Update on the morning glory disc anomaly

Rapid Resolution of Serous Retinal Detachment in Morning Glory Disc Anomaly With Oral Acetazolamide Treatment

Morning glory disc anomaly is a rare congenital anomaly affecting the optic disc and is frequently associated with retinal detachment. This report presents a unique case of a 10-year-old boy with morning glory disc anomaly and serous retinal detachment, treated with oral acetazolamide. Remarkably, half of the retina exhibiting bullous detachment was reattached leading to full recovery of vision within a few days after starting acetazol-amide treatment. There was no recurrence after discontinuation of medication. Oral acetazolamide can be considered an alternative treatment option for retinal detachment associated with morning glory disc anomaly of non-rhegmatogenous origin. [Ophthalmic Surg Lasers Imaging Retina 2024;55:XX-XX.].

Ocular manifestations of renal ciliopathies

Renal ciliopathies are a common cause of kidney failure in children and adults, and this study reviewed their ocular associations. Genes affected in renal ciliopathies were identified from the Genomics England Panels. Ocular associations were identified from Medline and OMIM, and the genes additionally examined for expression in the human retina ( https://www.proteinatlas.org/humanproteome/tissue ) and for an ocular phenotype in mouse models ( http://www.informatics.jax.org/ ). Eighty-two of the 86 pediatric-onset renal ciliopathies (95%) have an ocular phenotype, including inherited retinal degeneration, oculomotor disorders, and coloboma. Diseases associated with pathogenic variants in ANK6, MAPKBP1, NEK8, and TCTN1 have no reported ocular manifestations, as well as low retinal expression and no ocular features in mouse models. Ocular abnormalities are not associated with the most common adult-onset "cystic" kidney diseases, namely, autosomal dominant (AD) polycystic kidney disease and the AD tubulointerstitial kidney diseases (ADTKD). However, other kidney syndromes with cysts have ocular features including papillorenal syndrome (optic disc dysplasia), Hereditary Angiopathy Nephropathy, Aneurysms and muscle Cramps (HANAC) (tortuous retinal vessels), tuberous sclerosis (retinal hamartomas), von Hippel-Lindau syndrome (retinal hemangiomas), and Alport syndrome (lenticonus, fleck retinopathy). Ocular abnormalities are associated with many pediatric-onset renal ciliopathies but are uncommon in adult-onset cystic kidney disease. However the demonstration of ocular manifestations may be helpful diagnostically and the features may require monitoring or treatment.

Congenital Optic Disc Anomalies: Insights from Multimodal Imaging

In this comprehensive review, we delve into the significance of multimodal imaging in diagnosing and managing complications of congenital optic disc anomalies. While the fundus examination is the gold standard tool in the diagnosis of these pathologies, spectral domain (SD) optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) could shed light on the pathogenesis and treatment. Moreover, this review seeks to offer a comprehensive insight into the multimodal approach of these rare congenital pathologies. In conclusion, congenital anomalies of the optic nerve represent a major challenge for ophthalmologists. Further research could be useful to clarify the pathophysiology of these diseases and define a correct and more specific treatment approach.

Analysis of macula structural changes in Moyamoya disease using AI-assisted OCT

OBJECTIVE

To investigate macula structure thickness and volume changes in patients with moyamoya disease (MMD).

METHOD

In this cross-sectional study, we used artificial intelligence (AI) -assisted optical coherence tomography (OCT) to analyze the thickness and volume of macula in Moyamoya patients. ETDRS zoning divides the macula into nine different regions. In 15 patients with radial scanning OCT, the average thickness and volume of retina, RNFL, GCL, and choroid in these regions were measured. In 30 patients with radial or horizontal scanning OCT, based on the anatomical structure, the macula is divided into seven segments. Mean Sattler layer-choriocapillaris complex thickness (SLCCT), Haller layer thickness, and total choroidal thickness were measured for each segment using AI-assisted OCT.

RESULTS

We recruited 30 patients (59 eyes) with MMD. In the 15 patients (29 eyes) who underwent radial scanning OCT, no significant change in retina, RNFL, GCL, and choroidal thickness was identified between the two groups (p > 0.05). There was no significant change in retina, RNFL, or choroidal volume between the two groups in different ETDRS macula regions (p > 0.05). The GCL volume in the macula's inner ring nasal portion (IN) was significantly lower. SLCCTs were considerably reduced in six macula regions in moyamoya groups (p < 0.05). There was no statistically significant change in Haller layer thickness. Only the nasal perifovea (PE_N) exhibited a significant variation in choroidal thickness. The Moyamoya group showed reduced choroidal thickness in PE_N segment.

CONCLUSION

In patients with MMD, there is thinning of the Sattler layer-choriocapillaris complex in the choroid.

Congenital Malformations of the Eye: A Pictorial Review and Clinico-Radiological Correlations

Congenital malformations of the eye represent a wide and heterogeneous spectrum of abnormalities that may be part of a complex syndrome or be isolated. Ocular malformation severity depends on the timing of the causative event during eye formation, ranging from the complete absence of the eye if injury occurs during the first weeks of gestation, to subtle abnormalities if the cause occurs later on. Knowledge of ocular malformations is crucial to performing a tailored imaging protocol and correctly reporting imaging findings. Together with the ophthalmologic evaluation, imaging may help frame ocular malformations and identify underlying genetic conditions. The purpose of this pictorial review is to describe the imaging features of the main ocular malformations and the related ophthalmologic findings in order to provide a clinico-radiological overview of these abnormalities to the clinical radiologist. Sight is a crucial sense for children to explore the world and relate with their parents from birth. Vision impairment or even blindness secondary to ocular malformations deeply affects children's growth and quality of life.

Evaluation of baseline optic disc pit and optic disc coloboma maculopathy features by spectral domain optical coherence tomography

PURPOSE

The aim of this study is to describe and compare the baseline demographic, ocular, and imaging characteristics of a cohort of patients with optic disc pit (ODP) or optic disc coloboma (ODC) maculopathy.

METHODS

This retrospective study included patients diagnosed with ODP or ODC on clinical examination between June 2017 and December 2022. These patients' baseline demographics, ocular characteristics, and optical coherence tomography (OCT) imaging characteristics were analyzed.

RESULTS

Fundus examination revealed 11 eyes of 11 patients with ODP and 14 eyes of 9 patients with ODC, respectively. On OCT, maculopathy was observed more frequently in ODP (n = 10) than in ODC (n = 4) [p = 0.004] cases. Eyes with ODP were more likely to exhibit retinoschisis and/or serous macular detachment [SMD] (n = 7, 70%), communication of the retinoschisis with the optic disc (p = 0.015), whereas the SMD did not communicate with the optic disc (p = 0.005), and significant outer retinal layer thinning (p = 0.015). In contrast, eyes with ODC exhibited only SMD (p = 0.005) and no retinoschisis on the non-colobomatous retina. SMD in ODC communicated with the margin of the optic disc. In both clinical entities, hyperreflective foci were observed in the SMD.

CONCLUSION

In summary, baseline maculopathy characteristics on OCT, including its type, location, and relationship to the optic disc, are among the most distinguishing characteristics between an ODP and an ODC.

TRIAL REGISTRATION NUMBER

Not applicable.

Morphology of Serous Retinal Detachment in Morning Glory Optic Disc Anomaly in a Patient before and after Treatment with Systemic Carboanhydrase Inhibitors

BACKGROUND

Morning glory optic disc anomaly (MGODA) is a rare congenital defect of the optic nerve head. The optic nerve is enlarged, and its conical excavation is filled with glial tissue. It may be associated with cerebral malformations and ocular complications, whereas serous retinal detachment occurs in 38% of affected patients. Surgical treatment of detachment showed poor visual outcome in the past and conservative treatment options are scarce.

CASE

A woman with MGODA presented in our clinic with sudden vision loss due to serous retinal detachment. She denied any previous ophthalmological problems and her past medical history was unremarkable. Vision testing showed normal visual acuity in her left eye and finger counting in her right eye. Slit lamp examination was unremarkable. Fundus examination of the right eye showed retinal detachment without holes or traction membranes and an enlarged optic disc with raised peripapillary tissue and glial tissue in the center of the optic disc. Due to the pathognomonic otpic disc finding, we diagnosed MGODA complicated by a serous retinal detachment. We treated the patient with systemic carboanhydrase inhibitors and documented the initial clinical findings as well as the course of disease under treatment by optical coherent tomography (OCT), fundus autofluorescence imaging (FAF), and visual field testing. During follow-up, we detected noticeable subretinal fluid regression and improvement in visual acuity.

CONCLUSION

The application of oral carboanhydrase inhibitors appears to be a valid therapeutic option in patients with MGODA-associated serous macular detachment. OCT and FAF imaging are useful modalities for documentation of subretinal fluid regression and structural changes in the peripapillary region.

Unusual Trigger for Contractile Movements of Optic Disc in Peripapillary Staphyloma

Purpose

To report a case of contractile movements of the optic disc in peripapillary staphyloma.

Methods

A 65-year-old female received a comprehensive ophthalmic examination, multimodal imaging, and computed tomography.

Results

The patient was diagnosed with peripapillary staphyloma in her right eye. Best-corrected visual acuity in her right and left eye was 20/32 and 20/40, respectively, with moderate cataracts in both eyes. Multimodal imaging revealed contractile movements of the optic disc in the right eye that were initiated by the circular rotation of the eye but by none of the triggers previously described in the literature. The patient reported no changes in her vision during contractile movements. Optical coherence tomography revealed a muscle-like structure in the optic disc during the peak of the contraction. Computed tomography did not reveal any abnormality of the optic nerve or the extraocular muscles of the right eye.

Conclusion

Contractile movements in peripapillary staphyloma may be initiated by previously unknown triggers. The pattern of the contractile movements and optical coherence tomography findings support the muscular nature of these movements.

Optic disc coloboma associated with macular retinoschisis: A case report

BACKGROUND

To report an unusual case of bilateral optic disc coloboma associated with macular retinoschisis in the left eye.

CASE SUMMARY

A 37-year-old woman presented with complaints of blurred and distorted vision in her left eye for more than 1 year. Fundus examination demonstrated choroidal atrophy around the optic disc in both eyes, with a cup-to-disc ratio of 0.9. Serous retinal detachment in the macular area of the left eye. Left eye macular blood flow imaging optical coherence tomography (Angio-OCT) showed macular retinal serous cleavage. En-face OCT showed that the canal gully-like structure formed by the defect of the optic disc nerve fiber layer between the optic disc and macula, serous detachment area was connected with the enlarged optic disc coloboma through the canal gully-like structure, and the fluid leaked from the enlarged and thinned optic disc coloboma into the retinal layer of the macular area. Patients with optic disc abnormalities and macular degeneration must be monitored appropriately. During the follow-up period, the use of optic disc stereography and 3D-OCT, en-face, and Angio-OCT imaging can clarify the correlation between macular retinoschisis and optic disc coloboma.

CONCLUSION

Macular retinoschisis may be owing to the combined force of disc edge loss, enlarged optic disc coloboma, the canal gully-like structure formed by the defect of the nerve fiber layer around the optic disc, and the traction of the posterior vitreous cortex.

Morning Glory Syndrome- A case report

Morning Glory Syndrome (MGS) is an uncommon congenital anomaly of the eye nerve (optic nerve) that resembles a flower known as morning glory, impairs vision, and may be associated with both ocular and non-ocular abnormalities. It has a characteristic fundoscopic appearance consisting of a large funnel-shaped cavity on the optical disc. We register an unusual congenital anomaly of the optic disc in a three-year-old female child.

Internal limiting membrane packing for treatment of morning glory syndrome with rhegmatogenous retinal detachment

Purpose

Observations

Conclusions and importance

•

Morning Glory syndrome (MGS) is a rare congenital optic disc abnormality.

•

We report a case of MGS combined with rhegmatogenous retinal detachment (RRD) in which the contractile movement of the retinal hole was observed.

•

This case is the first to report the successful treatment of a retinal hole in a MGS patient by internal limiting membrane tamponade combined with autologous blood coverage.

Clinical and Echographic Features of Morning Glory Disc Anomaly in Children: A Retrospective Study of 249 Chinese Patients

Purpose

To report the clinical and echographic features, the prevalence of retinal detachment (RD), and associated visual acuity in a cohort of pediatric patients with morning glory disc anomaly (MGDA).

Methods

This was a retrospective review of 249 pediatric patients with MGDA (271 eyes) seen at the Dept. of Ophthalmology, Xinhua Hospital. Their medical records were reviewed for demographic data and ocular and systemic findings. The maximal depth and width of the cavity were measured using standardized echographic images. The ratios of cavitary depth to axial length, cavitary depth to maximal cavitary width, and the product of cavitary depth and width were calculated and used to indicate the relative size of the excavation. The clinical and echographic findings were correlated with visual acuity and the occurrence of RD of the patient.

Results

The relative size of the excavation and the presence of RD were positively associated with increased risk of poor vision (p < 0.05). The presence of persistent fetal vasculature was not associated with the risk of RD and poor vision. The ratio of cavitary depth to axial length more than or equal to 0.25 conferred an increased risk of RD (OR, 2.101; 95% CI, 1.469–3.003).

Conclusions

Clinical and echographic features of MGDA may be used in predicting the risk of RD. Measuring the relative size of excavation via echography may guide the follow-ups and assist in the early diagnosis of RD.

A case of anterior persistent hyperplastic primary vitreous associated with morning glory disc anomaly and retinopathy of prematurity like retinopathy in a term-born child

Background

Association of morning glory disc anomaly (MGDA) with persistent hyperplastic primary vitreous (PHPV) has been reported earlier. Retinopathy of prematurity (ROP) like retinopathy in preterm babies with optic disc anomalies has also been published. Our case is unique in terms of presence MGDA, PHPV, unilateral ROP like retinopathy in a term infant with normal birth weight.

Case presentation

A 5-month-old girl, born at term with a birth weight of 3750 g, presented with anterior PHPV, MGDA and ROP like retinopathy. In order to prevent retinal detachment, she received 360 degree barrage laser photocoagulation at the edge of the optic disc excavation of the left eye. In the follow-up a month later, laser scars were found in her left fundus without other complications.

Conclusion

PHPV and MGDA with ROP like retinopathy in term and normal weight baby is rare. The peripheral avascular retinal area, caused by the dragging of the defected optic disc, might have been more vulnerable to the oxygen change after birth which resulted in ROP like retinopathy. High sensitivity to oxygen results in a series of changes such as upregulation of VEGF and IGF-1 may cause ROP-like retinopathy.

Optic Nerve Abnormalities in Morning Glory Disc Anomaly: An MRI Study

BACKGROUND

The morning glory disc anomaly (MGDA) is a rare congenital malformation of the optic disc. The association with a significant enlargement of the optic nerve has been recently reported in a few cases, raising the question of potentially associated optic nerve gliomas. The objective was to report the anatomy of optic nerves on MRI in patients with MGDA.

METHODS

In this retrospective single-center study, files of patients with a clinical diagnosis of MGDA were identified through a rare disease database (CEMARA) and included. We reviewed every cerebral and orbital MRI available, performed between 2008 and 2018. Anatomy of the optic nerve from the optic disc to the chiasm was evaluated on MRI.

RESULTS

Nine patients were included. All presented unilateral MGDA. Age at first MRI was 0.6-62 years, median = 3.8 years. MRI showed posterior protrusion of the globe (staphyloma) centered by the optic disc in all cases (100%). Ipsilateral optic nerve abnormalities were found in all cases (100%). The optic nerve was found thinner than the contralateral one in its intraorbital, intracanalar, and intracranial portions in 1 case (11%); in 8 cases (89%), the thickness of the optic nerve was irregular and varied along its pathway: thick, normal, and/or thin. When gadolinium injection had been performed (3 cases), none exhibited gadolinium enhancement. When serial MRI scanning was available (4 cases), there was no evolution of the abnormalities.

CONCLUSION

In patients with MGDA, optic nerve and chiasm abnormalities are the rule, with most often a unique pattern of irregular optic nerve thickness-hypertrophy and hypoplasia-from the orbit to the chiasm. Such pattern should be recognized and points to a developmental abnormality, rather than an optic nerve glioma.

Morning glory syndrome with Moyamoya disease: A rare association with role of imaging

Morning glory disc anomaly (MGDA) is a congenital optic nerve anomaly characterized by a funnel-shaped excavation of the posterior globe that incorporates the optic disc. Most cases are isolated and not associated with systemic anomalies. Systemic anomalies include midline cranial facial defects, hypertelorism, agenesis of the corpus callosum, cleft lip and palate, basal encephalocele, congenital forebrain abnormalities, and renal anomalies. We report a case of 4-year-old male child who presented with reduced visual acuity on left eye with poor fixation. The left eye demonstrated 6-diopter esotropia. Examination of fundus revealed features of MGDA. The child was further subjected to magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of brain to rule out other associated anomalies. It demonstrated narrowing at the distal part of internal carotid artery on both sides, left more than right with prominence of lenticulostriate and leptomeningeal vessels. MRI also revealed funnel-shaped excavation of the posterior globe on the left side consistent with MGDA. Ascertaining the accurate diagnosis of MGDA guides appropriate ophthalmic management and should also prompt a search for associated intracranial abnormalities. Although the diagnosis of MGDA is typically made clinically, imaging may feed supplementary value in establishing the diagnosis and reveal the extent and character of associated ocular abnormalities, and cross-sectional imaging permits for evaluation of the globe in the setting of associated opacities of the refractive media, including persistent hyperplastic primary vitreous, which may alleviate the capacity to make this diagnosis on the basis of the fundoscopy examination alone.

Management of Retinal Detachment Associated with Morning Glory Disc Syndrome

We report a case of morning glory disc anomaly in a young patient with tractional retinal detachment successfully repaired with complex pars plana vitrectomy, membrane peel, laser, and oil tamponade. A 19-year-old female with a history of right morning glory disc anomaly associated with PAX6 gene mutation presented with floaters, photopsia, central scotoma, and visual acuity (VA) of 1/200. A complex macula-involving tractional retinal detachment centered around the optic nerve with a morning glory disc anomaly. Retinal detachment was treated with 25-gauge pars plana vitrectomy with difficult separation of the posterior hyaloid. Fibrous preretinal membranes were peeled, a temporal relaxing retinotomy was required, subretinal fluid was drained through a superonasal retinotomy during air-fluid exchange, endolaser was applied, and tamponade was achieved with 1,000-centistoke silicone oil. The retina remained attached at 1-year follow-up, with VA count fingers throughout. Morning glory disc is a rare congenital anomaly associated with PAX6 gene mutation that most often occurs unilaterally. It is rarely associated with tractional retinal detachment. Optimization of visual outcome is imperative despite a poor visual prognosis.

A rare triad of morning glory disc anomaly, moyamoya vasculopathy, and transsphenoidal cephalocele: pathophysiological considerations and surgical management

Morning glory disc anomaly is a congenital abnormality of the optic disc and peripapillary retina reported as an isolated condition or associated with various anomalies, including basal encephaloceles and moyamoya vasculopathy. However, the co-occurrence of these three entities is extremely rare and the pathogenesis is still poorly understood. Moreover, data on the surgical management and long-term follow-up of the intracranial anomalies are scarce. Here, we describe the case of a 11-year-old boy with morning glory disc anomaly, transsphenoidal cephalocele, and moyamoya vasculopathy, who underwent bilateral indirect revascularization with encephalo-duro-myo-arterio-pericranio-synangiosis at the age of 2 years, and endoscopic repair of the transsphenoidal cephalocele at the age of 6 years. A rare missense variant (c.1081T>C,p.Tyr361His) was found in OFD1, a gene responsible for a X-linked ciliopathy, the oral-facial-digital syndrome type 1 (OFD1; OMIM 311200). This case expands the complex phenotype of OFD1 syndrome and suggests a possible involvement of OFD1 gene and Shh pathway in the pathogenesis of these anomalies.

Morning Glory Disc Anomaly with Contractile Peripapillary Staphyloma in an 18-Month-Old Girl

We present an 18-month-old girl with strabismus and a variable esotropia of the left eye. Fixation of the affected eye was intermittent with a relative afferent pupillary defect. A fundus photography of the left eye displayed a combination of features of both morning glory disc anomaly and peripapillary staphyloma. A B-scan ultrasonography examination of the left eye showed a conical excavation of the posterior pole. Cycloplegic refraction measurements showed a large amount of anisometropia. Correction with glasses and part-time occlusion was prescribed and a strict follow-up routine was advised. No other systemic associations with the disease have been discovered so far in our patient. We support the theory that morning glory disc anomaly and peripapillary staphyloma may represent two different morphologies in the spectrum of the same disease.

Total retinal detachment and contractile movement of the disc in eyes with morning glory syndrome

Purpose

This study aimed to report clinical characteristics, intraoperative findings, and surgical outcomes of 2 eyes of 2 patients with retinal detachment (RD) associated with morning glory syndrome (MGS) and contractile movement of the disc.

Observations

Case 1 was a 3-year-old Japanese boy who presented with congenital microphthalmos in the left eye. The presence of total RD with MGS and contractile movement of the disc was confirmed by ophthalmoscopic examination. During vitrectomy, migration of perfluorocarbon liquid into the subretinal space was observed, suggesting a communication between the vitreous cavity and the subretinal space. Here, the retina was reattached briefly after the surgery; however, it detached again 2 months after surgery. Case 2 was a 3-month-old Japanese girl who was referred to our hospital for evaluation of RD and MGS in her left eye. Partial RD, MGS, and contractile movement of the disc were confirmed by ophthalmoscopic examination. The RD remained unchanged up to 18 months from the first visit, but atresia of the pupil was found 21 months after the first visit. Severe proliferative vitreoretinopathy and contractile movement of the disc were found after lensectomy. It was impossible to completely remove the membrane despite meticulous effort of peeling it off. At the 15-month follow-up, the retinal configuration improved but remained detached.

Conclusion and importance

Total RD with contractile movement of the disc associated with MGS is a rare condition that seems difficult to treat.

Unilateral morning glory disc anomaly in a patient with prenatal Zika virus exposure

Background

To report a case of morning glory disc anomaly (MGDA) in a pediatric patient with prenatal Zika virus (ZIKV) exposure.

Case presentation

A 3-year-old male with prenatal exposure to ZIKV, confirmed by real-time polymerase chain reaction testing during the second trimester of pregnancy, was evaluated due to visual loss. Physical examination was remarkable for unilateral MGDA. Neuroimaging showed a base of skull encephalocele through the floor of the sella and callosal dysgenesis.

Conclusions

This is the first report to suggest an association between prenatal ZIKV exposure and MGDA. Prenatal ZIKV exposure may be associated to a wider pathologic spectrum than previously reported.

Contractile morning glory disk anomaly: analysis of the cyclic contractions and literature review

PURPOSE

To investigate the contraction mechanism of morning glory disk anomaly using computer-assisted analysis of the cyclic contractions frame by frame and to review the literature on contractile morning glory disk anomaly cases.

METHODS

The fundus video of the patient under anesthesia was recorded using RetCam C300 lens. Frames at 1 second intervals were extracted to quality-preserving TIFF images and manually selected areas of cup, disk, and pigmented ring were measured with image analysis software. Measurements were repeated twice, and estimated uncertainties were calculated.

RESULTS

Two full-contraction phases and 1 half- and 1 full-dilation phase were recorded and analyzed. At the end of the second dilation phase, cup, disk, and pigmented ring were dilated to 93.7%, 97.6%, and 98.3% of their areas after first dilation. At the end of the second contraction cup, disk and pigmented ring areas remained 1.24, 1.01, and 1.01 times larger, respectively, than the areas at the end of the first contraction.

CONCLUSIONS

Ectopic cholinergic muscle contraction alone is unlikely to explain the cyclic contraction dilation movements under constant stimulus. Potentially present smooth muscle cells can be provoked by the stretch caused by the influx of fluid into the subretinal space. Change in spatial configuration and oscillations with decreasing magnitudes can be explained by decreasing contractions due to decreasing stretch with decreasing fluid influx in each cycle after the initial triggering of outside pressure, causing the greatest pressure gradient and the greatest fluid influx.

Internal carotid artery origin of the anterior cerebral artery: A rare anatomic intracranial arterial variation in a child with morning glory disc anomaly and moyamoya vascular pattern; case report and review of literature

Morning glory disc anomaly (MGDA) characterizes a congenital dysgenetic disorder of the optic disc, coexisting with arterial intracranial abnormalities, including Moyamoya vascular disease, a significantly rare disease in the European populations. We report a 2.5-year-old female child from Greece previously diagnosed with MGDA, who presented with right-hand paresis, accompanied by focal epileptic spasms, followed by an episode of brief absence seizure, as well as some arm clonic spasms. Magnetic resonance angiography scan revealed the presence of an anomalous origin of the anterior cerebral artery (ACA) from the internal carotid artery (ICA) along with vascular abnormalities, compatible with Moyamoya pattern. To the very best of our knowledge, this is the first reported case of anomalous origin of ACA from the supraclinoid ICA accompanied by severe occlusive intracranial disease (moyamoya-like pattern) in a patient with known MGDA, highlighting the embryonic character of the vascular manifestations in MGDA. It also verifies the association of Moyamoya pattern with MGDA, thus linking vascular dysgenesis as a possible cause of MGDA.

An unusual association of Morning Glory Syndrome with chronic myeloid leukemia-Philadelphia chromosome

Morning glory disc anomaly (MGDA) is a rare congenital malformation that results from the incomplete formation of the optic nerve in utero. The majority of the patients have unilateral involvement and poor vision leading to sensory strabismus. Morning Glory Syndrome (MGS) may be a part of other syndromes and systemic abnormalities like transsphenoidal basal encephalocele, midfacial malformations, absent optic chiasma, MoyaMoya syndrome, and renal agenesis. In the present report, we describe a patient with a large disc with an excavated posterior scleral opening with a white glial tuft at the centre. The blood vessels were increased in number and arranged radially from the disc with peripapillary hyperpigmentation in clumps. Funnel-shaped excavation of the posterior globe was also noted on MRI. Associated ocular features were microcornea, nystagmus, esotropia, and systemic features included chronic myeloid leukemia- Philadelphia chromosome (CML-PC) and empty sella turcica. We report an unusual association of MGS with CML-PC.

A hybrid coloboma and optic disc pit associated with macular retinoschisis

Background

To report and describe an unusual case of a patient with optic disc pit in one eye and optic disc coloboma with a focal pit associated with macular retinoschisis in the other eye.

Case presentation

A 21-year-old woman presented with optic disc pit in the right eye and optic disc coloboma with a focal pit like excavation in the left eye. Macular spectral domain optical coherence tomography (SD-OCT) of the left eye revealed macular retinoschisis, without serous detachment.

Conclusions

Proper monitoring of patients with disc anomalies associated with maculopathy is mandatory. The use of OCT imaging during follow-up can help to identify involvement of the fovea or enlargement of the retinoschisis area.

Case Report: Optical Coherence Tomography Angiography in Morning Glory Disc Anomaly

SIGNIFICANCE

Morning glory disc anomaly is a congenital abnormality of the optic disc. Optical coherence tomography angiography shows vascular rarefaction of the superficial and deep capillary plexuses and increased vascularity of the radial peripapillary capillary plexus. We hypothesize that this congestion represents a compensatory mechanism to an abnormal vasculogenesis.

PURPOSE

The aim of this study was to describe the optic disc vascular alterations occurring at choriocapillaris and retinal vascular plexuses in a patient affected by bilateral morning glory disc anomaly with optical coherence tomography angiography.

CASE REPORT

A 24-year-old white man presented for clinical evaluation to our Department of Ophthalmology (San Raffaele Hospital, Milan) complaining of reduced vision in his left eye. Whereas his right eye was unremarkable (20/20), the visual acuity in the left one was limited to 20/30 Snellen equivalent. Funduscopic examination revealed bilateral funnel-shaped optic disc excavation, with a central mass of glial tissue and straight retinal vessels radially emerging from the disc margin, more evident in the left eye; this presentation was considered compatible with bilateral morning glory disc anomaly. Optical coherence tomography angiography of the optic disc disclosed prominent vascular rarefaction of the peripapillary superficial and deep capillary plexuses and choriocapillaris, with an increased vascularity of the radial peripapillary capillary network.

CONCLUSIONS

Based on these observations, we hypothesize that the congestion of the radial peripapillary capillary plexus might be a compensatory mechanism to the abnormal vasculogenesis occurring in the optic disc of patients affected by morning glory disc anomaly.

Delayed presentation of morning glory disc anomaly and transsphenoidal encephalocele: A management dilemma

Background Morning glory disc anomaly (MGDA) is a rare developmental abnormality of the optic disc that is associated with many other neurological and vascular conditions. Most cases are diagnosed in childhood. Case Report We report a 57-year-old woman who presented to the ophthalmology department for assessment of long-standing poor vision in the left eye and exotropia. Examination showed a left MGDA and bitemporal hemianopsia. These findings prompted magnetic resonance imaging, revealing a transsphenoidal basal meningoencephalocele with herniation of the optic chiasm and inferior hypothalamus into the dural sac. Due to the eloquence of the neurovascular structures it contained, a decision was made not to reduce the meningoencephalocele. Instead, a ventriculoperitoneal shunt was placed. The patient's ophthalmologic examination remained stable over the following year. Conclusion While rare, MGDA can be first diagnosed in late adulthood and a thorough evaluation should be completed to assess for midline cranial defects, vascular abnormalities, and other associated abnormalities. Patients presenting late in life with basal encephalocele, herniation of the optic chiasm, and bitemporal hemianopsia present a management dilemma. In this case, a ventriculoperitoneal shunt was placed with the intention of lowering intracranial pressure to prevent further herniation and reduce the risk of cerebrospinal fluid leak.

Postoperative follow-up of a case of atypical morning glory syndrome associated with persistent fetal vasculature

BACKGROUND

Morning glory syndrome is a relatively rare congenital optic disc anomaly that is often difficult to identify when associated with additional congenital ocular anomalies. This case report describes the diagnosis, treatment, and postoperative follow-up care of a young girl with morning glory syndrome accompanied by persistent fetal vasculature, retinal fold, and retinal detachment. Here, we also give a brief review of the relevant literature.

CASE PRESENTATION

A 5-year-old girl was referred to our clinic for a complaint of decreased vision for 6 months in the right eye. The best corrected visual acuity was hand motion in her right eye and 0.8 in her left eye. A fundus examination indicated vitreous opacities and scattered hemorrhages, as well as striped folds in the temporal retina of the affected eye. B-ultrasound and magnetic resonance imaging scans suggested that it could be a congenital dysplasia of the right eye. Pars plana vitrectomy was performed in the right eye. Morning glory syndrome associated with persistent fetal vasculature was confirmed in subsequent follow-up observation according to the fundus appearance, optical coherence tomography, and fundus fluorescein angiography imaging.

CONCLUSIONS

The patient was diagnosed as morning glory syndrome associated with persistent fetal vasculature and retinal fold. The morning glory disc with the presence of retinal folds did not seem quite typical and that made the diagnosis difficult. This report stresses the importance of considering concurrent morning glory syndrome and persistent fetal vasculature. Vitrectomy may be beneficial in the management of the morning glory syndrome and persistent fetal vasculature if accompanied by retinal detachment in similar cases.

Marcus Gunn Jaw-Winking Syndrome Associated with Morning Glory Disc Anomaly

Marcus Gunn jaw-winking syndrome (MGJWS) is a rare form of congenital blepharoptosis and one of the congenital cranial dysinnervation disorders (CCDD). In addition, morning glory disc anomaly (MGDA) is a congenital optic disc anomaly of unknown etiology. The present report is the first to describe an association between MGJWS and MGDA in an otherwise healthy 7-year-old boy. He also had counting finger vision, anisometropia, esotropia, and monocular elevation deficiency in the same eye. In the literature, both MGJWS and MGDA have been reported to be associated with Duane retraction syndrome, a form of CCDD.

Morning glory disc anomaly and ipsilateral sporadic optic pathway glioma

Purpose

To present a rare case of morning glory disc anomaly in association with an ipsilateral low grade glioma.

Observations

A 5 year old male presented with a unilateral morning glory disc anomaly and an ipsilateral sporadic optic pathway glioma with chiasmal involvement. After a strict patching regimen his vision improved from 20/400 to 20/80.

Conclusions and importance

This report strengthens the recommendation for brain magnetic resonance imaging in patients with morning glory disc anomaly. Patching of the contralateral eye should be attempted since the role of amblyopia may be significant.

Optic disk contractility in morning glory disk anomaly

Morning glory disk anomaly is a nonhereditary, congenital optic disk dysplasia characterized by conical excavation of the posterior fundus with a central glial tuft and radial retinal vessels. We report the case of a 4-year-old girl who presented with esotropia, enophthalmos, no light perception, and afferent pupillary defect in her left eye; fundus examination revealed morning glory disk anomaly. Ultrasound B-scan showed axial length increasing in the left eye on consensual light exposure. Magnetic resonance imaging/angiogram of the brain and orbits were within normal limits except for globe elongation posteriorly in the left eye. On examination under anesthesia with video indirect ophthalmoscopy, the left optic disk showed contraction and expansion when stimulated by strong light to the fellow eye and no spontaneous contraction on direct light stimulation. Morning glory disk contractility with increasing axial length on consensual light exposure in a child has not been reported previously.

Congenital anomalies of the optic disc: insights from optical coherence tomography imaging

PURPOSE OF REVIEW

Congenital anomalies of the optic nerve are rare but significant causes of visual dysfunction in children and adults. Accurate diagnosis is dependent on a thorough funduscopic examination, but can be enhanced by imaging information garnered from optical coherence tomography (OCT). We review common congenital optic nerve anomalies, including optic disc pit, optic nerve coloboma, morning glory disc anomaly, and hypoplasia of the optic nerve, review their systemic associations, and discuss insights from OCT imaging.

RECENT FINDINGS

Optic disc pits are a result of a defect in the lamina cribrosa and abnormal vitreomacular adhesions have been shown to cause maculopathy. In patients with optic nerve colobomas, OCT can be instrumental in diagnosing choroidal neovascularization, a rare but visually devastating complication. The pathogenesis of morning glory disc anomaly has been more clearly elucidated by OCT as occurring from a secondary postnatal mesenchymal abnormality rather than only the initial neuroectodermal dysgenesis of the terminal optic stalk in isolation. OCT studies of optic nerve hypoplasia have demonstrated significant thinning of the inner and outer retinal layers of the perifoveal region and thicker layers in the fovea itself, resulting in a foveal hypoplasia-like pathology, that is, significantly correlated to poorer visual outcomes.

SUMMARY

OCT provides detailed in-vivo analysis of these anatomic anomalies and their resulting pathologies, shedding new insights on the pathogenesis, diagnosis, and potential visual outcomes of these conditions in children. Further study employing OCT to elucidate structure-function relationships of congenital optic nerve anomalies will help expand the role of OCT in clinical practice related to diagnosis, prognosis, and management of these entities.

Intraoperative optical coherence tomography assisted analysis of pars Plana vitrectomy for retinal detachment in morning glory syndrome: a case report

BACKGROUND

The pathogenesis of non-rhegmatogenous retinal detachment (non-RRD) associated with morning glory syndrome (MGS) is not established, as well as best surgical approach to treat RD. Our purpose was to analyse intraoperative optical coherence tomography data (iOCT) in all steps of pars plana vitrectomy (PPV) for non-RRD in MGS, in order to follow pathophysiological aspects of the disease and to understand the tissues behaviour during surgical workflow.

CASE PRESENTATION

Intraoperative spectral domain optical coherent tomography (iSD-OCT) assisted PPV using Rescan 700 (Carl Zeiss Meditech, Jena, Germany) with epiretinal membrane (ERM) and internal retinal membrane (ILM) peeling, and air endotamponade was performed on the only eye of a 21 years old female with non-RRD associated with MGS. BCVA, pre-, intra- and postoperative OCT were performed along with standard ocular examination. iOCT video and snapshots were analysed intra- and postoperatively using post-processing approach using graphic software. The progression of non-RRD resulted in best corrected visual acuity (BCVA) decrease from 0.8 to 0.2. Triamcinolone enhanced iOCT imaging revealed strong vitreous traction and adhesion above the macula and optic disc. Internal limiting membrane was peeled under iOCT control to prevent the peeling of inner layers of the retinal schisis. No retinal break was detected, and only air endotamponade was performed. The retina reattached during first 4 weeks of follow-up with gradual resolution of intraretinal- and subretinal fluid, and remained stable in 12 months. BCVA improved to 0.8.

CONCLUSION

Based on iSD-OCT findings we assume that non-RRD in this case of MGS is caused primarily by the vitreous traction with further possible formation of the retinal breaks. Retinal reattachment reached only with air endotamponade strongly advocates the tractional component of non-RRD and retinal schisis assotiated with MGS. Early PPV for central non-RRD and retinal schisis with the use of iOCT can be performed in more safe and controlled manner and has to be considered to reduce the risk of retinal break formation and to prevent the central vision loss.

A case of morning glory syndrome associated with persistent hyperplastic primary vitreous and Peters' anomaly

We report a case of morning glory syndrome (MGS) associated with persistent hyperplastic primary vitreous (PHPV) and Peters’ anomaly. A 2-day-old girl, born at term with a birth weight of 3,350 g was diagnosed with Peters’ anomaly, cataract, microphthalmia, PHPV, and MGS. A right limbal lensectomy and vitrectomy with stalk cauterization was performed 8 days later. No early postoperative complication occurred, the family was discharged with advice on medication, and follow-up examination was scheduled. The case report reveals the coexistence of PHPV, Peters’ anomaly, and MGS, which may suggest a genetic link.

Congenital optic nerve anomalies

OBJECTIVE

To update the current knowledge about congenital optic disc anomalies.

METHODS

A comprehensive literature search was performed in the major biomedical databases.

RESULTS

Patients with these anomalies usually have poor vision in infancy. Refractive errors are common, and serous retinal detachment may develop in some of these anomalies. It is critically important to clinically differentiate between these congenital optic disc anomalies, as central nervous system malformations are common in some, whereas others may be associated with systemic anomalies.

CONCLUSIONS

Congenital optic disc anomalies are a heterogeneous group of pathologies with characteristic fundus appearance and systemic associations. We should always try to make a correct diagnosis, in order to ask for specific tests, as well as to provide an adequate follow-up.

Morning Glory Disc Anomaly, A Report of a Successfully Treated Case of Functional Amblyopia

Morning Glory Disc Anomaly (MGDA) is a congenital malformation of the optic nerve characterized by the presence of a funnel-shaped macropapilla with neuroglial remnants in its center surrounded by an elevated and pigmented chorioretinal ring. Its incidence is rare and no gender predisposition has been found. Associated conditions like strabismus lead to an early diagnosis. We report the case of a 3.8-year-old boy with amblyopia of the right eye (count fingers 0.3 meters) due to MGDA. Correction of the refractive error with glasses, along with occlusive therapy resulted in a visual acuity of 20/100 after a five-year follow up. The presence of amblyopia in these cases demands an early management oriented to improve the visual acuity. Every patient with an anatomical malformation diagnosed during the period of sensory maturation should be treated with occlusive therapy and followed on a regular basis to diagnose associated conditions such as retinal detachment. We recommend occlusive therapy in every patient diagnosed with MGDA or in any patient with unilateral or asymmetric structural abnormalities that could lead to amblyopia. This 5-year case follow-up provides additional evidence of the importance of treatment during the period of amblyopia reversibility.

Morning glory disc anomaly in childhood - a population-based study

PURPOSE

To report prevalence, ocular characteristics and coexisting neurological, behavioural, somatic and neuroradiological abnormalities in children and adolescents with morning glory disc anomaly (MGDA).

METHODS

In a cross-sectional population-based study, 12 patients with MGDA, aged 2-20 years, were identified. All 12 agreed to ophthalmological assessments including visual functions, refraction, fundus photography, optical coherence tomography (OCT) and ocular motor score (OMS). Neurological examinations and behavioural/developmental screening were carried out. Data from previous or new neuroradiological investigations were collected.

RESULTS

The prevalence of MGDA was 2.6/100 000. MGDA was unilateral in 11/12 patients with a best-corrected visual acuity (BCVA) in the MGDA eye ranging from hand motion to 0.65 (median 0.06). Severe microphthalmus prevented unilaterality to be determined in one adolescent. All patients had a binocular BCVA of ≥0.5. OMS showed abnormalities in pupil response, vestibulo-ocular reflex, stereo visual acuity, strabismus and convergence. OCT revealed peripapillary or macular oedema in 5/8 patients and foveal aplasia in 3/8 patients. Three patients had extensive capillary hemangiomas, of which one had PHACES syndrome and one had additional cerebrovascular anomalies and corpus callosum agenesis. Neuroradiology showed craniovascular anomalies in two patients. Neurology was mostly normal. Behavioural/developmental screening showed attention deficit hyperactivity disorder in one patient.

CONCLUSIONS

The prevalence data, previously not reported, of morning glory disc anomaly was 2.6/100 000. Coexisting retinal peripapillary or macular oedema was common, as were cerebral abnormalities and/or cutaneous vascular malformations. The associated findings may not be discovered through routine ophthalmological examination why OCT and neuroimaging are called for.

Congenital anomalies of the optic nerve

Congenital optic nerve head anomalies are a group of structural malformations of the optic nerve head and surrounding tissues, which may cause congenital visual impairment and blindness. Each entity in this group of optic nerve anomalies has individually become more prevalent as our ability to differentiate between them has improved due to better characterization of cases. Access to better medical technology (e.g., neuroimaging and genetic analysis advances in recent years) has helped to expand our knowledge of these abnormalities. However, visual impairment may not be the only problem in these patients, some of these entities will be related to ophthalmologic, neurologic and systemic features that will help the physician to identify and predict possible outcomes in these patients, which sometimes may be life-threatening. Herein we present helpful hints, associations and management (when plausible) for them.

Systemic abnormalities in children with congenital optic disc excavations

PURPOSE

Together with optic disc hypoplasia, excavated optic disc anomalies represent the most frequent congenital abnormality involving the optic nerve head. The purpose of the present study was to retrospectively review the results of a screening for extraocular abnormalities in children presenting with congenital optic disc excavations.

MATERIALS AND METHODS

The medical records of 37 patients diagnosed with a unilateral or bilateral non glaucomatous optic disc excavation were retrospectively reviewed to analyze the result of the extra ocular evaluation and to report the associated ocular abnormalities.

RESULTS

An ocular abnormality was observed in conjunction with the excavated optic disc in 31% of the eyes. The systematic investigations revealed the presence of at least one extra-ocular disorder in 48% of the cases, and the optic disc excavation could be considered as syndromic in 30% of patients. The prevalence of extraocular malformations was significantly higher in infants presenting with associated ocular malformations or abnormal vision/development.

CONCLUSIONS

The present study suggests that a systematic approach to search for any associated systemic abnormalities could be envisioned in patients presenting with congenital excavated optic discs, and particularly those presenting with abnormal vision, associated ocular defects or abnormal development.

Unilateral Morning Glory Disc Anomaly With Ipsilateral Limbal Dermoids

The authors present the case of a child with multiple limbal dermoids and morning glory disc anomaly in the right eye. These anomalies are rarely associated and this is the first report of co-occurrence in the same eye in a patient without additional systemic anomalies.

Morning glory disc anomaly with Chiari type I malformation

Morning glory disc anomaly is a rare optic nerve dysplasia associated with various neovascular abnormalities. Due to these associations, children with morning glory disc anomaly have brain imaging and angiography to detect other congenital defects. The authors report the case of an infant with morning glory disc anomaly and coexisting Chiari type I malformation.

Congenital abnormalities of the optic nerve: from gene mutation to clinical expression

Optic nerve malformations are common causes of congenital blindness and are recognized with increasing prevalence. The importance of identifying these malformations lies not only in determining the cause and level of visual impairment, but also in looking for associated treatable or life threatening systemic conditions. A number of genetic mutations have been identified in the development of optic disc anomalies, such as ones in PAX2 or PAX6. Recent advances in genetic testing like array comparative genomic hybridization allow the detection of microdeletions that were previously difficult or impossible to identify.

Clinical characteristics and treatment of 22 eyes of morning glory syndrome associated with persistent hyperplastic primary vitreous

PURPOSE

To describe the clinical manifestations and treatment outcomes in a retrospective case series of morning glory syndrome (MGS) associated with persistent hyperplastic primary vitreous (PHPV).

METHODS

The medical records of 85 eyes/74 patients referred for ophthalmology consultation diagnosed as MGS in our clinic were reviewed retrospectively. All patients underwent thorough ophthalmological examinations. 22 eyes of 19 patients diagnosed as having MGS associated with PHPV were included, accounting for 25.88% of all the MGS eyes. Clinical manifestations and management of these patients were documented.

RESULTS

15 patients (78.95%) were younger than 1 year old at the first diagnosis. Six eyes were associated with microphthalmia. 19 of 22 eyes (86.36%) had complications, including cataract (10 eyes), secondary glaucoma (8 eyes), corneal leucoma or oedema (8 eyes), retinal detachment (8 eyes), strabismus (3 eyes) and nystagmus (2 eyes). Treatment methods varied depending on the severity of the complications. Nine eyes with secondary glaucoma or cataract got lensectomy; three eyes underwent combined vitrectomy and lensectomy. Eight patients underwent cranial MRI/MR angiography or CT examination. Widened cerebral fissures of bilateral temporal lobes, abnormal dilated branch of middle cerebral artery in the left hemisphere and abnormal signal in the grey matter of frontal and occipital lobes were revealed respectively in three patients.

CONCLUSIONS

Our study revealed the coexistence of PHPV in a significant percentage of patients with MGS, suggesting a potential common genetic link. Compared with MGS and PHPV alone, the combination of the two conditions manifested with higher incidence and more severe complications in younger patients. Close follow-up was recommended. Lensectomy and vitrectomy were beneficial in the management of the complications.

Morning glory disc anomaly: characteristic MR imaging findings

SUMMARY

Establishing the diagnosis of morning glory disc anomaly is crucial to appropriate patient treatment. Although typically made clinically, the diagnosis is not always straightforward, especially in circumstances where physical examination is limited. The goal of this study was to define the spectrum and frequency of orbital findings in a series of patients with funduscopically-confirmed morning glory disc anomaly by using MR imaging. MR imaging demonstrated 3 findings in all patients: 1) funnel-shaped morphologic pattern of the posterior optic disc with elevation of the adjacent retinal surface; 2) abnormal tissue associated with the distal intraorbital segment of the ipsilateral optic nerve, with effacement of the regional subarachnoid spaces; and 3) discontinuity of the uveoscleral coat. These findings were not observed in any of the unaffected globes of the study patients. In summary, these consistent and characteristic findings of morning glory disc anomaly should allow for accurate differentiation from other ocular anomalies and have the potential to guide appropriate management of this patient population.