Bilateral macular retinoschisis in a patient with x-linked alport syndrome

Multiple Vitelliform Lesions as a Retinal Manifestation of Alport Syndrome

Alport syndrome is associated with various ocular phenotypic features, including several retinal manifestations. The purpose of this case report was to describe a case of multiple vitelliform lesions in Alport syndrome. This particular finding has, to our knowledge, not been reported previously. A 63-year-old man with known Alport syndrome presented with symptomatic, bilateral anterior lenticonus. Fundoscopic examination revealed multiple vitelliform lesions, which were symmetrically distributed at the posterior poles. Additional retinal findings included an irregular foveal contour and central macular thinning in both eyes, as well as a multilayered retinoschisis in the left eye. The underlying pathophysiology of the vitelliform lesions may be a dysfunctional Bruch's membrane.

A triad of retinal signs in Alport syndrome: The 'stair-case' fovea, choroidal thinning and peripheral schisis

BACKGROUND

Alport syndrome is an inherited Type IV collagenopathy characterised by renal failure, hearing loss and ophthalmic manifestations such as lenticonus and dot-and-fleck retinopathy. New signs have been described which can be useful both for diagnosis and for prognosticating the risk of complications. This study examines and describes a triad comprising the unusual 'stair-case' foveal sign, together with choroidal thinning and late-stage peripheral schisis in a patient with Alport syndrome.

CASE PRESENTATION

This is a case report of a 49-year-old Caucasian male with a background of X-linked Alport syndrome presenting with gradual and progressive diminution of vision in the left eye with a central blur. He had already undergone three renal allografts, was deaf and suffered from hypertension by the time of his first presentation to ophthalmology. On examination, corrected visual acuity was 6/9.5 in the right eye and 6/30 in the left eye. Optical coherence tomography imaging showed an unusual 'stair-case' sign of the fovea in both eyes, together with choroidal thinning. We postulate that an abnormal vitreomacular interface followed by vitreomacular traction and eventually separation, removing layers of the inner retina with the vitreous, led to this unusual appearance. Subsequently, this patient also developed schitic changes more peripherally in the retina which progressed over the following 5 years.

CONCLUSION

The stair-case foveal sign, choroidal thinning and mid-peripheral schisis are three signs that clinicians might expect to encounter on optical coherence tomography imaging of patients with Alport syndrome. These findings can be attributed to unique mutations of collagen IV which lead to a variety of clinical phenotypes affecting basement membrane structures. Identification of these features may not only be useful diagnostically and in forecasting complications such as macular holes, but also predict mode of inheritance and likelihood of early-onset renal failure.

MACULAR HOLES, VITELLIFORM LESIONS, AND MIDPERIPHERAL RETINOSCHISIS IN ALPORT SYNDROME

PURPOSE

To describe the retinal findings in two cases of Alport syndrome.

METHODS

Observational case series. The clinical findings of the two patients were documented with color fundus photography and high resolution spectral domain optical coherence tomography.

RESULTS

Patient 1 was found to have fleck retinopathy in both eyes, inner retinal thinning in the right eye and a full-thickness macular hole in the left eye. Patient 2 was found to have a full-thickness macular hole in the right eye as well as retinoschisis in the temporal macula in the right eye. The left eye revealed inner retinal thinning involving the fovea, a vitelliform lesion of the temporal macula and midperipheral retinoschisis involving multiple retinal layers.

CONCLUSION

Retinal abnormalities including fleck retinopathy, retinal thinning, macular holes, retinoschisis, and vitelliform lesions are variably present in Alport syndrome. This is only the second report of a vitelliform lesion in a patient with Alport syndrome and the first report of midperipheral retinoschisis. The array of retinal findings is believed to reflect a dysfunctional Type IV collagen present in the internal limiting membrane and Bruch membrane.

Choroidal thinning and "stair-case" foveal sign in a patient with Alport syndrome

PURPOSE

To quantitatively describe choroidal thickness in a patient with Alport syndrome and to qualitatively describe an unusual "stair-case" foveal sign.

METHODS

Retrospective case report.

RESULTS

This is the first case, to our knowledge, of the stair-case foveal sign. This is also the first case where choroidal thickness in a patient with Alport rsyndrome has been quantitatively described using enhanced depth imaging optical coherence tomography.

CONCLUSION

Stair-case foveal sign and choroidal thinning are two new signs that clinicians can expect to encounter on optical coherence tomography imaging of patients with Alport syndrome.