of amblyopia was 18% in children with moderate to severe congenital ptosis. Visual deprivation was the predominant risk factor that was reliably distinguished by its earlier onset in young children. The best indicator of amblyopia in children is visual acuity rather than MRD measurements. Systemic disorders are frequent in children with moderate to severe congenital ptosis.

Bilateral persistent pupillary membrane with tetralogy of fallot: a case report and review of the literature

Case Report. A 15-year-old boy presented to the Fatih Sultan Mehmet Education and Research Hospital with the complain of bilateral vision blurring associated with severe glare and photophobia. On ophthalmological examination, uncorrected visual acuity was 20/200 in the right eye and 20/100 in the left eye, and there was no improvement with pinhole testing. The slit-lamp examination showed persistent pupillary membranes (PPM) in both eyes. According to the history obtained from his parents, he had received cardiac surgery for tetralogy of Fallot (TOF) 8 years ago. Conclusion. This patient is unique because this is the first reported case of bilateral PPM with congenital heart anomaly in the literature. Bilaterality of the eye anomaly strengthens the possibility of an uncommon association between PPM and TOF, rather than local failure in embryonic development.

MAPK activation in mature cataract associated with Noonan syndrome

Background

Noonan syndrome is an autosomal, dominantly inherited disease; it is physically characterized by short stature, short neck, webbed neck, abnormal auricles, high arched palate, and cardiovascular malformation. Its pathological condition is thought to be due to a gain-of-function mutation in the Ras-mitogen-activated protein kinase (MAPK) signal transduction pathway. Eyelid abnormalities such as ocular hypertelorism and blepharoptosis are the most commonly observed eye complications.

Case presentation

We report a case of Noonan syndrome associated with mature cataract that required operation. A 42-year-old man was diagnosed with Noonan syndrome at the age of 1 year. He underwent an eye examination after complaining of decreased visual acuity in the right eye and was diagnosed with mature cataract, which was treated by cataract surgery. There were no intraoperative complications, and the postoperative course was uneventful. Protein analysis of lens capsule and epithelium at capsulorhexis showed MAPK cascade proteins such as ERK and p38MAPK were upregulated. An abnormality in the PTPN11 gene was also observed; a potential mechanism of cataract onset may be that opacity of the lens rapidly progressed due to abnormal activation of the Ras-MAPK signal transduction pathway.

Conclusion

This case highlights the possible association of cataract formation with MAPK cascade protein upregulation in Noonan syndrome.

A case of 22q11.2 deletion syndrome with right microphthalmia and left corneal staphyloma

Abstract Background: A microdeletion in the chromosome 22q11.2 (DiGeorge or velocardiofacial syndrome) is the most common human deletion syndrome. Patients with 22q11.2 deletion may have a wide range of ocular findings but severe ocular involvement is uncommon. Here, we describe a 2-year-old boy who had growth retardation, developmental delay, right renal agenesis, ventricular septal defect and severe bilateral ocular anomalies.

MATERIALS AND METHODS

The systemic and ocular findings and cranial magnetic resonance imaging study results were reviewed. Fluorescence in situ hybridization analysis was performed on his peripheral blood.

RESULTS

The patient presented with the oculodigital sign. On examination, he had severe right microphthalmia with no light perception and his left eye could not fix and follow. The left eye had anterior segment dysgenesis, mild sclerocornea, corneal staphyloma and congenital aphakia. Systemic findings included growth deficiency, microcephaly, micrognathia, ventricular septal defect, atrial septal defect and right renal agenesis. Fluorescence in situ hybridization analysis of this patient was significant for a heterozygous deletion covering DiGeorge critical region 2 and spanning a 250 kb region in the 22q11.2 locus.

CONCLUSION

The 22q11.2 deletion syndrome may be associated with severe bilateral ocular malformations including microphthalmia, sclerocornea, corneal staphyloma, anterior segment dysgenesis and congenital aphakia. Corneal staphyloma might have resulted from the oculodigital phenomenon or increased intraocular pressure.

Persistent plus disease after laser in retinopathy of prematurity with tetralogy of Fallot

INTRODUCTION

We present a patient with retinopathy of prematurity (ROP) who received panretinal photocoagulation (PRP), but in whom plus disease developed, likely secondary to a complicated cardiovascular history, including DiGeorge syndrome and tetralogy of Fallot.


METHOD

Interventional case report with clinical and angiographic correlation. 


RESULTS

Our patient had been born at 29 weeks and 2 days gestational age with a birthweight of 940 grams, tetralogy of Fallot, DiGeorge syndrome, and major aortopulmonary collaterals. Type 1 Early Treatment for Retinopathy of Prematurity ROP (zone 2, stage 2 with plus) developed, requiring PRP. Worsening plus disease developed and mild further PRP was performed. Despite this, plus disease persisted.


CONCLUSIONS

We report plus disease even after appropriate PRP therapy for ROP. In this case, it is likely the patient's cardiovascular diseases that caused the persistent plus disease. Vascular tortuosity can be due to a number of different systemic disorders, so it is important to consider an infant's systemic conditions in the evaluation of ROP.

Patent ductus arteriosus and indomethacin treatment as independent risk factors for plus disease in retinopathy of prematurity

PURPOSE

To examine whether clinically significant patent ductus arteriosus (PDA) or indomethacin treatment are associated with plus disease or retinopathy of prematurity (ROP) requiring treatment.

METHODS

Retrospective, cross-sectional study. Charts were reviewed for gestational age, birth weight, birth head circumference, birth length, maternal characteristics, gender, bronchopulmonary dysplasia, neurologic comorbidities, PDA and its treatments, gastrointestinal comorbidities, blood transfusions, and sepsis. Main outcome measures were increased rates of plus disease or ROP requiring treatment.

RESULTS

A total of 450 premature infants screened for ROP in a mid-sized, urban neonatal intensive care unit were included. On univariate analysis, gestational age, birth weight, birth head circumference, birth length, bronchopulmonary dysplasia, neurologic comorbidities, PDA and its treatments, gastrointestinal comorbidities, and sepsis were significantly correlated to plus disease and ROP requiring treatment. PDA was significantly associated with bronchopulmonary dysplasia, neurologic comorbidities, sepsis, and blood transfusions (P < .0001). With type 3 multivariate analysis, only gestational age and bronchopulmonary dysplasia were independent risk factors for ROP.

CONCLUSION

PDA and indomethacin were associated with plus disease and ROP requiring treatment on univariate analysis but this was not significant after adjusting for other risk factors. PDA was also strongly related to bronchopulmonary dysplasia and blood transfusions, which may explain its effect on ROP.

Eyelash trichomegaly: review of congenital, acquired, and drug-associated etiologies for elongation of the eyelashes

Eyelash trichomegaly is defined as eyelashes which are found to be of increased length, thickness, and pigmentation. This unique finding can be present at birth as part of a variety of congenital syndromes or as a benign familial trait. There are also acquired conditions and drugs that are known to cause these changes. Case reports and clinical studies in the medical literature concerning eyelash trichomegaly were investigated and summarized to compile a comprehensive review of the etiology of eyelash trichomegaly. Previously published reviews and studies that report on the finding of increased generalized hair growth and which do not specifically mention eyelashes were not included. Trichomegaly of the eyelashes may occur as a key feature among rare congenital syndromes, develop in association with certain acquired diseases, or present as an intended or treatment-related adverse drug effect. Eyelash trichomegaly may be present from birth or manifest later in life in association with acquired diseases or drug therapy. The relevance of this finding may be benign, however eyelash trichomegaly in some individuals can be a symptom for immune dysfunction or a clinical measure of response to drug therapy.

Retinal Vascular Tortuosity in a Patient with Weill-Marchesani Syndrome

Weill-Marchesani syndrome (WMS) is a rare connective tissue disorder with characteristic phenotypic skeletal and ocular manifestations. A 28-year-old myopic female presented with an 8-month history of bilateral blurred vision. On examination, she was noted to be of short stature with brachydactyly. On ocular examination, she was found to be spherophakic with bilateral inferiorly subluxated lenses. Serum and urine homocysteine were normal and a syphilis screen was negative. A diagnosis of Weill-Marchesani syndrome was made. Fundoscopy revealed bilateral tortuous retinal vessels. We report the first illustrated case of retinal vascular tortuosity as an ocular manifestation of Weill-Marchesani syndrome.

Proliferative retinopathy in a child with congenital cyanotic heart disease

In congenital cyanotic heart disease, oxygenated and deoxygenated blood mixes, and oxygen saturation of the arterial blood is not maintained. As a result, an ischemic environment prevails in the entire body. While various ocular findings have been described in patients with cyanotic heart disease, proliferative retinopathy has not been previously noted. We report a child with congenital cyanotic heart disease and multiple fibrovascular fronds over the fundus consistent with proliferative retinopathy.

Anesthetic management for pediatric strabismus surgery: Continuing professional development

PURPOSE

Strabismus surgery is one of the most common pediatric ophthalmic procedures. The purpose of this continuing professional development module is to update physicians on the anesthetic considerations of pediatric patients undergoing strabismus surgery.

PRINCIPAL FINDINGS

The preoperative assessment is important, as patients undergoing strabismus surgery may have an associated neuromuscular disorder, congenital syndrome, or cardiac disease. Malignant hyperthermia is no longer considered as being an issue associated with strabismus. The laryngeal mask airway is used frequently and has been shown as being associated with a low incidence of complications in strabismus surgery. The anesthesia technique can be adapted to decrease the incidence of the oculocardiac reflex and the oculorespiratory reflex, and the use of anticholinergic prophylaxis remains debatable. Since patients are at high risk for postoperative nausea and vomiting (PONV), combination anti-emetic therapy is recommended using dexamethasone and ondansetron. Metoclopramide was not found to provide additional benefit when combined with other anti-emetics. Droperidol is effective, but there remains a black box warning for dysrhythmias. Effective analgesics in this patient population include acetaminophen, nonsteroidal anti-inflammatory drugs, peribulbar blocks, and subtenon blocks. Topical tetracaine drops have demonstrated mixed results, and topical nonsteroidal anti-inflammatory drops were found not to be effective. The use of opioids should be minimized due to the increased incidence of PONV.

CONCLUSIONS

To provide optimal care for the pediatric patient undergoing strabismus surgery, it is important to understand the unique anesthetic considerations for strabismus surgery and to appreciate how each decision regarding the anesthetic technique can alter these considerations.

Chronic cyanosis and vascular function: implications for patients with cyanotic congenital heart disease

In patients with cyanotic congenital heart disease, chronic hypoxaemia leads to important changes in blood vessel function and structure. Some of these alterations are maladaptive and probably contribute to impaired cardiopulmonary performance and an increased incidence of thrombotic and embolic events. Recent evidence suggests that deranged endothelial function, a sequel of chronic cyanosis, could be an important factor in the pathogenesis of cyanosis-associated cardiovascular risk. In this article, we discuss the physiological and mechanical consequences of compensatory erythrocytosis and possible pathophysiological mechanisms of vascular dysfunction in chronic cyanosis.

The facial phenotype of the velo-cardio-facial syndrome

Velo-cardio-facial syndrome (VCFS) is a genetic disorder that is common but often variable in its expression. Several key organ systems are most often affected, including the craniofacial skeleton and soft tissues. Identification of the associated facial features will aid in the improved detection of patients. This review aims to highlight the approaches to facial analysis that are essential to the detection of the facial dysmorphisms in velo-cardio-facial syndrome, many of which may be subtle.

Velo-cardio-facial syndrome: the pediatric otolaryngologist's perspective

PURPOSE OF REVIEW

The understanding of velo-cardio-facial syndrome has grown markedly since the initial descriptions of this common genetic disorder nearly 30 years ago. Our knowledge of the syndrome has advanced in part from opportunities to monitor many patients into adulthood because of advances in the fields of cardiothoracic surgery and immunology. Longitudinal study has brought to light psychiatric and behavioral features of the syndrome that are often not apparent until late adolescence or the early adult years. Certain endocrine and immunologic features of the syndrome thought to be resolved in childhood are now witnessed in older patients. Variable expression and lack of disease awareness are two major factors that contribute to the delays in diagnosis in many cases. To address this, there has been a call to delineate screening parameters for patients at risk of carrying the deletion.

RECENT FINDINGS

Several areas are highlighted in this review, reflecting the focus of scholarly work on velo-cardio-facial syndrome in the past year. Molecular genetics has shown smaller deletions in many families with the syndrome. The gene TBX1 has been found to be important to the phenotype. Surgical outcomes data reveal the greater challenges involved in correcting velopharyngeal insufficiency.

SUMMARY

Defining the genetic basis of velo-cardio-facial syndrome will allow clinicians and basic scientists to make further inroads into understanding the variable expressivity of this syndrome. It is also important to be aware of the continued diagnostic challenges encountered by clinicians in attempts to improve the detection of patients with this syndrome.

Velo-cardio-facial syndrome

PURPOSE OF REVIEW

Velo-cardio-facial syndrome has emerged from obscurity to become one of the most researched disorders this past decade. It is one of the most common genetic syndromes in humans, the most common contiguous gene syndrome in humans, the most common syndrome of cleft palate, and the most common syndrome of conotruncal heart malformations. Velo-cardio-facial syndrome has an expansive phenotype, a factor reflected in the wide range of studies that cover both clinical features and molecular genetics. In this review, we cover multiple areas of research during the past year, including psychiatric disorders, neuroimaging, and the delineation of clinical features.

RECENT FINDINGS

The identification of candidate genes for heart anomalies, mental illness, and other clinical phenotypes has been reported in the past year with a focus on TBX1 for cardiac and craniofacial phenotypes and COMT and PRODH for psychiatric disorders. The expansive phenotype of velo-cardio-facial syndrome continues to grow with new behavioral and structural anomalies reported. Treatment issues are beginning to draw attention, although most authors continue to focus on diagnostic issues.

SUMMARY

Its high population prevalence, estimated to be as common as 1:2000 has sparked a large amount of research, as has the model the syndrome serves for identifying the causes of mental illness and learning disabilities, but it is obvious that more information is needed. Intensive scrutiny of velo-cardio-facial syndrome will undoubtedly continue for many years to come with the hope that researchers will turn more of their attention to treatment and treatment outcomes.

Ischemic retinopathy and uveitis in a patient with tetralogy of Fallot

PURPOSE

To describe ischemic retinopathy in a patient with tetralogy of Fallot.

DESIGN

Interventional case report.

TESTING

Clinical and imaging evaluation.

MAIN OUTCOME MEASURES

Clinical, imaging, and laboratory findings in a patient with tetralogy of Fallot.

RESULTS

A 20-year-old female patient with tetralogy of Fallot had progressive visual loss of 3 weeks duration. Bilateral examination revealed dilated, tortuous, conjunctival vessels; prominent anterior chamber reaction; iris neovascularization; posterior synechia; retinal vascular tortuosity in both eyes; and inferior exudative retinal detachment. Fluorescein angiography revealed delayed retinal and choroidal filling. The working diagnosis was ischemic retinopathy with uveitis. The patient was treated for 6 months with a high-dose oral corticosteroid combined with a topical corticosteroid, a topical mydriatic, and panretinal photocoagulation. Conjunctival, vascular congestion subsided with a decrease in anterior chamber reaction. The inferior, exudative retinal detachment resolved, and vision was restored.

CONCLUSIONS

Retinal ischemic syndrome combined with uveitis can develop in patients with tetralogy of Fallot. Treatment can restore vision in such patients.

Medical Imaging in Pediatric Neuro-Ophthalmology

This article provides an outline of the congenital and acquired conditions encountered in the practice of pediatric neuro-ophthalmology. Although some entities can be effectively evaluated clinically, CT and MR imaging studies may prove instrumental in many instances for detailed evaluation, narrowing of the differential diagnosis, or exclusion of underlying central nervous system pathologic findings.