CENTRAL RETINAL VEIN OCCLUSION IN OTHERWISE HEALTHY CHILDREN AND ADOLESCENTS: Association With Multigenetic Variants of Thrombophilia

Ocular venous occlusion in pediatrics: Should thrombophilia investigation and anticoagulant treatment be initiated?

Retinal vein occlusion (RVO) and superior ophthalmic vein thrombosis (SOVT) are rare diseases in the pediatric population; however, the ophthalmic and neurologic morbidity are significant. As published data are scarce for these conditions, we present our experience with pediatric ocular venous thrombosis in four patients, and discuss recommended management for evaluation and treatment. We suggest performing thrombophilia workup for all pediatric patients with RVO or SOVT. In patients with thrombophilia risk factors or patients with additional thrombi, we highly recommend initiating anticoagulation therapy. There is a need for more research in order to determine the optimal management strategy.

Pediatric Central Retinal Vein Occlusion Secondary to Concurrent Mechanisms of Optic Neuritis and Antiphospholipid Syndrome

Purpose: To report a pediatric case of optic neuritis with subsequent development of central retinal vein occlusion (CRVO). Methods: A case and its findings were analyzed. Results: A 16-year-old boy presented with painful vision loss in the left eye, an afferent pupillary defect, and optic disc edema. Magnetic resonance imaging showed optic nerve enhancement and contrast-enhancing cerebral white-matter lesions, consistent with optic neuritis and demyelinating disease. He received intravenous methylprednisolone followed by a prednisone taper. At the 3-week follow-up, the visual acuity (VA) in the left eye had worsened and fundoscopic examination showed a new CRVO. A hypercoagulable workup showed antiphospholipid syndrome, which was treated with warfarin. He received intravitreal antivascular endothelial growth factor treatment with subsequent improvement in VA and resolution of the macular edema. Conclusions: This case describes an unusual mechanism for CRVO via a combination of optic disc edema from optic neuritis and hypercoagulability from antiphospholipid syndrome. It is important to recognize this complication of optic disc edema and the necessary workup for a pediatric CRVO.

An Exploratory Study Using Next-Generation Sequencing to Identify Prothrombotic Variants in Patients with Cerebral Vein Thrombosis

Prothrombotic hereditary risk factors for cerebral vein thrombosis (CVT) are of clinical interest to better understand the underlying pathophysiology and stratify patients for the risk of recurrence. This study explores prothrombotic risk factors in CVT patients. An initial screening in patients of the outpatient clinic of the Department of Transfusion Medicine and Hemostaseology of the University Hospital Erlangen, Germany, revealed 183 patients with a history of CVT. An initial screening identified a number of common prothrombic risk factors, including Factor V Leiden (rs6025) and Prothrombin G20210A (rs1799963). All patients without relevant findings (58 individuals) were invited to participate in a subsequent genetic analysis of 55 relevant genes using next-generation sequencing (NGS). Three intron variants (ADAMTS13: rs28446901, FN1: rs56380797, rs35343655) were identified to occur with a significantly higher frequency in the CVT patient cohort compared to the general European population. Furthermore, the combined prevalence of at least two of four potentially prothrombic variants (FGA (rs6050), F13A1 (rs5985), ITGB3 (rs5918), and PROCR (rs867186)) was significantly higher in the CVT subjects. The possible impact of the identified variants on CVT is discussed.

Clinical Features of Central Retinal Vein Occlusion in Young Patients

Retinal vein occlusion (RVO) is the second most common retinal vascular disease. Central RVO (CRVO), in which obstruction occurs posterior to the lamina cribrosa due to various causes, manifests with extensive venous tortuosity, dilatation of blood vessels in the four quadrants, and retinal hemorrhage. The presence of macular edema decreases visual acuity in patients with CRVO, especially in elderly patients with hypertension, hyperlipidemia, and diabetes. In the last decade, treatment modalities for CRVO have improved, with anti-vascular endothelial growth factor agents being widely used as treatment. However, there are cases of refractory or recurrent macular edema. Moreover, CRVO also occurs in young patients. This article reviews previous studies and case reports and summarizes the differences in etiological factors, clinical manifestations, treatment, and prognosis between young and elderly patients. Due to the low incidence of CRVO in young patients, clinical data from these age groups are limited. Hence, further studies are warranted to explore the differences between age groups to improve individualization of treatment of young patients.

Optic disk anatomical features of children with central retinal vein occlusion

PURPOSE

To report a case series of children with central retinal vein occlusion (CRVO) showing a high prevalence of crowded optic disks with minimal cupping.

METHODS

We retrospectively reviewed the medical records of children diagnosed with CRVO from 2008 to 2019 at a single tertiary care pediatric hospital. Clinical records, fundus photographs, and optical coherence tomography (OCT) images were reviewed. Optic disk anatomical parameters of the unaffected fellow eyes, including OCT-measured optic disk area and vertical cup:disk ratio, were collected and analyzed.

RESULTS

Six patients with unilateral CRVO were identified. All patients were female. Age at presentation ranged between 9 and 17 years. Five patients were otherwise healthy, with negative systemic investigations (idiopathic group). The remaining patient had a known systemic risk factor of active Takayasu arteritis. Within the idiopathic group, "disk-at-risk" optic nerve configuration, defined as a cup:disk ratio of 0.2 or smaller, was identified in the fellow eye of all 5 patients. In the unaffected eyes, mean OCT-measured optic disk area was 1.67 ± 0.13 mm² and mean cup:disk ratio was 0.19 ± 0.12. The patient with Takayasu arteritis had normal OCT disk area of 2.1 mm² and cup:disk ratio of 0.61.

CONCLUSIONS

We observed a high prevalence of anatomical features potentially consistent with a constrictive optic disk configuration in pediatric patients with CRVO.

Baseline clinical features predict visual outcome in young patients with central retinal vein occlusion

PURPOSE

To evaluate prognostic factors in young patients with central retinal vein occlusion (CRVO).

METHODS

Retrospective case series. CRVO patients aged ≤ 50 and follow-up ≥ 6 months were enrolled. The best corrected visual acuity (BCVA) and central retinal thickness (CRT) at baseline, 3 months, 6 months, and last visit were documented. Severity of retinopathy was graded by comparing to standard photos. Prognostic factors associated with visual outcome at 6 months were evaluated by multiple linear regression models.

RESULTS

A total of 73 eyes from 69 patients with mean age 37.6 ± 8.5 were enrolled. Forty-seven (68%) patients were male. The mean follow-up duration was 25.9 ± 23.0 months. LogMAR BCVA improved from 0.979 ± 0.785 at baseline to 0.594 ± 0.748 at the 6 months (p < 0.001) and CRT improved from 475 ± 222 μm to 299 ± 104 μm (p < 0.001). Forty-eight (66%) eyes required anti-vascular endothelial growth factor (anti-VEGF) treatment. The mean number of injections was 2.25 ± 1.41 in the first 6 months and 75% of eyes received ≦ 3 injections during the clinical course. The baseline BCVA (coefficient 0.518, p < 0.001), grade of retinal hemorrhage (coefficient 0.230, p = 0.006), grade of retinal venous engorgement (coefficient 0.238, p = 0.011), grade of optic disc edema (coefficient - 0.226, p = 0.005), and diabetes mellitus (coefficient 0.264, p = 0.047) were the independent factors associated with visual outcome at 6 months.

CONCLUSIONS

Baseline clinical features are useful for the prediction of visual outcome at 6 months in young CRVO patients.