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Raming K, Pfau M, Herrmann P, Holz FG, Pfau K. Anti-VEGF Treatment for Secondary Neovascularization in Pseudoxanthoma Elasticum - Age of Onset, Treatment Frequency, and Visual Outcome. Am J Ophthalmol 2024; 265:127-136. [PMID: 38614195 DOI: 10.1016/j.ajo.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 03/25/2024] [Accepted: 03/25/2024] [Indexed: 04/15/2024]
Abstract
PURPOSE To assess the onset, treatment frequency, and visual outcome of anti-vascular endothelial growth factor (anti-VEGF) treatment due to secondary choroidal neovascularization (CNV) in patients with pseudoxanthoma elasticum (PXE). DESIGN Retrospective cohort study METHODS: One-hundred six eyes of 53 patients with PXE were analyzed. The assessment of CNV activity relied on hemorrhage visible on funduscopy and intra- / subretinal fluid on optical coherence tomography (OCT), individually defining a shortening or extension of treatment interval. Best-corrected visual acuity (BCVA) at baseline, age at anti-VEGF therapy initiation, and BCVA-drop events at exudation onset (worsening of BCVA of 2 or more lines) were documented. Further, we assessed the number of injections during the first year and the total number of injections, the time to treatment initiation of the fellow eye, and BCVA over time. RESULTS During a median observation period of 77 months (IQR 49; 126) patients received a median number of 28.0 anti-VEGF-injections (IQR 9.8; 43.5). Eight patients received no injection (median age at baseline 38.1 years), 11 patients underwent anti-VEGF treatment in one eye (median age 47.2 years) and 34 patients in both eyes (median age 51.8 years). The median age at the first anti-VEGF treatment was 52.80 years (IQR 47.2-57.6). Applying Cox regression models, the median "survival" time of fellow eye until treatment initiation was 16.8 months. In the group of bilateral treated patients, the median time difference was 9.6 months (IQR 2.1- 32.4, range 0-122) The median number of injections was 5.5 per eye in the first year of treatment (IQR 3-7) and was associated with the total number of injections in the observation period (2.33, CI 1.22-3.44, P < .001). A better BCVA at the last follow-up visit was associated with a better baseline BCVA (P < .001, R2 = 0.318) and with the absence of a BCVA drop at the onset of exudation (P = 0.035, R2 = 0.339). CONCLUSIONS The results of this study indicate that anti-VEGF treatment is required for most PXE patients at a relatively young age. Once treatment in one eye is initiated, the time to fellow eye treatment is relatively short. A BCVA drop before treatment initiation is a risk factor for worse visual outcomes, suggesting that treatment is prudent before exudation affects the central retina. Given the young age of onset and intensive treatment needs, patients with PXE might particularly benefit from longer-acting anti-VEGF therapeutics.
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Affiliation(s)
- Kristin Raming
- From the Department of Ophthalmology (K.R, P.H, F.H, K.P), University of Bonn, Bonn, Germany
| | - Maximilian Pfau
- Institute of Molecular and Clinical Ophthalmology Basel (M.P), Basel, Switzerland; Department of Ophthalmology (M.P, K.P), University of Basel, Basel, Switzerland
| | - Philipp Herrmann
- From the Department of Ophthalmology (K.R, P.H, F.H, K.P), University of Bonn, Bonn, Germany
| | - Frank G Holz
- From the Department of Ophthalmology (K.R, P.H, F.H, K.P), University of Bonn, Bonn, Germany
| | - Kristina Pfau
- From the Department of Ophthalmology (K.R, P.H, F.H, K.P), University of Bonn, Bonn, Germany; Department of Ophthalmology (M.P, K.P), University of Basel, Basel, Switzerland.
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Cicinelli MV, Ramtohul P, Bianco L, Introini U, Bandello F, Freund KB, Parodi MB. Prevalence, Features, and Outcomes of Type 1 Neovascularization in Eyes with Angioid Streaks. Ophthalmol Retina 2024:S2468-6530(24)00364-6. [PMID: 39127109 DOI: 10.1016/j.oret.2024.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Revised: 08/01/2024] [Accepted: 08/02/2024] [Indexed: 08/12/2024]
Abstract
PURPOSE This study aimed to delineate the characteristics, prevalence, and outcomes of neovascularization (NV), particularly aneurysmal Type 1 NV, in patients with angioid streaks (AS) secondary to pseudoxanthoma elasticum (PXE), and to introduce a clinical classification based on multimodal imaging (MMI). DESIGN Retrospective longitudinal cohort study. PARTICIPANTS 85 patients (168 eyes) with AS secondary to PXE at two tertiary referral centers. METHODS Data collection included demographic, medical, and ocular histories. Diagnostic methods comprised fundus photography, autofluorescence, indocyanine green angiography, optical coherence tomography (OCT), and OCT angiography. MAIN OUTCOME MEASURES Prevalence of Type 1 NV, visual acuity (VA), risk of exudation. RESULTS Type 1 NV was identified in 127 eyes (76%), with 85 of these (67%) showing exclusively Type 1 NV. These lesions often originated around the disc, at sites of Bruch's membrane dehiscences, and followed the path of AS, extending to the posterior pole in 101 eyes (80%). Despite 65% of Type 1 NV remaining non-exudative, 36% evolved into exudative over five years, and 11 eyes experienced mid-peripheral subretinal hemorrhages. Aneurysmal dilations, observed in 57% of cases, substantially increased exudation risk (hazard ratio = 3.86, p=0.02). Despite treatment, VA significantly deteriorated in exudative Type 1 NV (p=0.02). Type 2 NV, detected in 56 eyes (33%), often coexisted with Type 1 NV and was associated with poorer visual outcomes and higher rates of macular atrophy. A classification of AS was developed, ranging from empty AS (stage 0, no NV) to advanced NV (stage 3, both Type 1 and Type 2 NV). CONCLUSIONS Type 1 NV predominates in AS. Although predominantly non-exudative, its progression correlates with substantial visual impairment, similar to the deficits observed with Type 2 NV. Aneurysmal Type 1 NV poses a significant exudation risk, underscoring the need for vigilant monitoring.
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Affiliation(s)
- Maria Vittoria Cicinelli
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Prithvi Ramtohul
- Ophthalmology Department, Hopital Nord, Aix-Marseille University, Marseille, France
| | - Lorenzo Bianco
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ugo Introini
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Bandello
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - K Bailey Freund
- Vitreous Retina Macula Consultants of New York, New York, New York, USA; Department of Ophthalmology, New York University Grossman School of Medicine, New York, NY, USA
| | - Maurizio Battaglia Parodi
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Laghi A, Mandel VD, Zubba I, Franceschini C, Demofonte I, Chello C, Miraglia E, Ardigò M, Giustini S. Comprehensive analysis of pseudoxanthoma elasticum: epidemiological, genetic, and clinical findings from the leading Italian center. Ital J Dermatol Venerol 2024; 159:430-435. [PMID: 39069841 DOI: 10.23736/s2784-8671.24.07949-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
BACKGROUND Pseudoxanthoma elasticum (PXE) is a rare genetic autosomal recessive metabolic disease characterized by progressive mineralization and fragmentation of elastic fibers from soft connective tissues. The objective of our study was to analyze the epidemiological, genetic, cutaneous, and extracutaneous clinical data from the largest Italian monocentric cohort of PXE patients. METHODS We included all patients diagnosed with PXE and referred to Neurocutaneous Rare Diseases at Umberto I Polyclinic Hospital (Rome, Italy) between January 1983 and February 2024. A retrospective analysis of their data was performed. RESULTS We enrolled 86 patients (77.9% women), revealing compound heterozygosity in 19.8% of cases and homozygosity in 5.8%. Missense (34.9%), non-sense (5.8%), splice-site (5.8%), deletion (4.7%), and frameshift (2.3%) mutations were disclosed. Cutaneous alterations were noted in the neck (69.7%), axilla (33.7%), inguinal (17.5%), and cubital folds (11.7%). The most common ocular findings were angioid streaks (64.0%) and choroidal neovascularization (18.6%), with blindness reported in 5.8% of cases. Thicker intima-media was observed around the mid-fifties in the supra-aortic trunks (40.7%), lower limb arteries (32.6%), and renal arteries (4.7%). Regurgitation was more common in atrioventricular valves (48.8%) than in semilunar ones (10.5% and 9.3%). Dyslipidemia (19.8%), hypertension (18.8%), and fatty liver disease (12.8%) were prevalent, with calcifications found in the kidneys (25.6%), liver (15.1%), spleen (11.6%), and testicles (8.1% of males). Autoimmune diseases and depression were observed in 11.6% and 4.7% of cases, respectively. CONCLUSIONS Enhanced understanding of PXE can improve patients' quality of life and facilitate the development of more effective therapeutic strategies.
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Affiliation(s)
- Alessandro Laghi
- Unit of Dermatology and STDs, Department of Medicine, Celio Military Hospital, Rome, Italy -
- Unit of Dermatology, Department of Internal Medicine and Medical Specialties, Sapienza University, Rome, Italy -
| | - Victor D Mandel
- Unit of Porphyria and Rare Diseases, IRCCS San Gallicano Dermatological Institute, Rome, Italy
| | - Ilaria Zubba
- Unit of Dermatology, Department of Internal Medicine and Medical Specialties, Sapienza University, Rome, Italy
| | - Chiara Franceschini
- Unit of Porphyria and Rare Diseases, IRCCS San Gallicano Dermatological Institute, Rome, Italy
| | - Ilaria Demofonte
- Unit of Dermatology, Department of Internal Medicine and Medical Specialties, Sapienza University, Rome, Italy
| | - Camilla Chello
- Unit of Dermatology, Department of Internal Medicine and Medical Specialties, Sapienza University, Rome, Italy
| | - Emanuele Miraglia
- Department of Dermatology, San Sebastiano Hospital, Frascati, Rome, Italy
| | - Marco Ardigò
- Unit of Porphyria and Rare Diseases, IRCCS San Gallicano Dermatological Institute, Rome, Italy
- Unit of Dermatology, IRCCS Humanitas Clinic, Rozzano, Milan, Italy
| | - Sandra Giustini
- Unit of Dermatology, Department of Internal Medicine and Medical Specialties, Sapienza University, Rome, Italy
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Pfau K, Lengyel I, Ossewaarde-van Norel J, van Leeuwen R, Risseeuw S, Leftheriotis G, Scholl HPN, Feltgen N, Holz FG, Pfau M. Pseudoxanthoma elasticum - Genetics, pathophysiology, and clinical presentation. Prog Retin Eye Res 2024; 102:101274. [PMID: 38815804 DOI: 10.1016/j.preteyeres.2024.101274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 05/17/2024] [Accepted: 05/20/2024] [Indexed: 06/01/2024]
Abstract
Pseudoxanthoma elasticum (PXE) is an autosomal-recessively inherited multisystem disease. Mutations in the ABCC6-gene are causative, coding for a transmembrane transporter mainly expressed in hepatocytes, which promotes the efflux of adenosine triphosphate (ATP). This results in low levels of plasma inorganic pyrophosphate (PPi), a critical anti-mineralization factor. The clinical phenotype of PXE is characterized by the effects of elastic fiber calcification in the skin, the cardiovascular system, and the eyes. In the eyes, calcification of Bruch's membrane results in clinically visible lesions, including peau d'orange, angioid streaks, and comet tail lesions. Frequently, patients must be treated for secondary macular neovascularization. No effective therapy is available for treating the cause of PXE, but several promising approaches are emerging. Finding appropriate outcome measures remains a significant challenge for clinical trials in this slowly progressive disease. This review article provides an in-depth summary of the current understanding of PXE and its multi-systemic manifestations. The article offers a detailed overview of the ocular manifestations, including their morphological and functional consequences, as well as potential complications. Lastly, previous and future clinical trials of causative treatments for PXE are discussed.
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Affiliation(s)
- Kristina Pfau
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland; Department of Ophthalmology, University Hospital Bonn, Bonn, Germany.
| | - Imre Lengyel
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom; Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | | | - Redmer van Leeuwen
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Sara Risseeuw
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Georges Leftheriotis
- University Hospital Nice, Vascular Physiology and Medicine Unit, 06000, Nice, France
| | | | - Nicolas Feltgen
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland
| | - Frank G Holz
- Department of Ophthalmology, University Hospital Bonn, Bonn, Germany
| | - Maximilian Pfau
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland; Institute of Molecular and Clinical Ophthalmology Basel, Basel, Basel-Stadt, Switzerland
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Dias MQ, Gouveia N, Félix R, Estrela-Silva S, Cabral D, Carvalho AL, Murta J, Silva R, Marques JP. Mutational spectrum and deep phenotyping in Pseudoxanthoma Elasticum: Findings from a Portuguese cohort. Eur J Ophthalmol 2024:11206721241247676. [PMID: 38602027 DOI: 10.1177/11206721241247676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
INTRODUCTION Pseudoxanthoma Elasticum (PXE) is a rare autosomal recessive disorder originated by disease-causing variants in ABCC6 gene. The purpose of this study was to characterize the genetic landscape, phenotypic spectrum and genotype-phenotype correlations in a Portuguese cohort of PXE patients. METHODS Multicentric cross-sectional study conducted in patients with a clinical and genetic diagnosis of PXE. Patients were identified using the IRD-PT registry (www.retina.com.pt). Genotypes were classified into 3 groups: (1) two truncating variants, (2) two non-truncating variants, or (3) mixed variants. Deep phenotyping comprised a comprehensive ophthalmologic and systemic evaluation using the updated Phenodex Score (PS). RESULTS Twenty-seven patients (23 families) were included. Sixteen different ABCC6 variants were identified, 7 of which are novel. The most prevalent variant was the nonsense variant c.3421C > T p.(Arg1141*) with an allele frequency of 18.5%. All patients exhibited ocular manifestations. Cutaneous manifestations were present in most patients (88.9%, n = 24/27). A PS score > E2 was strongly associated with worse visual acuity (B = -29.02; p = 0.001). No association was found between genotypic groups and cutaneous, vascular or cardiac manifestations. CONCLUSIONS This study describes the genetic spectrum of patients with PXE for the first time in a Portuguese cohort. A total of 16 different variants in ABCC6 were found (7 of which are novel), thus highlighting the genotypic heterogeneity associated with this condition and expanding its mutational spectrum. Still, no major genotype-phenotype associations could be established.
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Affiliation(s)
- Margarida Q Dias
- Ophthalmology Unit, Centro Hospitalar e Universitário de Coimbra, (CHUC), Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
| | - Nuno Gouveia
- Ophthalmology Unit, Centro Hospitalar e Universitário de Coimbra, (CHUC), Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
| | - Raquel Félix
- Ophthalmology Unit, Centro Hospitalar e Universitário de Coimbra, (CHUC), Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
| | - Sérgio Estrela-Silva
- Ophthalmology Unit, Centro Hospitalar e Universitário de São João (CHUSJ), Porto, Portugal
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Diogo Cabral
- Ophthalmology Unit, Hospital Garcia de Orta (HGO), Lisbon, Portugal
| | - Ana Luísa Carvalho
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
- Medical Genetics Unit, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
- University Clinic of Medical Genetics, Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal
| | - Joaquim Murta
- Ophthalmology Unit, Centro Hospitalar e Universitário de Coimbra, (CHUC), Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
- University Clinic of Ophthalmology, Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal
| | - Rufino Silva
- Ophthalmology Unit, Centro Hospitalar e Universitário de Coimbra, (CHUC), Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
- University Clinic of Ophthalmology, Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal
| | - João Pedro Marques
- Ophthalmology Unit, Centro Hospitalar e Universitário de Coimbra, (CHUC), Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
- University Clinic of Ophthalmology, Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal
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Risseeuw S, Pilgrim MG, Bertazzo S, Brown CN, Csincsik L, Fearn S, Thompson RB, Bergen AA, ten Brink JB, Kortvely E, Spiering W, Ossewaarde–van Norel J, van Leeuwen R, Lengyel I. Bruch's Membrane Calcification in Pseudoxanthoma Elasticum: Comparing Histopathology and Clinical Imaging. OPHTHALMOLOGY SCIENCE 2024; 4:100416. [PMID: 38170125 PMCID: PMC10758992 DOI: 10.1016/j.xops.2023.100416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 10/10/2023] [Accepted: 10/18/2023] [Indexed: 01/05/2024]
Abstract
Purpose To investigate the histology of Bruch's membrane (BM) calcification in pseudoxanthoma elasticum (PXE) and correlate this to clinical retinal imaging. Design Experimental study with clinicopathological correlation. Subjects and Controls Six postmortem eyes from 4 PXE patients and 1 comparison eye from an anonymous donor without PXE. One of the eyes had a multimodal clinical image set for comparison. Methods Calcification was labeled with OsteSense 680RD, a fluorescent dye specific for hydroxyapatite, and visualized with confocal microscopy. Scanning electron microscopy coupled with energy-dispersive x-ray spectroscopy (SEM-EDX) and time-of-flight secondary ion mass spectrometry (TOF-SIMs) were used to analyze the elemental and ionic composition of different anatomical locations. Findings on cadaver tissues were compared with clinical imaging of 1 PXE patient. Main Outcome Measures The characteristics and topographical distribution of hydroxyapatite in BM in eyes with PXE were compared with the clinical manifestations of the disease. Results Analyses of whole-mount and sectioned PXE eyes revealed an extensive, confluent OsteoSense labeling in the central and midperipheral BM, transitioning to a speckled labeling in the midperiphery. These areas corresponded to hyperreflective and isoreflective zones on clinical imaging. Scanning electron microscopy coupled with energy-dispersive x-ray spectroscopy and TOF-SIMs analyses identified these calcifications as hydroxyapatite in BM of PXE eyes. The confluent fluorescent appearance originates from heavily calcified fibrous structures of both the collagen and the elastic layers of BM. Calcification was also detected in an aged comparison eye, but this was markedly different from PXE eyes and presented as small snowflake-like deposits in the posterior pole. Conclusions Pseudoxanthoma elasticum eyes show extensive hydroxyapatite deposition in the inner and outer collagenous and elastic BM layers in the macula with a gradual change toward the midperiphery, which seems to correlate with the clinical phenotype. The snowflake-like calcification in BM of an aged comparison eye differed markedly from the extensive calcification in PXE. Financial Disclosures Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Sara Risseeuw
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Matthew G. Pilgrim
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Sergio Bertazzo
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Connor N. Brown
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Lajos Csincsik
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Sarah Fearn
- Department of Materials, Imperial College London, London, United Kingdom
| | - Richard B. Thompson
- University of Maryland School of Medicine, Department of Biochemistry and Molecular Biology, Baltimore, Maryland
| | - Arthur A. Bergen
- Departments of Human Genetics and Ophthalmology, Amsterdam UMC, location AMC Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Jacoline B. ten Brink
- Departments of Human Genetics and Ophthalmology, Amsterdam UMC, location AMC Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Elod Kortvely
- Roche Pharma Research and Early Development, Roche Innovation Center Basel, Basel, Switzerland
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, The Netherlands
| | | | - Redmer van Leeuwen
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Imre Lengyel
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
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Gambichler T, Hoffjan S, Nagel M, Terschlüsen M, Mansour R, Würfel L, Hoffmann K, Susok L, Dickel H, Doerler M. A 21-year-old woman with progressive asymptomatic skin laxity in flexural regions. Clin Exp Dermatol 2023; 48:1198-1201. [PMID: 37171041 DOI: 10.1093/ced/llad170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/19/2023] [Accepted: 05/01/2023] [Indexed: 05/13/2023]
Abstract
We describe a 21-year-old woman with progressive asymptomatic skin laxity in the flexural regions.
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Affiliation(s)
- Thilo Gambichler
- Skin Cancer Center, Department of Dermatology, Ruhr-University Bochum, Bochum, Germany
- Department of Dermatology, Christian Hospital Unna, Unna, Germany
| | - Sabine Hoffjan
- Department of Human Genetics, Ruhr-University Bochum, Germany
| | - Mato Nagel
- Center for Nephrology and Metabolic Medicine, Weißwasser, Germany
| | - Meike Terschlüsen
- Skin Cancer Center, Department of Dermatology, Ruhr-University Bochum, Bochum, Germany
| | - Rita Mansour
- Skin Cancer Center, Department of Dermatology, Ruhr-University Bochum, Bochum, Germany
| | - Lina Würfel
- Skin Cancer Center, Department of Dermatology, Ruhr-University Bochum, Bochum, Germany
| | - Klaus Hoffmann
- Skin Cancer Center, Department of Dermatology, Ruhr-University Bochum, Bochum, Germany
| | - Laura Susok
- Skin Cancer Center, Department of Dermatology, Ruhr-University Bochum, Bochum, Germany
| | - Heinrich Dickel
- Skin Cancer Center, Department of Dermatology, Ruhr-University Bochum, Bochum, Germany
| | - Martin Doerler
- Skin Cancer Center, Department of Dermatology, Ruhr-University Bochum, Bochum, Germany
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Fésűs L, Kiss N, Farkas K, Plázár D, Pálla S, Navasiolava N, Róbert L, Wikonkál NM, Martin L, Medvecz M. Correlation of systemic involvement and presence of pathological skin calcification assessed by ex vivo nonlinear microscopy in Pseudoxanthoma elasticum. Arch Dermatol Res 2023; 315:1897-1908. [PMID: 36847829 PMCID: PMC10366029 DOI: 10.1007/s00403-023-02557-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 12/24/2022] [Accepted: 01/28/2023] [Indexed: 03/01/2023]
Abstract
Pseudoxanthoma elasticum (PXE (OMIM 264800)) is an autosomal recessive connective tissue disorder mainly caused by mutations in the ABCC6 gene. PXE results in ectopic calcification primarily in the skin, eye and blood vessels that can lead to blindness, peripheral arterial disease and stroke. Previous studies found correlation between macroscopic skin involvement and severe ophthalmological and cardiovascular complications. This study aimed to investigate correlation between skin calcification and systemic involvement in PXE. Ex vivo nonlinear microscopy (NLM) imaging was performed on formalin fixed, deparaffinized, unstained skin sections to assess the extent of skin calcification. The area affected by calcification (CA) in the dermis and density of calcification (CD) was calculated. From CA and CD, calcification score (CS) was determined. The number of affected typical and nontypical skin sites were counted. Phenodex + scores were determined. The relationship between the ophthalmological, cerebro- and cardiovascular and other systemic complications and CA, CD and CS, respectively, and skin involvement were analyzed. Regression models were built for adjustment to age and sex. We found significant correlation of CA with the number of affected typical skin sites (r = 0.48), the Phenodex + score (r = 0.435), extent of vessel involvement (V-score) (r = 0.434) and disease duration (r = 0.48). CD correlated significantly with V-score (r = 0.539). CA was significantly higher in patients with more severe eye (p = 0.04) and vascular (p = 0.005) complications. We found significantly higher CD in patients with higher V-score (p = 0.018), and with internal carotid artery hypoplasia (p = 0.045). Significant correlation was found between higher CA and the presence of macula atrophy (β = - 0.44, p = 0.032) and acneiform skin changes (β = 0.40, p = 0.047). Based on our results, the assessment of skin calcification pattern with nonlinear microscopy in PXE may be useful for clinicians to identify PXE patients who develop severe systemic complications.
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Affiliation(s)
- Luca Fésűs
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Mária Street 41, Budapest, 1085, Hungary
| | - Norbert Kiss
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Mária Street 41, Budapest, 1085, Hungary
| | - Klára Farkas
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Mária Street 41, Budapest, 1085, Hungary
| | - Dóra Plázár
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Mária Street 41, Budapest, 1085, Hungary
| | - Sára Pálla
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Mária Street 41, Budapest, 1085, Hungary
| | - Nastassia Navasiolava
- PXE National Reference Centre, Angers University Hospital, 4 Rue Larrey, 49100, Angers, France
| | - Lili Róbert
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Mária Street 41, Budapest, 1085, Hungary
| | - Norbert M Wikonkál
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Mária Street 41, Budapest, 1085, Hungary
| | - Ludovic Martin
- PXE National Reference Centre, Angers University Hospital, 4 Rue Larrey, 49100, Angers, France
| | - Márta Medvecz
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Mária Street 41, Budapest, 1085, Hungary.
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9
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Sacconi R, Fragiotta S, Sarraf D, Sadda SR, Freund KB, Parravano M, Corradetti G, Cabral D, Capuano V, Miere A, Costanzo E, Bandello F, Souied E, Querques G. Towards a better understanding of non-exudative choroidal and macular neovascularization. Prog Retin Eye Res 2023; 92:101113. [PMID: 35970724 DOI: 10.1016/j.preteyeres.2022.101113] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 07/14/2022] [Accepted: 08/03/2022] [Indexed: 02/01/2023]
Abstract
Non-exudative macular and choroidal neovascularization (MNV and CNV) usually refers to the entity of treatment-naïve type 1 neovascularization in the absence of associated signs of exudation. Histopathological studies, dating back in the early 70s, identified the presence of non-exudative MNV, but the first clinical report of this finding was in the late 90s using indocyanine green angiography in eyes with age-related macular degeneration (AMD). With more advanced retinal imaging, there has been an ever increasing appreciation of non-exudative MNV associated with AMD and CNV with other macular disorders. However, consensus regarding the exact definition and the clinical management of this entity is lacking. Furthermore, there may be variation in the imaging features and clinical course suggesting that a spectrum of disease may exist. Herein, we review the large body of published work that has provided a better understanding of non-exudative MNV and CNV in the last decade. The prevalence, multimodal imaging features, clinical course, and response to treatment are discussed to elucidate further key insights about this entity. Based on these observations, this review also proposes a new theory about the origin and course of different sub-types of non-exudative MNV/CNV which can have different etiologies and pathways according to the clinical context of disease.
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Affiliation(s)
- Riccardo Sacconi
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Division of Head and Neck, Ophthalmology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Serena Fragiotta
- UniCamillus-Saint Camillus International University of Health Sciences, Rome, Italy
| | - David Sarraf
- Retinal Disorders and Ophthalmic Genetics Division, Stein Eye Institute, University of California, Los Angeles, Los Angeles, CA, USA; Greater Los Angeles VA Healthcare Center, Los Angeles, CA, United States
| | - SriniVas R Sadda
- Doheny Eye Institute, Los Angeles, CA, United States; Department of Ophthalmology, University of California, Los Angeles, Los Angeles, CA, United States
| | - K Bailey Freund
- Vitreous Retina Macula Consultants of New York, New York, NY, United States; Department of Ophthalmology, NYU Grossman School of Medicine, New York, NY, United States
| | | | - Giulia Corradetti
- Doheny Eye Institute, Los Angeles, CA, United States; Department of Ophthalmology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Diogo Cabral
- Vitreous Retina Macula Consultants of New York, New York, NY, United States; Department of Ophthalmology, NYU Grossman School of Medicine, New York, NY, United States
| | - Vittorio Capuano
- Department of Ophthalmology, Hospital Intercommunal de Creteil, University Paris Est Creteil, Creteil, France
| | - Alexandra Miere
- Department of Ophthalmology, Hospital Intercommunal de Creteil, University Paris Est Creteil, Creteil, France
| | | | - Francesco Bandello
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Division of Head and Neck, Ophthalmology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eric Souied
- Department of Ophthalmology, Hospital Intercommunal de Creteil, University Paris Est Creteil, Creteil, France
| | - Giuseppe Querques
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Division of Head and Neck, Ophthalmology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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10
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Cicinelli MV, Torrioli E, La Franca L, Agrawal H, Barthelmes D, Chhablani J, Chowers I, Foa N, Goldstein M, Mansour A, Muhammed RP, Sivaprasad S, Vilela MAP, Zweifel S, Bandello F, Battaglia Parodi M. Incidence and Risk Factors of Visual Impairment in Patients with Angioid Streaks and Macular Neovascularization. Ophthalmol Retina 2022; 7:431-440. [PMID: 36503161 DOI: 10.1016/j.oret.2022.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To estimate the incidence and risk factors of visual impairment and complications in eyes with macular neovascularization (MNV) because of angioid streaks (ASs). DESIGN Longitudinal multicenter retrospective cohort study. SUBJECTS Patients with AS-associated MNV treated with anti-VEGF agents and a follow-up of > 3 months. METHODS Clinical and MNV characteristics were collected at baseline. Visual acuity (VA) values and the presence of atrophy or fibrosis were collected at each visit. MAIN OUTCOME MEASURES Rate of VA change over time and associated factors; the incidence rate of moderate-to-severe visual impairment (MSVI) and blindness and hazard ratio (HR) of candidate risk factors for MSVI; the incidence rate of fibrosis and macular atrophy. RESULTS Overall, 84 eyes of 66 patients (39 men, 58%) with a mean (standard deviation) age of 55.7 (13.8) years were followed for a mean (standard deviation) of 67.7 (48.5) months. The median number of anti-VEGF doses per eye was 13. The average rate (95% confidence interval [CI]) of visual loss was +0.04 (0.02-0.06) logarithm of the minimum angle of resolution/year (P < 0.001); the visual loss was faster in nonnaive eyes (P = 0.007) and those with better baseline VA (P < 0.001); it was slower in eyes with pattern dystrophy-like features (P = 0.04). The incidence rates (95% CI) of MSVI and blindness were 10.4 (6.88-15)/100-eye-years and 2.33 (1.12-4.29)/100-eye-years. A higher number of injections (HR [95% CI] = 0.45 [0.19-0.94] for receiving ≥ 13 injections vs. < 13; P = 0.03) was protective against MSVI. The incidence rates (95% CI) of fibrosis and macular atrophy were 24.1 (17.5-32.3)/100-eye-years and 14.3 (10.1-19.6)/100-eye-years. CONCLUSIONS Eyes with MNV-related AS had a high rate of visual impairment and propensity to macular fibrosis and atrophy. A higher number of injections yielded better chances of maintaining good VA, suggesting the need for intensive treatment. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.
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Affiliation(s)
- Maria Vittoria Cicinelli
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Edoardo Torrioli
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Lamberto La Franca
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Hitesh Agrawal
- Smt. Kanuri Santhamma Centre for Vitreo-Retinal Diseases, L V Prasad Eye Institute, Hyderabad, India
| | - Daniel Barthelmes
- Department of Ophthalmology, University Hospital Zurich, Zurich, Switzerland
| | - Jay Chhablani
- UPMC Eye Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Itay Chowers
- Hadassah Medical Center, and the Faculty of Medicine, Hadassah-Hebrew University Medical School, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Nastasia Foa
- Department of Ophthalmology, University Hospital Zurich, Zurich, Switzerland
| | - Michaella Goldstein
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ahmad Mansour
- Department of Ophthalmology, American University of Beirut, Beirut, Lebanon
| | | | - Sobha Sivaprasad
- NIHR Moorfields Biomedical Research Centre, London, United Kingdom
| | - Manuel A P Vilela
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Sandrine Zweifel
- Department of Ophthalmology, University Hospital Zurich, Zurich, Switzerland
| | - Francesco Bandello
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maurizio Battaglia Parodi
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
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11
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Charbel Issa P, Hess K. The complexity of visual dysfunction in patients with pseudoxanthoma elasticum. Eye (Lond) 2022; 36:492-494. [PMID: 34862446 PMCID: PMC8873307 DOI: 10.1038/s41433-021-01858-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/09/2021] [Accepted: 11/11/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Peter Charbel Issa
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.
| | - Kristina Hess
- Division of Epidemiology and Clinical Applications, National Eye Institute, National Institutes of Health, Bethesda, MD, USA
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12
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Jin KW, Joo K, Woo SJ. Clinical Characterization of Korean Patients with Pseudoxanthoma Elasticum and Angioid Streaks. Genes (Basel) 2021; 12:genes12081207. [PMID: 34440381 PMCID: PMC8391950 DOI: 10.3390/genes12081207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 07/31/2021] [Accepted: 08/01/2021] [Indexed: 12/04/2022] Open
Abstract
This study aimed to characterize Korean patients with pseudoxanthoma elasticum (PXE) presenting with angioid streaks. Retinal phenotypes were longitudinally evaluated by multimodal ophthalmic imaging, and targeted gene panel sequencing for inherited retinal diseases was conducted. Seven subjects from unrelated families (median age, 51.2 years) were enrolled and followed for a median of 3.2 years. Four asymptomatic patients were significantly younger than three symptomatic patients with decreased visual acuity at presentation (mean age; 38.1 vs. 61.5 years, p = 0.020). The asymptomatic patients maintained good vision (20/32 or better) and had no choroidal neovascularization (CNV) over the observation period. The symptomatic patients showed additional reduction in visual acuity and bilateral CNV occurrence during the longitudinal follow-up. Pathogenic ABCC6 variants were identified in all patients, leading to a diagnosis of PXE. Heterozygous monoallelic variants were identified in four patients and compound heterozygous variants were detected in three patients. Nine ABCC6 variants were identified, including one novel variant, c.2035G>T [p.Glu679Ter]. This is the first genetic study of Korean patients with PXE.
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13
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Legrand A, Pujol C, Durand CM, Mesnil A, Rubera I, Duranton C, Zuily S, Sousa AB, Renaud M, Boucher JL, Pietrancosta N, Adham S, Orssaud C, Marelli C, Casali C, Ziccardi L, Villain N, Ewenczyk C, Durr A, Mignot C, Stevanin G, Billon C, Hureaux M, Jeunemaitre X, Goizet C, Albuisson J. Pseudoxanthoma elasticum overlaps hereditary spastic paraplegia type 56. J Intern Med 2021; 289:709-725. [PMID: 33107650 DOI: 10.1111/joim.13193] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 09/29/2020] [Indexed: 01/31/2023]
Abstract
PURPOSE Pseudoxanthoma elasticum (PXE) is a recessive disorder involving skin, eyes and arteries, mainly caused by ABCC6 pathogenic variants. However, almost one fifth of patients remain genetically unsolved despite extensive genetic screening of ABCC6, as illustrated in a large French PXE series of 220 cases. We searched for new PXE gene(s) to solve the ABCC6-negative patients. METHODS First, family-based exome sequencing was performed, in one ABCC6-negative PXE patient with additional neurological features, and her relatives. CYP2U1, involved in hereditary spastic paraplegia type 56 (SPG56), was selected based on this complex phenotype, and the presence of two candidate variants. Second, CYP2U1 sequencing was performed in a retrospective series of 46 additional ABCC6-negative PXE probands. Third, six additional SPG56 patients were evaluated for PXE skin and eye phenotype. Additionally, plasma pyrophosphate dosage and functional analyses were performed in some of these patients. RESULTS 6.4% of ABCC6-negative PXE patients (n = 3) harboured biallelic pathogenic variants in CYP2U1. PXE skin lesions with histological confirmation, eye lesions including maculopathy or angioid streaks, and various neurological symptoms were present. CYP2U1 missense variants were confirmed to impair protein function. Plasma pyrophosphate levels were normal. Two SPG56 patients (33%) presented some phenotypic overlap with PXE. CONCLUSION CYP2U1 pathogenic variants are found in unsolved PXE patients with neurological findings, including spastic paraplegia, expanding the SPG56 phenotype and highlighting its overlap with PXE. The pathophysiology of ABCC6 and CYP2U1 should be explored to explain their respective role and potential interaction in ectopic mineralization.
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Affiliation(s)
- A Legrand
- From the, Université de Paris, PARCC, INSERM, Paris, France.,Centre de Référence des Maladies Vasculaires Rares, AP-HP, Hôpital européen Georges Pompidou, Paris, France
| | - C Pujol
- Sorbonne Université; Inserm, U1127; CNRS, UMR 7225; Institut du Cerveau, Paris, France
| | - C M Durand
- Inserm, U1211, Laboratoire Maladies Rares: Génétique et Métabolisme, Univ. Bordeaux; Centre de Référence Neurogénétique, Service de Génétique Médicale, CHU Bordeaux, Bordeaux, France
| | - A Mesnil
- Département de Génétique AP-HP, Hôpital européen Georges Pompidou, Paris, France
| | - I Rubera
- Université Côte d'Azur, CNRS-UMR 7370, Laboratoire de Physiomédecine Moléculaire, LabEx ICST, Nice, France
| | - C Duranton
- Université Côte d'Azur, CNRS-UMR 7370, Laboratoire de Physiomédecine Moléculaire, LabEx ICST, Nice, France
| | - S Zuily
- Université de Lorraine, Inserm UMR_S 1116; CHRU de Nancy, Service de Médecine vasculaire, Centre de Compétences Régional des Maladies Vasculaires Rares, Nancy, France
| | - A B Sousa
- Medical Genetics, Department of Pediatrics, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisboa, Portugal
| | - M Renaud
- CHRU de Nancy, Service de Neurologie, Nancy, France
| | - J L Boucher
- UMR 8601 CNRS, Université de Paris, Paris, France
| | | | - S Adham
- Centre de Référence des Maladies Vasculaires Rares, AP-HP, Hôpital européen Georges Pompidou, Paris, France.,Université de Paris, Paris, France
| | - C Orssaud
- Unité fonctionnelle d'ophtalmologie, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - C Marelli
- Inserm U1198 MMDN; Gui de Chauliac University Hospital, Department of Neurology, Expert Centre for Neurogenetic Diseases and Adult Mitochondrial and Metabolic Diseases, Montpellier, France
| | - C Casali
- Department of SBMC, Sapienza University Rome, Rome, Italy
| | - L Ziccardi
- IRCCS- Fondazione Bietti, Neurophysiology of Vision and Neuroophthalmology Unit, Rome, Italy
| | - N Villain
- Sorbonne Université; Inserm, U1127; CNRS, UMR 7225; Institut du Cerveau; Sorbonne Université, GRC n° 21, Alzheimer Precision Medicine; AP-HP, Hôpital de la Pitié-Salpêtrière; Département de Neurologie, Institut de la Mémoire et de la maladie d'Alzheimer, Paris, France
| | - C Ewenczyk
- Sorbonne Université; Inserm, U1127; CNRS, UMR 7225; Institut du Cerveau; AP-HP, Hôpital de la Pitié-Salpêtrière, Département de Génétique, Paris, France
| | - A Durr
- Sorbonne Université; Inserm, U1127; CNRS, UMR 7225; Institut du Cerveau; AP-HP, Hôpital de la Pitié-Salpêtrière, Département de Génétique, Paris, France
| | - C Mignot
- Sorbonne Université; Inserm, U1127; CNRS, UMR 7225; Institut du Cerveau; AP-HP, Hôpital de la Pitié-Salpêtrière, Département de Génétique; Centre de Référence Déficiences Intellectuelles de Causes Rares, Paris, France
| | - G Stevanin
- Sorbonne Université; Inserm, U1127; CNRS, UMR 7225; Institut du Cerveau; PSL research University, Ecole Pratique des Hautes Etudes, Neurogenetics team, Paris, France
| | - C Billon
- From the, Université de Paris, PARCC, INSERM, Paris, France.,Centre de Référence des Maladies Vasculaires Rares, AP-HP, Hôpital européen Georges Pompidou, Paris, France
| | - M Hureaux
- From the, Université de Paris, PARCC, INSERM, Paris, France.,Département de Génétique AP-HP, Hôpital européen Georges Pompidou, Paris, France
| | - X Jeunemaitre
- From the, Université de Paris, PARCC, INSERM, Paris, France.,Centre de Référence des Maladies Vasculaires Rares, AP-HP, Hôpital européen Georges Pompidou, Paris, France
| | - C Goizet
- Inserm, U1211, Laboratoire Maladies Rares: Génétique et Métabolisme, Univ. Bordeaux; Centre de Référence Neurogénétique, Service de Génétique Médicale, CHU Bordeaux, Bordeaux, France
| | - J Albuisson
- From the, Université de Paris, PARCC, INSERM, Paris, France.,Centre de Référence des Maladies Vasculaires Rares, AP-HP, Hôpital européen Georges Pompidou, Paris, France.,Département de Biologie et Pathologie des Tumeurs, Centre Georges François Leclerc, Dijon, France
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14
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Bartstra JW, Risseeuw S, de Jong PA, van Os B, Kalsbeek L, Mol C, Baas AF, Verschuere S, Vanakker O, Florijn RJ, Hendrikse J, Mali W, Imhof S, Ossewaarde-van Norel J, van Leeuwen R, Spiering W. Genotype-phenotype correlation in pseudoxanthoma elasticum. Atherosclerosis 2021; 324:18-26. [PMID: 33812167 DOI: 10.1016/j.atherosclerosis.2021.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/26/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Pseudoxanthoma elasticum (PXE) is caused by variants in the ABCC6 gene. It results in calcification in the skin, peripheral arteries and the eyes, but has considerable phenotypic variability. We investigated the association between the ABCC6 genotype and calcification and clinical phenotypes in these different organs. METHODS ABCC6 sequencing was performed in 289 PXE patients. Genotypes were grouped as two truncating, mixed, or two non-truncating variants. Arterial calcification mass was quantified on whole body, low dose CT scans; and peripheral arterial disease was measured with the ankle brachial index after treadmill test. The presence of pseudoxanthoma in the skin was systematically scored. Ophthalmological phenotypes were the length of angioid streaks as a measure of Bruchs membrane calcification, the presence of choroidal neovascularizations, severity of macular atrophy and visual acuity. Regression models were built to test the age and sex adjusted genotype-phenotype association. RESULTS 158 patients (median age 51 years) had two truncating variants, 96 (median age 54 years) a mixed genotype, 18 (median age 47 years) had two non-truncating variants. The mixed genotype was associated with lower peripheral (β: 0.39, 95%CI:-0.62;-0.17) and total (β: 0.28, 95%CI:-0.47;-0.10) arterial calcification mass scores, and lower prevalence of choroidal neovascularizations (OR: 0.41 95%CI:0.20; 0.83) compared to two truncating variants. No association with pseudoxanthomas was found. CONCLUSIONS PXE patients with a mixed genotype have less severe arterial and ophthalmological phenotypes than patients with two truncating variants in the ABCC6 gene. Research into environmental and genetic modifiers might provide further insights into the unexplained phenotypic variability.
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Affiliation(s)
- Jonas W Bartstra
- Department of Radiology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Sara Risseeuw
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Pim A de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Bram van Os
- Department of Radiology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Lianne Kalsbeek
- Department of Radiology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Chris Mol
- Department of Radiology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Annette F Baas
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Shana Verschuere
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Olivier Vanakker
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Ralph J Florijn
- Department of Clinical Genetics, Academic Medical Center, Amsterdam, the Netherlands
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Willem Mali
- Department of Radiology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Saskia Imhof
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | | | - Redmer van Leeuwen
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands.
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15
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Risseeuw S, van Leeuwen R, Imhof SM, Spiering W, Norel JOV. The Natural History of Bruch’s Membrane Calcification in Pseudoxanthoma Elasticum. OPHTHALMOLOGY SCIENCE 2021. [PMID: 37487136 PMCID: PMC9560584 DOI: 10.1016/j.xops.2020.100001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Purpose To describe the natural history of Bruch’s membrane (BM) calcification in patients with pseudoxanthoma elasticum (PXE). Design Retrospective cohort study. Participants Both eyes of 120 PXE patients younger than 50 years, 78 of whom had follow-up imaging after more than 1 year. Methods All patients underwent multimodal imaging, including color fundus photography, near-infrared reflectance (NIR) imaging, and late phase indocyanine green angiography (ICGA). We determined the distance from the optic disc to the central and temporal border of peau d’orange on NIR, expressed in horizontal optic disc diameter (ODD). The length of the longest angioid streak was classified into 5 zones. Main Outcome Measures Age-specific changes of peau d’orange, angioid streaks, and ICGA hypofluorescence as surrogate markers for the extent of BM calcification. Results In cross-sectional analysis, longer angioid streaks were associated with increasing age (P < 0.001 for trend). The temporal border of peau d’orange showed a weak association with increasing age (β = 0.02; 95% confidence interval [CI], 0.00–0.04), whereas the central border showed a strong association (β = 0.12; 95% CI, 0.09–0.15). Longitudinal analysis revealed a median shift of the central border to the periphery of 0.08 ODD per year (interquartile range [IQR], 0.00–0.17; P < 0.001). This shift was more pronounced in patients younger than 20 years (0.12 ODD per year [IQR, 0.08–0.28]) than in patients older than 40 years (0.07 ODD per year [IQR, –0.05 to 0.15]). The temporal border did not shift during follow-up (P = 0.69). New or growing angioid streaks were detected in 39 of 156 eyes (25%). The hypofluorescent area on ICGA was visible only in the fourth or fifth decade and correlated with longer angioid streaks. Conclusions In PXE patients, the speckled BM calcification slowly confluences during life. The location of the temporal border of peau d’orange remains rather constant, whereas the central border shifts to the periphery. This suggests the presence of a predetermined area for BM calcification. A larger ICGA hypofluorescent area correlates with older age and longer angioid streaks, which implies that it depends on the degree of BM calcification.
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16
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Autofluorescence Imaging of the Skin Is an Objective Non-Invasive Technique for Diagnosing Pseudoxanthoma Elasticum. Diagnostics (Basel) 2021; 11:diagnostics11020260. [PMID: 33567497 PMCID: PMC7915757 DOI: 10.3390/diagnostics11020260] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 01/05/2023] Open
Abstract
Pseudoxanthoma elasticum (PXE) is a rare multisystemic autosomal recessive connective tissue disease. In most cases, skin manifestations of PXE are the first to develop, followed later by severe ocular and cardiovascular complications. In our present study, in addition to dermoscopy, we introduced novel techniques, autofluorescence (AF) and diffuse reflectance (DR) imaging for the assessment of affected skin sites of five PXE patients. PXE-affected skin areas in most skin sites showed a previously observed pattern upon dermoscopic examination. With the novel imaging, PXE-affected skin lesions displayed high AF intensity. During our measurements, significantly higher mean, minimum and maximum AF intensity values were found in areas of PXE-affected skin when compared to uninvolved skin. Conversely, images acquired with the use of 660 and 940 nm illumination showed no mentionable difference. Our results demonstrate that AF imaging may be used in the in vivo diagnostics and quantification of the severity of the skin lesions of PXE patients. In addition, it is a safe, fast and cost-effective diagnostic method. AF imaging may be also used to objectively monitor the efficacy of the possible novel therapeutic approaches of PXE in the future.
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17
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Risseeuw S, Ossewaarde-van Norel J, van Buchem C, Spiering W, Imhof SM, van Leeuwen R. The Extent of Angioid Streaks Correlates With Macular Degeneration in Pseudoxanthoma Elasticum. Am J Ophthalmol 2020; 220:82-90. [PMID: 32702361 DOI: 10.1016/j.ajo.2020.07.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 01/05/2023]
Abstract
PURPOSE To investigate whether the extent of Bruch's membrane calcification is associated with choroidal neovascularization (CNV) and macular atrophy in patients with pseudoxanthoma elasticum (PXE) by using the extent of angioid streaks as a surrogate marker for the degree of Bruch's membrane calcification. DESIGN Retrospective cross-sectional study. METHODS We investigated 301 patients with PXE (median age, 52 years; range, 9-79 years) in a tertiary referral center. For both eyes, we graded the extent of angioid streaks, that is, their distance from the optic disc, into 5 groups. Imaging was systematically assessed for signs of CNV and macular atrophy. Associations between the extent of angioid streaks and CNV or macular atrophy were investigated using regression analysis. RESULTS CNV was present in 148 patients (49%) and retinal atrophy in 71 patients (24%). The extent of angioid streaks was associated with older age (P for trend = 1.92 × 10-15) and a higher prevalence of CNV and/or macular atrophy (P for trend = 4.22 × 10-10 and P for trend = 5.17 × 10-6, respectively). In addition, the extent of angioid streaks was associated with the presence of CNV when adjusted for age and sex (odds ratio, 1.9; 95% confidence interval, 1.3-2.9) and with more severe macular atrophy (proportional odds ratio, 2.3; 95% confidence interval, 1.5-3.6). CONCLUSIONS In patients with PXE, longer angioid streaks are associated with an increased risk of CNV and macular atrophy, even after adjustment for age. These findings are relevant when counseling PXE patients on their visual prognosis.
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Marques JP, Bernardes J, Geada S, Soares M, Teixeira D, Farinha C, Pires I, Cachulo ML, Silva R. Non-exudative macular neovascularization in pseudoxanthoma elasticum. Graefes Arch Clin Exp Ophthalmol 2020; 259:873-882. [PMID: 33074374 DOI: 10.1007/s00417-020-04979-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/24/2020] [Accepted: 10/09/2020] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To characterize morphological changes in the retina and to report the frequency and natural history of non-exudative macular neovascularization (MNV) in a cohort of pseudoxanthoma elasticum (PXE). METHODS A single-center, retrospective study was complemented by a cross-sectional examination. Consecutive patients with a definitive genetic and/or clinical diagnosis of PXE, visiting our department between January 2019 and December 2019, and with a minimum follow-up of 6 months were recruited. Baseline data were retrieved from each patient file. Additionally, a cross-sectional examination comprising color fundus photography, spectral-domain optical coherence tomography (SD-OCT), OCT-Angiography (OCT-A), and fundus autofluorescence was performed. The presence of typical PXE-related findings, as well as related complications, was multimodally evaluated. The prevalence and natural history of non-exudative MNV were assessed. All images were graded by two independent graders. RESULTS Forty-eight eyes from 24 patients (mean age 59.11 ± 18.14) with a median follow-up of 53.00 months were included. Angioid streaks and peau d'orange were observed in 46/48 and 42/48 eyes, while MNV was present in 75.00% of the cohort. The prevalence of non-exudative MNV was 33.33% (6/18). In the 2 eyes that developed exudation, time to conversion was 9.50 ± 4.95 months. No significant difference in visual acuity was found between eyes with non-exudative MNV and those with no signs of MNV. CONCLUSION We have shown that non-exudative MNV is a frequent finding in PXE but the majority of eyes did not develop exudation during follow-up. Our results are a clear evidence of the utility of OCT-A in the management of PXE.
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Affiliation(s)
- João Pedro Marques
- Ophthalmology Unit, Centro de Responsabilidade Integrado em Oftalmologia (CRIO), Centro Hospitalar e Universitário de Coimbra (CHUC), Praceta Prof. Mota Pinto, 3000-075, Coimbra, Portugal.
- University Clinic of Ophthalmology, Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal.
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal.
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra (FMUC), University of Coimbra, Coimbra, Portugal.
| | - João Bernardes
- Ophthalmology Unit, Centro de Responsabilidade Integrado em Oftalmologia (CRIO), Centro Hospitalar e Universitário de Coimbra (CHUC), Praceta Prof. Mota Pinto, 3000-075, Coimbra, Portugal
| | - Sara Geada
- Ophthalmology Unit, Centro de Responsabilidade Integrado em Oftalmologia (CRIO), Centro Hospitalar e Universitário de Coimbra (CHUC), Praceta Prof. Mota Pinto, 3000-075, Coimbra, Portugal
| | - Mário Soares
- Ophthalmology Unit, Centro de Responsabilidade Integrado em Oftalmologia (CRIO), Centro Hospitalar e Universitário de Coimbra (CHUC), Praceta Prof. Mota Pinto, 3000-075, Coimbra, Portugal
| | - Dora Teixeira
- Ophthalmology Unit, Centro de Responsabilidade Integrado em Oftalmologia (CRIO), Centro Hospitalar e Universitário de Coimbra (CHUC), Praceta Prof. Mota Pinto, 3000-075, Coimbra, Portugal
| | - Cláudia Farinha
- Ophthalmology Unit, Centro de Responsabilidade Integrado em Oftalmologia (CRIO), Centro Hospitalar e Universitário de Coimbra (CHUC), Praceta Prof. Mota Pinto, 3000-075, Coimbra, Portugal
- University Clinic of Ophthalmology, Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra (FMUC), University of Coimbra, Coimbra, Portugal
| | - Isabel Pires
- Ophthalmology Unit, Centro de Responsabilidade Integrado em Oftalmologia (CRIO), Centro Hospitalar e Universitário de Coimbra (CHUC), Praceta Prof. Mota Pinto, 3000-075, Coimbra, Portugal
- University Clinic of Ophthalmology, Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra (FMUC), University of Coimbra, Coimbra, Portugal
| | - Maria Luz Cachulo
- Ophthalmology Unit, Centro de Responsabilidade Integrado em Oftalmologia (CRIO), Centro Hospitalar e Universitário de Coimbra (CHUC), Praceta Prof. Mota Pinto, 3000-075, Coimbra, Portugal
- University Clinic of Ophthalmology, Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra (FMUC), University of Coimbra, Coimbra, Portugal
| | - Rufino Silva
- Ophthalmology Unit, Centro de Responsabilidade Integrado em Oftalmologia (CRIO), Centro Hospitalar e Universitário de Coimbra (CHUC), Praceta Prof. Mota Pinto, 3000-075, Coimbra, Portugal
- University Clinic of Ophthalmology, Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal
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Risseeuw S, van Leeuwen R, Imhof SM, de Jong PA, Mali WPTM, Spiering W, Ossewaarde–van Norel J. The effect of etidronate on choroidal neovascular activity in patients with pseudoxanthoma elasticum. PLoS One 2020; 15:e0240970. [PMID: 33079965 PMCID: PMC7575070 DOI: 10.1371/journal.pone.0240970] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/05/2020] [Indexed: 12/15/2022] Open
Abstract
Aim To assess the effect of the bisphosphonate etidronate on choroidal neovascular (CNV) activity in patients with pseudoxanthoma elasticum (PXE). Methods This is an ancillary study in a single center, randomized, double-blind placebo-controlled trial (RCT) in which 74 patients with PXE were assigned to either one-year etidronate or placebo treatment. Spectral domain optical coherence tomography (SD-OCT) imaging and color fundus photography were performed every three months for one year and were systematically assessed on signs of CNV activity. Results In the etidronate group, 11 (30%) of the patients had CNV activity at baseline, compared to 25 (67%) of the patients in the placebo group (P = 0.005). The proportion of eyes with CNV activity during the study ranged from 18–33% in the etidronate group and 42–56% in the placebo group and no significant difference in improvement or worsening of CNV activity was found (P = 0.168). Using a generalized mixed model for repeated measures, there was a protective effect of etidronate in crude analysis (RR 0.86, 95% CI 0.75–0.98) that disappeared when adjusting for baseline CNV activity (RR 0.97, 95% CI 0.84–1.13). Conclusion In this post-hoc RCT analysis we did not observe a protecting or deteriorating effect of etidronate on CNV activity in patients with PXE after adjustment for baseline CNV.
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Affiliation(s)
- Sara Risseeuw
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Redmer van Leeuwen
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Saskia M. Imhof
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pim A. de Jong
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Willem P. Th. M. Mali
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Risseeuw S, Bartstra J, Ossewaarde-van Norel J, Geurts LJ, Li CHZ, Imhof SM, Spiering W, de Jong PA, van Leeuwen R. Is arterial stiffness in the carotid artery associated with choroidal thinning in patients with pseudoxanthoma elasticum or controls? Acta Ophthalmol 2020; 98:492-499. [PMID: 31943777 DOI: 10.1111/aos.14346] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 12/20/2019] [Indexed: 01/14/2023]
Abstract
PURPOSE Patients with pseudoxanthoma elasticum (PXE) develop calcification of Bruch's membrane (BM) and choroidal thinning, as well as calcification of intracranial arteries, leading to arterial stiffness. We investigated whether arterial stiffness is associated with choroidal thinning in PXE patients, besides the presumed effect of BM calcification. METHODS Cross-sectional study with 75 PXE patients and 40 controls. Macular choroidal thickness was measured using optical coherence tomography scans. Functional magnetic resonance imaging was used to calculate the pulsatility index (PI) of the carotid siphon as a measure of arterial stiffness. Associations between PI and choroidal thickness were investigated using linear mixed effects models adjusted for age and ocular axial length. Furthermore, we investigated choroidal thickness in relation to the presence of retinal pigment epithelium (RPE) atrophy, its topographical distribution and age. RESULTS Median age was 58 years (IQR 53-66) in PXE patients and 62 years (IQR 56-67) in controls (p = 0.08). Pseudoxanthoma elasticum (PXE) patients had a thinner choroid than controls (138 μm versus 248 μm, p < 0.01). No association was observed between PI and choroidal thickness in PXE patients (β = -1.6, 95% CI -59.4 to 54.5) nor in controls (β =-47.6, 95% CI -129.7 to 31.9). In PXE patients, RPE atrophy was associated with a thinner choroid (p < 0.01). Also, the nasal choroid was thinner than the temporal choroid, and choroidal thickness already decreased with age in PXE eyes without RPE atrophy. CONCLUSION There was no independent association between measures of arterial stiffness and choroidal thinning in PXE patients and controls. Probably, changes in BM lead to choroidal thinning in PXE.
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Affiliation(s)
- Sara Risseeuw
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jonas Bartstra
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Lennart J Geurts
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Catherina H Z Li
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Saskia M Imhof
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pim A de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Redmer van Leeuwen
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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21
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Risseeuw S, Bennink E, Poirot MG, de Jong PA, Spiering W, Imhof SM, van Leeuwen R, Ossewaarde-van Norel J. A Reflectivity Measure to Quantify Bruch's Membrane Calcification in Patients with Pseudoxanthoma Elasticum Using Optical Coherence Tomography. Transl Vis Sci Technol 2020; 9:34. [PMID: 32855880 PMCID: PMC7422762 DOI: 10.1167/tvst.9.8.34] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 05/19/2020] [Indexed: 12/12/2022] Open
Abstract
Purpose Progressive calcification of Bruch's membrane (BM) causes considerable visual morbidity in patients with pseudoxanthoma elasticum (PXE). Since calcification is hyperreflective on optical coherence tomography (OCT), our aim was to measure BM calcification with OCT imaging. Methods Case-control study with 45 patients with PXE under 40 years (range, 11-39) and 25 controls (range, 14-39). Spectralis HRA-OCT imaging consisted of seven macular B-scans with 250-µm spacing. Retinal segmentation was performed with the IOWA Reference Algorithms. MATLAB was used to extract and average z-axis reflectivity profiles. Layer reflectivities were normalized to the ganglion cell and inner plexiform layers. Both median and peak layer reflectivities were compared between patients with PXE and controls. The discriminative value of the retinal pigment epithelium (RPE)-BM peak reflectivity was analyzed using receiver operating characteristic analysis. Results The reflectivity profile of patients with PXE differed from controls in the outer retinal layers. The normalized median RPE-BM reflectivity was 41.1 (interquartile range [IQR], 26.3-51.9) in patients with PXE, compared with 22.5 (IQR, 19.3-29.5) in controls (P = 2.09 × 10-3). The normalized RPE-BM peak reflectivity was higher in patients with PXE (67.5; IQR, 42.1-84.2) than in controls (32.7; IQR, 25.7-38.9; P = 2.43 × 10-5) and had a high discriminative value with an area under the curve of 0.85 (95% confidence interval, 0.76-0.95). In patients with PXE under 40 years, increasing age did not have a statistically significant effect on the RPE-BM peak reflectivity (patients under 20 years: 44.2 [IQR, 40.5-74.6]; 20-30 years: 66.0 [IQR, 45.1-83.8]; 30-40 years: 70.8 [IQR, 49.0-88.0], P = 0.47). Conclusions BM calcification can be measured as increased RPE-BM reflectivity in young patients with PXE and has a high discriminative value. Translational Relevance In patients with PXE, the OCT reflectivity of Bruch's membrane may be the first biomarker for Bruch's membrane calcification and a valuable ophthalmologic endpoint in clinical trials.
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Affiliation(s)
- Sara Risseeuw
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Edwin Bennink
- Image Sciences Institute, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Maarten G Poirot
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pim A de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Saskia M Imhof
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Redmer van Leeuwen
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Wang K, Statler B, Ramos M, DeBenedictis MJ, Babiuch A, Yuan A, Traboulsi EI. Hickam's Dictum: Pseudoxanthoma elasticum and Usher syndrome in a single patient. Ophthalmic Genet 2020; 41:465-469. [PMID: 32664777 DOI: 10.1080/13816810.2020.1790616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND To report the case of a patient with two distinct genetic systemic diseases - pseudoxanthoma elasticum (PXE) and Usher syndrome - confirmed by genetic testing. MATERIALS AND METHODS Single Retrospective Case Report. RESULTS A 36-year-old woman presented with acute central vision loss of the left eye (OS). Fundus exam revealed choroidal neovascularization OS in the setting of angioid streaks secondary to an underlying diagnosis of PXE. Unexpectedly, she also exhibited peripheral bony spicules with significant visual field constriction. Physical exam revealed skin papules on her neck and hearing loss. The presence of angioid streaks and skin findings was compatible with PXE; the etiology of her pigmentary retinopathy and hearing loss was elucidated using genetic testing. The patient was found to be compound heterozygous for pathogenic variants in both the ABCC6 and USH2A genes, confirming the diagnosis of two rare disorders in a single patient. CONCLUSIONS PXE and Usher syndrome are rare systemic disorders that cause distinctive retinal abnormalities. This report highlights the importance of genetic testing in diagnosing uncommon hereditary retinal disorders and outlines the progression of disease over 6 years.
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Affiliation(s)
- Kevin Wang
- Cleveland Clinic, Cole Eye Institute , Cleveland, Ohio, USA
| | | | - Michael Ramos
- Cleveland Clinic, Cole Eye Institute , Cleveland, Ohio, USA
| | | | - Amy Babiuch
- Cleveland Clinic, Cole Eye Institute , Cleveland, Ohio, USA
| | - Alex Yuan
- Cleveland Clinic, Cole Eye Institute , Cleveland, Ohio, USA
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Murro V, Mucciolo DP, Giorgio D, Sodi A, Boraldi F, Quaglino D, Virgili G, Giansanti F. Pattern dystrophy-like changes and coquille d'oeuf atrophy in elderly patients affected by pseudoxanthoma elasticum. Graefes Arch Clin Exp Ophthalmol 2020; 258:1881-1892. [PMID: 32445016 DOI: 10.1007/s00417-020-04748-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/29/2020] [Accepted: 05/08/2020] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To evaluate the retinal features of elderly patients affected by pseudoxanthoma elasticum (PXE). MATERIALS AND METHODS This is a retrospective case series of 62 eyes of 31 elderly PXE patients (age > 50 years). Clinical data, ultra-widefield fundus imaging (color, red-free (RF), infra-red imaging (IR), fundus autofluorescence (FAF)), and OCT examinations were collected. Diagnosis was confirmed by genetic testing or skin biopsy. RESULTS Thirty-one patients (10 males and 21 females (mean age 61.3 years, range 50-74 years)) were included in our study. Visual acuity ranged from 20/20 Snellen equivalent to 20/200. The mean follow-up was 66.4 ± 20.7 months (range 10-88). Pattern dystrophy-like changes (PD) (52 eyes of 26 patients, 83.8%) and atrophy resembling the "diffuse trickling" pattern described in geographic atrophy were present in the majority of patients. Twenty-three eyes of 12 patients (67.6%) had peripapillary atrophy, 9 eyes of 5 patients (26.4%) macular atrophy, 6 eyes of 3 patients (17.6%) displayed posterior pole atrophy and in 6 eyes of 3 patients (17.6%), atrophy could be detected beyond the vascular arcades (mid-peripheral atrophy). End-stage atrophy covered the entire area indicated as "coquille d'oeuf" (eggshell). Choroidal neovascularization occurred in 49 eyes of 26 patients (94.2%) with PD and in 6 eyes of 3 patients (60%) without PD. Genetic examinations were available for 29 patients (29/31, 93.5%). CONCLUSIONS The elderly PXE patients were characterized by pattern dystrophy-like changes with more or less extensive atrophy, progressive over time, which in some cases affected the whole area of the coquille d'oeuf during the course of the disease.
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Affiliation(s)
- Vittoria Murro
- Department of Neuroscience, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Dario Pasquale Mucciolo
- Department of Neuroscience, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy. .,Careggi Teaching Hospital, Florence, Italy.
| | - Dario Giorgio
- Department of Neuroscience, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Andrea Sodi
- Department of Neuroscience, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Federica Boraldi
- Department of Life Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Daniela Quaglino
- Department of Life Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Gianni Virgili
- Department of Neuroscience, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Fabrizio Giansanti
- Department of Neuroscience, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
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24
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IS VAGINAL DELIVERY HARMFUL TO PATIENTS WITH PSEUDOXANTHOMA ELASTICUM? Retin Cases Brief Rep 2020; 16:422-425. [PMID: 32205712 DOI: 10.1097/icb.0000000000000997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/PURPOSE To investigate the effect of a vaginal delivery (VD) on retinal pathology in patients with pseudoxanthoma elasticum. METHODS Retrospective case series. All 14 consecutive women with pseudoxanthoma elasticum who visited the ophthalmology department during pregnancy and after delivery between 2010 and 2018 were included. Prepartum and postpartum imaging consisted of color imaging, near-infrared imaging, and optical coherence tomography and was assessed on occurrence of (sub)retinal hemorrhages and change in angioid streaks. RESULTS Fourteen patients (15 deliveries) were included, of whom 11 patients (79%) had a VD and three patients (21%) a secondary caesarian section. Data of three patients with VD (four deliveries) could not be assessed for (sub)retinal hemorrhage within 10 weeks postpartum. The median age at delivery was 31 years (IQR 29-37). One patient with VD (9%) had a choroidal neovascularization and was treated with anti-VEGF injections before assisted delivery. All patients had angioid streaks in the central 5,500 µm of the posterior pole of both eyes. After delivery, no patient in the VD or caesarian section group presented with progression of angioid streaks or (sub)retinal hemorrhage. CONCLUSION Pushing during the expulsion phase of VD seems safe in pseudoxanthoma elasticum patients without active choroidal neovascularization, and the presence of angioid streaks alone should not be an indication for elective caesarian section.
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25
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Gliem M, Birtel J, Herrmann P, Fimmers R, Berger M, Coch C, Wingen A, Holz FG, Charbel Issa P. Aflibercept for choroidal neovascularizations secondary to pseudoxanthoma elasticum: a prospective study. Graefes Arch Clin Exp Ophthalmol 2019; 258:311-318. [PMID: 31863395 DOI: 10.1007/s00417-019-04551-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/13/2019] [Accepted: 11/20/2019] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To evaluate the use of 2 mg intravitreal aflibercept for treatment of choroidal neovascularization (CNV) secondary to angioid streaks in patients with pseudoxanthoma elasticum (PXE). METHODS In this 12-month prospective, open-label, uncontrolled, non-randomized interventional clinical trial, 15 PXE patients with CNV (mean age: 53 years, range 22-65) received one initial intravitreal injection of 2 mg aflibercept. Further injections were based on CNV activity at monthly examinations. The primary endpoint was change of best corrected visual acuity (BCVA) after 12 months. Secondary outcomes were change of central retinal thickness (CRT), leakage from CNV, retinal sensitivity, and vision-related quality of life. RESULTS BCVA improved from 75.0 ± 10.8 (± SD, Snellen equivalent 20/32) to 79.3 ± 7.3 ETDRS letters (20/32) at final visit (p = 0.083). CRT decreased from 317 ± 81 to 279 ± 51 μm (p = 0.004). Retinal sensitivity on microperimetry changed from 17.8 ± 4.5 to 18.5 ± 4.3 dB (p = 0.103) and vision-related quality of life from a VQF-25 score of 80.7 ± 10.4 to 83.5 ± 14.5 (p = 0.554). The mean number of injections was 6.7 ± 2.6, and 5 participants had persistent or reactivated CNV activity at final visit. The observed adverse events were comparable with studies on aflibercept for other indications. CONCLUSION The results of this study indicate that intravitreal aflibercept is a treatment option for CNV secondary to PXE.
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Affiliation(s)
- Martin Gliem
- Department of Ophthalmology, University Hospital of Bonn, Bonn, Germany.,Centre for Rare Diseases Bonn (ZSEB), University of Bonn, Bonn, Germany
| | - Johannes Birtel
- Department of Ophthalmology, University Hospital of Bonn, Bonn, Germany.,Centre for Rare Diseases Bonn (ZSEB), University of Bonn, Bonn, Germany
| | - Philipp Herrmann
- Department of Ophthalmology, University Hospital of Bonn, Bonn, Germany.,Centre for Rare Diseases Bonn (ZSEB), University of Bonn, Bonn, Germany
| | - Rolf Fimmers
- Institute of Medical Biometry, Informatics and Epidemiology, University of Bonn, Bonn, Germany
| | - Moritz Berger
- Institute of Medical Biometry, Informatics and Epidemiology, University of Bonn, Bonn, Germany
| | - Christoph Coch
- Study Center Bonn, Institute of Clinical Chemistry and Clinical Pharmacology, University Hospital Bonn, Bonn, Germany
| | - Almut Wingen
- Study Center Bonn, Institute of Clinical Chemistry and Clinical Pharmacology, University Hospital Bonn, Bonn, Germany
| | - Frank G Holz
- Department of Ophthalmology, University Hospital of Bonn, Bonn, Germany.,Centre for Rare Diseases Bonn (ZSEB), University of Bonn, Bonn, Germany
| | - Peter Charbel Issa
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, and Nuffield Laboratory of Ophthalmology, Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
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26
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Gliem M, Wieg I, Birtel J, Müller PL, Faust I, Hendig D, Holz FG, Finger RP, Charbel Issa P. Retinal findings in carriers of monoallelic ABCC6 mutations. Br J Ophthalmol 2019; 104:1089-1092. [DOI: 10.1136/bjophthalmol-2018-313448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 02/06/2019] [Accepted: 02/13/2019] [Indexed: 12/21/2022]
Abstract
AimBiallelic ABCC6 mutations cause pseudoxanthoma elasticum, a systemic disease characterised by calcification of elastic tissue and a specific retinal phenotype. In this study, we investigated if monoallelic ABCC6 mutations are also associated with retinal alterations.MethodsIn this prospective, cross-sectional, monocentre case–control study, carriers of monoallelic ABCC6 mutations were investigated and compared with age-matched controls. The retinal phenotype was characterised using fundus photography, fundus autofluorescence, confocal near-infrared reflectance imaging, spectral domain optical coherence tomography and in selected cases late-phase indocyanine green angiography.ResultsThirty-eight subjects carrying monoallelic ABCC6 mutations (mean age 70.2 years, range 50–90, 26 female) were examined and compared with 77 age-matched controls (mean age 69.9 years, range 50–93, 43 female). Retinal alterations were more frequently found in carriers of monoallelic ABCC6 mutations compared with controls (50% vs 33.8%, p=0.107) with increasing prevalence at older age. Typical findings were peripapillary atrophy (37% vs 23%, p=0.184), pattern dystrophy-like changes (24% vs 12%, p=0.109), reticular pseudodrusen (21% vs 5%, p=0.019), small angioid streaks (8% vs 1%, p=0.105), choroidal neovascularisations and atrophic lesions (both 8% vs 0%, p=0.034). Late-phase indocyanine green angiography showed a reduced cyanescence centred to the posterior pole in 11 of 14 examined subjects with monoallelic ABCC6 mutations.ConclusionThe findings of this study indicate a possible ocular ABCC6 haploinsufficiency phenotype. Due to its late-onset and phenotypic similarities, misinterpretation as age-related macular degeneration is possible.
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