Aetiology of severe visual impairment and blindness in microphthalmos

Comprehensive genetic analysis uncovers the mutational spectrum of MFRP and its genotype-phenotype correlation in a large cohort of Chinese microphthalmia patients

PURPOSE

Microphthalmia is a severe congenital ocular disease featured by abnormal ocular development. The aim of this study was to detail the genetic and clinical characteristics of a large cohort of Chinese patients with microphthalmia related to MFRP variants, focusing on uncovering genotype-phenotype correlations.

METHODS

Fifty microphthalmia patients from 44 unrelated Chinese families were recruited. Whole-exome sequencing (WES) was conducted to analyze the coding regions and adjacent intronic regions of MFRP. Axial lengths (AL) were measured for all probands and available family members. Protein structures of mutations with high frequency in our cohort were predicted. The genotype-phenotype correlations were explored by statistical analysis.

RESULTS

Sixteen MFRP variants were detected in 17 families, accounting for 38.64 % of all microphthalmia families. There were 9 novel mutations (c.427+1G>C, c.428-2A>C, c.561_575del:p.A188_E192del, c.836G>A:p.C279Y, c.1010_1021del:p.H337_E340del:p.Y479*, c.1516_1517del:p.S506Pfs*66, c.1561T>G:p.C521G, c.1616G>A:p.R539H, and c.1735C>T:p.P579S) and six previously reported variants in MFRP, with p.E496K and p.H337_E340del being highly frequent, found in eight (47.06 %) and two families (11.76 %), respectively. Seven variants (43.75 %) were located in the C-terminal cysteine-rich frizzled-related domain (CRD) (7/16, 43.75 %). Protein prediction implicated p.E496K and p.H337_E340del mutations might lead to a destabilization of the MFRP protein. The average AL of all 42 eyes was 16.02 ± 1.05 mm, and 78.36 % of eyes with AL < 16 mm harbored p.E496K variant. Twenty-six eyes with variant variant had shorter AL than that of the other 16 eyes without this variant (p = 0.006), highlighting a novel genotype-phenotype correlation.

CONCLUSIONS

In this largest cohort of Chinese patients with microphthalmia, the 9 novel variants, high frequency of p.E496W, and mutation hotspots in CRD reveals unique insights into the MFRP mutation spectrum among Chinese patients, indicating ethnic variability. A new genotype-phenotype correlation that p.E496K variant associated with a shorter AL is unveiled. Our findings enhance the current knowledge of MFRP-associated microphthalmia and provide valuable information for prenatal diagnosis as well as future therapy.

Primary Transscleral Diode Laser Cyclophotocoagulation for Management of Glaucoma in Nanophthalmic Eyes

PURPOSE

The aim of this study was to assess the efficacy and safety of double-row transscleral cyclophotocoagulation in controlling intraocular pressure in patients with secondary angle closure glaucoma due to nanophthalmos, not being controlled by medical therapy.

PATIENTS AND METHODS

A prospective case series study that included 13 eyes of 8 patients diagnosed with secondary angle closure glaucoma due to nanophthalmos at the Giza Eye Subspeciality Center, treated by 24 cyclodiode applications in a double-row technique. Success was defined as complete success by control of intraocular pressure <21 mm Hg without medication and qualified success in which control of pressure <21 mm Hg achieved with 1 or 2 medications.

RESULTS

The average reduction in intraocular pressure at 3 months was 57.3±20.14% and at 6 months 44.5±32%, with an average eye drop intake of 1.3±0.8 drops. There was a significant reduction of intraocular pressure at 6 months compared with the preprocedure pressure ( P =0.01). Complete success achieved in 3 eyes, pressure controlled without any medication, and qualified success in 9 eyes.

CONCLUSION

Transscleral cyclophotocoagulation is a safe and effective primary therapy for managing glaucoma in nanophthalmic eyes.

Pathogenic variants of MFRP and PRSS56 genes are major causes of nanophthalmos in Japanese patients

BACKGROUND

Nanophthalmos (NNO) is a rare condition with significantly shorter axial length than normal. Several genes are known to cause NNO, among them the MFRP and PRSS56 genes have been reported to cause majority of NNOs. The purpose of this study was to determine the genetic basis of Japanese patients with NNO.

MATERIALS AND METHODS

We studied seven patients with NNO. Whole exome sequencing (WES) and Sanger sequencing were performed to determine the variants causing the NNO. We also reviewed the medical charts of the patients to determine the phenotype of these seven patients.

RESULTS

WES revealed that four patients from three families carried homozygous frameshift variants of the PRSS56 gene (c.1066dupC). Two novel variants of the MFRP gene were detected in the other two patients: one proband had a homozygous missense variant (c.1486 G>A) and the other had a compound heterozygous variant (c.1486 G>A and c.662_663insT). The axial length of the eight eyes with the PRSS56 variant was 15.69 ± 0.48 mm (mean ± SD) and that for the 4 eyes with the MFRP variant was 15.63 ± 0.69 mm. Three of the six cases with the PRSS56 or MFRP variant had the uveal effusion syndrome.

CONCLUSIONS

NNOs in Japanese patients are caused by variants of the PRSS56 and MFRP genes as in other ethnic populations. In addition, two new variants of the MFRP gene were found in our cohort. The phenotypes and anomalies in Japanese patients with NNO were similar to those reported for other ethnic populations.

Retinal arcades in posterior microphthalmos: biometric correlation

CLINICAL RELEVANCE

Posterior microphthalmos (PM) is a rare developmental disorder characterised by high hyperopia, short axial length, presence of retinal papillomacular fold and relatively normal anterior segment findings.

BACKGROUND

The purpose of the study was to compare the retinal arcade distance from fovea between PM cases and to correlate axial shortening in PM eyes with imaging findings.

METHODS

This retrospective, comparative case series included 24 eyes of 12 patients with PM as cases and an equal number of age- and sex-matched controls. Retinal findings on optical coherence tomography (OCT), OCT-angiography, Multicolour® image, axial length and corneal biometry were computed, compared and correlated between two groups.

RESULTS

Retinal papillomacular fold was noted in all 24 PM eyes. Retinal arcade narrowing was noted in PM (p < 0.001). The central retina (p < 0.001) and choroid (p = 0.003) was thick in PM. Corneal biometry showed shorter axial length (p < 0.001), high keratometry readings (p < 0.001) and small corneal diameters (p = 0.011) in PM. Vessel density (p = 0.031) on OCTA was denser and foveal avascular zone area (p = 0.033) reduced in PM. Strong negative correlation of axial length with spherical equivalent (r = > -0.804;p < 0.001), vessel density (r = > -0.803; p = <0.001) and K1 (r = > -0.76; p < 0.001) and K2 (r = > -0.67; p = 0.001) keratometry readings was noted in PM. Significant positive correlation was noted between axial length and anterior chamber depth (r = 0.75; p < 0.001), foveal avascular zone area (r = 0.56; p = 0.033) and corneal diameter (r = 0.65; p = 0.001). Vessel density on OCT-angiography correlated positively with central corneal thickness (r = 0.552;p = 0.005) and corneal powers K1 (r = 0.709; p = 0.001) and K2 (r = 0.56; p = 0.004) and negatively with corneal diameter (r = > -0.521; p = 0.033).

CONCLUSION

Increased choroidal thickening and retinal vascular arcade narrowing were two important, interesting observations noted with PM. Intercorrelation between the axial length, OCT, OCT-angiography and corneal biometry helped in understanding the pathogenesis and the structural and vascular changes in PM eyes.

The Comparison of Soft HydroCone (Toris K) Silicone Hydrogel and Rigid Gas-Permeable Contact Lenses in Patients With Posterior Microphthalmos

OBJECTIVE

To evaluate and compare soft HydroCone (Toris K) silicone hydrogel and rigid gas-permeable contact lenses (RGPCLs) in patients with posterior microphthalmos (PMs), for visual rehabilitation and comfort.

METHODS

The records of 11 patients who were followed up in our hospital with the diagnosis of PM and were fitted with both Toris K and RGPCLs in our contact lens department were reviewed retrospectively. Patient age, gender, axial length (AL), topographic keratometry (K) values and best-corrected visual acuity (BCVA) with both lens types and subjective lens comfort status were recorded.

RESULTS

A total of 22 eyes of 11 patients with a mean age of 20.9±11.1 years were included in the study. The mean AL were 16.01±0.1 and 15.9±0.2 mm in the right and left eyes, respectively. Mean K1 and K2 were 48.6±2.2 and 49.4±2.2 D, respectively. Mean logMAR BCVA of the 22 eyes before contact lens fitting was 0.63±0.56 with spectacle. After Toris K and RGPCLs fitting, mean logMAR BCVA were 0.43±0.20 and 0.35±0.25, respectively. Both lenses provided better visual acuity than spectacles; RGPCLs also provided significantly better visual acuity than HydroCone lens ( P <0.05). Eight of 11 patients (73%) had ocular discomfort with RGPLs, and there was no complaint with Toris K.

CONCLUSIONS

The corneal surfaces are steeper in patients with PMs than in normal population. For that reason, their vision should be rehabilitated by special design keratoconus lenses like Toris K and RGPCLs. Although vision rehabilitation seems better with RGPCLs, these patients prefer Toris K more because of discomfort.

Posterior Microphthalmos Pigmentary Retinopathy Syndrome

Purpose

To report a case of a rare disease entity Posterior Microphthalmos Pigmentary Retinopathy Syndrome (PMPRS) in a 47-year-old female with a brief review of literature.

Case Report

A 47-year-old woman presented with a history of defective vision with an associated difficulty in night vision. Clinical workup was done, which included a thorough ocular examination showing diffuse pigmentary mottling of fundus, ocular biometry showing short axial length with normal anterior segment dimensions, electroretinography showing extinguished response, optical coherence tomography showing foveoschisis, and ultrasonography showing thickened sclera-choroidal complex. Findings were consistent with those reported by other authors with PMPRS.

Conclusion

Posterior microphthalmia with or without other ocular and systemic associations should be suspected in cases with high hyperopia. It is mandatory to carefully examine the patient at presentation and close follow-ups are needed to maintain visual function.

Comparisons of size of foveal avascular zone area among children with posterior microphthalmos, high hyperopia, and normal eyes

PURPOSE

To determine the area of the surface foveal avascular zone (FAZ) in children with posterior microphthalmos (PM), high hyperopia, and normal eyes using optical coherence tomography (OCT) and OCT angiography (OCTA).

METHODS

Thirty-six children were studied including 6 cases 12 eyes of PM (mean age 9.5 ± 5.2 years), 15 cases 30 eyes of high hyperopia (6.9 ± 1.5 years), and 15 cases 30 eyes of healthy individuals (8.7 ± 1.7 years). The B- and C-scan images in all children were recorded by OCT and OCTA with a scanning area of 3.0 × 3.0 mm centered on the fovea. All images were corrected for axial length differences, and the area of the FAZ surface and central macular thickness (CMT) was measured manually and compared.

RESULTS

The area of FAZ in the PM group was 0.007 ± 0.003 mm², which was significantly smaller than that in the high hyperopia eyes at 0.286 ± 0.108 mm² and healthy eyes at 0.318 ± 0.129 mm² (both P < 0.001). The CMT in the PM group was 401.58 ± 33.60 mm, which was significantly thicker than in the high hyperopia eyes at 202.93 ± 12.28 mm and the normal eyes at 204.43 ± 18.76 mm. The area of the FAZ and CMT in the hyperopia group did not differ significantly from that of the normal healthy eyes.

CONCLUSION

These findings indicate that patients with PM have a hypoplastic macular region, which must be considered in any treatment of these eyes.

Outcomes of manual small incision cataract surgery and phacoemulsification in eyes with chorioretinal coloboma

PURPOSE

To evaluate outcomes of manual small-incision cataract surgery (MSICS) and phacoemulsification in eyes with chorioretinal coloboma.

SETTING

Tertiary eye center, South India.

DESIGN

Retrospective study.

METHODS

Electronic medical records of 71 patients with chorioretinal coloboma undergoing cataract surgery from January 2017 to December 2019 were evaluated. Demographics, corrected distance visual acuity (CDVA), slitlamp biomicroscopy findings, grade of cataract, type of coloboma and associated posterior segment pathology, outcomes of different surgical techniques and risk factors for poor visual outcomes, and intraoperative complications were analyzed.

RESULTS

Among the 78 eyes studied, 53.9% eyes achieved visual outcome of 20/40 or greater and 20.5% eyes achieved CDVA less than 20/200. For the MSICS group, the median preoperative CDVA was 1.78 (interquartile range [IQR] 1.08 to 2.60) logMAR), which improved to 0.60 (IQR 0.30-1.08) logMAR postoperatively. In phacoemulsification group, the CDVA improved from 0.78 (IQR 0.60-1.00) logMAR to 0.18 (IQR 0.18-0.30) logMAR. Statistically significant visual improvement was noticed in both groups (P < .001 in both). However, eyes that underwent phacoemulsification showed better visual recovery (P < .001). The mean age at presentation was 49.7 ± 10.8 years. MSICS was the most commonly performed surgery (61.54%), and 62 eyes had uneventful cataract surgery. Twelve eyes in MSICS group and 4 eyes in phacoemulsification group had intraoperative complications. Poor visual outcome was associated with male sex, microcornea, hard cataracts, and macular involvement of coloboma.

CONCLUSIONS

MSICS is an alternative to phacoemulsification in colobomatous eyes with advanced cataract. Hard cataract and microcornea were risk factors for intraoperative complications. Significant postoperative improvement in CDVA was noticed in both macula involved and macula not involved groups.

Bilateral severe microphthalmos with bilateral colobomatus orbitopalpebral cyst: accessibility of speciality eye-care and rehabilitation services in low and middle-income countries

A 12-year-old girl presented with an unusually large mass under the right lower eyelid and a smaller mass under the left lower lid since the last 6 months. The parents had noticed the absence of the right eyeball and a very small left eyeball and no vision in both eyes since birth but did not approach the healthcare system. The patient was diagnosed as a case of bilateral severe microphthalmos with colobomatous cyst with late presentation and was treated surgically. The parents were counselled for education and training of the child in schools for visually impaired. Early treatment and rehabilitation help patients lead a normal life in these cases. In rural areas, patients face challenges in getting access to the specialty eye-care services due to several barriers, including lack of availability and affordability. This case highlights the disparities in essential health services in low and middle-income countries.

Nanophthalmos: An Update on the Biological Parameters and Fundus Abnormalities

Nanophthalmos is a clinical phenotype of simple microphthalmos, in which the anterior and posterior segments of the eyeball do not develop into a normal size without other major ocular or systemic anomalies. Typical clinical manifestations of nanophthalmos include short axial length, thickened sclera, small cornea, shallow anterior chamber, and increased lens-to-eye volume ratio. Currently, there is a lack of recognized diagnostic criteria for nanophthalmos. With the development of eye examination technologies, such as biological measurement and imaging examination, visualization and quantification of the eyeball's shape and structure in nanophthalmos can be realized. New clinical features have been reported, which are of great significance for diagnosing and treating nanophthalmos. This review introduces the related concepts of nanophthalmos and the new developments in its clinical characterization.

Posterior segment abnormalities in posterior microphthalmos

Purpose

We report a case of posterior microphthalmos with characteristic papillomacular retinal folds, pigmentary retinopathy, and optic disc drusen.

Observations

A 19-year-old female presented with decreased visual acuity and was found to have bilateral posterior microphthalmos with the presence of papillomacular retinal folds, crowded optic nerves with buried disc drusen, and peripheral retinal pigmentary changes. Optical coherence tomography showed presence of retinal folds involving the inner retinal layers and loss of foveal contour.

Conclusions and Importance

Posterior microphthalmos can present with an array of unique clinical findings involving the posterior segment. It is important to recognize these findings as these patients often have decreased visual acuity and are at risk for the development of other posterior complications.

Cataract surgery contributes to ocular axis growth of aphakic eyes in infants with complex microphthalmos

To observe the ocular axis, visual acuity and intraocular pressure (IOP) of aphakic eye in infants with congenital cataract and complex microphthalmos after first-stage cataract surgery.This retrospective study included infants with congenital cataract and operated at the Qingdao Eye Hospital between January 2010 and December 2014. The infants were divided into 2 groups: preoperative axial length <18 mm (microphthalmos) or ≥18 mm (controls). Follow-up lasted 24 months; visual acuity, axial length, and IOP were evaluated.There were 28 infants (55 eyes) in the microphthalmos group and 35 (61 eyes) in the control group. The preoperative visual acuity was negative for optokinetic nystagmus, while the postoperative visual acuity was positive for optokinetic nystagmus in both groups. The growth rate was higher in the microphthalmos group (1.4 ± 0.8 vs 0.8 ± 0.4 mm/yr, P < .001 vs controls). The axial length was smaller in the microphthalmos group at all time points compared with the control group (all P < .001). There was no changes in IOP in the microphthalmos group from baseline to 24 months (P = .147), but the IOP was slightly decreased in the control group (P = .015).Cataract surgery may contribute to ocular axis growth in infants with complex microphthalmos.

The Pathogenesis and Treatment of Complications in Nanophthalmos

Microphthalmos is a type of developmental disorder ophthalmopathy, which can occur isolated or combined with other ocular malformations and can occur secondary to a systemic syndrome. Nanophthalmos is one of the clinical phenotypes of microphthalmos. Due to the special and complex structure of nanophthalmic eyes, the disorder is often associated with many complications, including high hyperopia, angle-closure glaucoma, and uveal effusion syndrome. The management of these complications is challenging, and conventional therapeutic methods are often ineffective in treating them. The purpose of this paper was to review the concept of nanophthalmos and present the latest progress in the study of the pathogenesis and treatment of its complications. As it is considerably challenging for ophthalmologists to prevent or treat these nanophthalmos complications, timely diagnosis and a suitable clinical treatment plan are vital to ensure that nanophthalmos patients are treated and managed effectively.

A novel MFRP gene variant in a family with posterior microphthalmos, retinitis pigmentosa, foveoschisis, and foveal hypoplasia

BACKGROUND

To characterize the phenotype and genotype of a syndrome associating posterior microphthalmos (PM), retinitis pigmentosa (RP), foveoschisis, and foveal hypoplasia (FH) in a consanguineous Portuguese family.

MATERIALS AND METHODS

Three siblings were studied and underwent comprehensive eye examinations for best-corrected visual acuity, axial length, refractive error, B-mode ultrasound, electroretinography, retinography, fluorescein angiography (FA), kinetic visual field (VF), and optical coherence tomography (OCT). Molecular analysis was performed by Sanger sequencing of the entire coding region of the MFRP gene.

RESULTS

All members presented nyctalopia, decreased visual acuity, and constriction of the VF, as well as bilateral shortening of the posterior ocular segment and normal anterior segment dimensions. The fundoscopy and ERG results were compatible with RP. Macular OCT analysis revealed schisis of the outer retinal layer, FH, as well as retinal and choroidal folds. We identified a homozygous mutation in intron 9 of the membrane frizzled-related protein (MFRP) gene (c.1124 + 1 G > A).

CONCLUSIONS

Our study shows a family with PM and RP due to a mutation in the MFRP gene. The relationship has previously been proven, but this specific mutation has never been described. These gene mutations show wide phenotypic variability, being evident in the presence of foveoschisis, retinal and choroidal folds, and FH, other than PM and RP.

The majority of autosomal recessive nanophthalmos and posterior microphthalmia can be attributed to biallelic sequence and structural variants in MFRP and PRSS56

This study aimed to genetically and clinically characterize a unique cohort of 25 individuals from 21 unrelated families with autosomal recessive nanophthalmos (NNO) and posterior microphthalmia (MCOP) from different ethnicities. An ophthalmological assessment in all families was followed by targeted MFRP and PRSS56 testing in 20 families and whole-genome sequencing in one family. Three families underwent homozygosity mapping using SNP arrays. Eight distinct MFRP mutations were found in 10/21 families (47.6%), five of which are novel including a deletion spanning the 5' untranslated region and the first coding part of exon 1. Most cases harbored homozygous mutations (8/10), while a compound heterozygous and a monoallelic genotype were identified in the remaining ones (2/10). Six distinct PRSS56 mutations were found in 9/21 (42.9%) families, three of which are novel. Similarly, homozygous mutations were found in all but one, leaving 2/21 families (9.5%) without a molecular diagnosis. Clinically, all patients had reduced visual acuity, hyperopia, short axial length and crowded optic discs. Retinitis pigmentosa was observed in 5/10 (50%) of the MFRP group, papillomacular folds in 12/19 (63.2%) of MCOP and in 3/6 (50%) of NNO cases. A considerable phenotypic variability was observed, with no clear genotype-phenotype correlations. Overall, our study represents the largest NNO and MCOP cohort reported to date and provides a genetic diagnosis in 19/21 families (90.5%), including the first MFRP genomic rearrangement, offering opportunities for gene-based therapies in MFRP-associated disease. Finally, our study underscores the importance of sequence and copy number analysis of the MFRP and PRSS56 genes in MCOP and NNO.

Multimodal imaging in posterior microphthalmos

Purpose

To evaluate the multimodal imaging including optical coherence tomography angiography (OCTA) findings in patients with posterior microphthalmos (PM).

Methods

In an observational case series, four eyes of two patients, eight and twenty-three years old, with clinical proven PM underwent complete ophthalmic examination, including refraction, fluorescein angiography, optical coherence tomography (OCT), OCTA, B-scan ultrasonography, axial length measurement using IOL Master optical measuring, and Pentacam evaluation.

Results

Both patients were high hyperopic with partial thickness retinal fold in macula, retinoschisis, and foveal hypoplasia. Axial length was less than 17 mm with scleral thickening in all eyes. OCTA showed absence of foveal avascular zone (FAZ) in both superficial and deep capillary plexuses. Pentacam showed corneal steepness, shallow anterior chamber, and low anterior chamber volume.

Conclusion

OCTA findings showed absence of avascular zone in both superficial and deep capillary plexuses, while OCT shows partial thickness retinal fold and retinoschisis.

Retinal structural and vascular changes in posterior microphthalmos

BACKGROUND

Posterior microphthalmos (PM) is a rare developmental disorder characterised by high hyperopia, short axial length, presence of retinal papillomacular fold and relatively normal anterior segment findings. The study objective is to describe the retinal structural and vascular changes in eyes with PM with spectral domain optical coherence tomography, optical coherence tomography angiography and multicolour imaging.

METHODS

In this retrospective, comparative case series, 10 eyes of five patients with PM as cases and 10 eyes of five age- and sex-matched controls were included. Structural changes, namely inner and outer retinal layer thicknesses, were measured using optical coherence tomography. Multicolour imaging findings were noted. Perifoveal vascular changes with qualitative and quantitative assessments were analysed using optical coherence tomography angiography.

RESULTS

The foveal dip was absent in all 10 eyes (100 per cent) with PM. There was an elevated retinal papillomacular fold in six eyes (60 per cent) and intraretinal cystoid spaces in two eyes (20 per cent) with PM. The inner retinal layers were thicker in PM. On multicolour imaging, foveal avascular zone and retinal wrinkles were identified in eyes with retinal papillomacular fold in blue and green reflectance images. Perifoveal vascular changes in optical coherence tomography angiography included foveal area size reduction in superficial and deep vascular networks. The foveal capillary vessel densities were higher in PM compared to the controls in both superficial (46.3 ± 3.7 per cent; p = 0.000) and deep (54.7 ± 3.5 per cent; p = 0.000) capillary plexuses. Flow areas in superficial (p = 0.693) and deep (p = 0.088) capillary plexuses were not statistically relevant.

CONCLUSION

The study suggests that in PM, retinal foreshortening occurs in one meridian leading to secondary changes such as loss of foveal dip, posterior bowing of the outer layers of the eye, thickening of the inner retina and ultimately, retinal papillomacular fold formation. The findings of the study need further validation in a larger series of patients with PM.

Posterior Microphthalmia, Peripheral Pigmentary Retinal Changes, Yellow Lesions, and Cleft Lip: A Case Report and Literature Review

Purpose

Posterior microphthalmia is a sporadic or inherited developmental ocular anomaly that may occur isolated or in association with multiple ocular and systemic anomalies. This report documents a case of posterior microphthalmia with atypical presentation including white dots in the posterior pole in addition to systemic anomalies including facial defect that can represent an underlying genetic mutation.

Method

Case report.

Results

A 29-year-old male with high hyperopia and history of bilateral clear lens presented with pigmentary changes and white-yellow dots in the posterior pole in both eyes. Patient had a history of cleft lip repair. A complete ocular evaluation including A/B scan and optical coherence tomography confirmed the diagnosis of posterior microphthalmia with a retinitis pigmentosa like fundus and drusen deposits in the subretinal pigment epithelium.

Conclusion

The white-yellow drusenoid deposits in the posterior pole in association with posterior microphthalmia are poorly documented in the literature. Cases of craniofacial developmental defects in association with posterior microphthalmia may represent a genetic defect.

Medical Management of Children With Congenital/Infantile Cataract Associated With Microphthalmia, Microcornea, or Persistent Fetal Vasculature

PURPOSE

To report the surgical outcomes of children with cataract associated with microphthalmia, microcornea, or persistent fetal vasculature (MMP) and children with isolated cataract.

METHODS

The study included 111 children (cataract associated with MMP: n = 25) who underwent cataract surgery at younger than 16 years. Exclusion criteria were duration of follow-up less than 5 years, intraindividual differences in age at surgery, eye disorders other than MMP, secondary cataract, and syndromal diseases. Main outcome measures were proportion of eyes with glaucoma and best corrected visual acuity (BCVA). Both groups were dichotomized by age at surgery (early intervention group: ≤ 48 days). Descriptive analysis was performed throughout.

RESULTS

Median age at surgery was 3.9 months for cataract associated with MMP and 23.3 months for isolated cataract. The median (interquartile range [IQR]) duration of follow-up was 95.9 months (range: 76.0 to 154.5 months). In children with bilateral cataract associated with MMP, the proportion of eyes with final BCVA worse than 0.3 logMAR was similar regardless of age at surgery (early intervention: 80%, later intervention: 78%). In bilateral isolated cataract, the proportions were 56% and 33%, respectively. Children with cataract associated with MMP had a high prevalence of glaucoma (28%). Glaucoma prevalence was lower in the later intervention group.

CONCLUSIONS

In the presence of MMP, early cataract surgery is associated with a high risk of post-lensectomy glaucoma, but does not offer the benefit of better visual outcomes. [J Pediatr Ophthalmol Strabismus. 2019;56(1):43-49.].

Ocular findings in posterior microphthalmos

AIM

To report a critical case series of six patients with posterior microphthalmos (PM).

METHOD

Complete ophthalmologic examinations of all patients were performed using best-corrected visual acuity (BCVA), cycloplegic refraction, applanation tonometry, slit lamp biomicroscopy of the anterior segment, fundoscopy, A and B mode ultrasonography (USG), keratometry, and optic coherence tomography (OCT).

RESULTS

The most significant clinical characteristics of male patients aged 10-25 years was the presence of shorter posterior segments (mean: 15.27-18.91 mm) accompanying high hyperopia (mean +9.00 - +18.50 diopter) despite the normal anterior segment findings. The BCVA ranged between 20/320 and 40/100. Retinal folds were detected bilaterally on the papillomacular band in all patients. Although neurosensory retina was included in the fold in OCT images, retinal pigment epithelium, choroid, and sclera were not included in the fold. Pigmentary retinopathy was detected in one patient.

CONCLUSION

Despite normal anterior segment, posterior microphthalmos is characterized with high hyperopia, and shorter axial length and bilateral papillomacular retinal fold. Refractive amblyopia, uveal effusion syndrome, retinal detachment and macular hole are complications that can be corrected. Posterior microphthalmos must be kept in mind in patients with a normal anterior segment, and high hyperopia.

Outcomes of cataract surgery in Microophthalmia

Objective

To find out outcomes of cataract surgery with Microophthalmia in children less than two years.

Methods

This cross-sectional study was conducted at Al-Ibrahim Eye Hospital, Karachi from January 2016 to August 2017. It included thirty micro ophthalmic eyes of infants with visually significant cataract of age less than two years who had cataract surgery without intraocular lens implantation. Axial length of globe was 19 mm or less in all thirty eyes of seventeen infants. in which thirteen infants had bilateral cataract and four had unilateral cataract.

Result

Thirty Simple Micro ophthalmic eyes from seventeen patients having visually significant congenital cataract were studied. Thirteen had bilateral cataract and four had unilateral cataract. Mean preoperative IOP was 9.0±1.2 mmHg and postoperative IOP after three months was 10.9±3.2 mmHg. Three patients had secondary capsular opacification 17.6%. Two patients had posterior synachae 11.8% after three months.

Conclusion

The results suggest that cataract surgery in simple microophthalmia is safe procedure. Postoperative complications in this study were within acceptable limits. Long term study with intraocular lens is required to confirm our observation.

[Glaucoma and nanophthalmos]

The term nanophthalmos refers to a clinically small eye that appears morphologically normal. A nanophthalmos is characterized by hyperopia but can also be associated with various secondary pathologies, such as angle-closure glaucoma. In particular, the perioperative risks associated with a nanophthalmic eye necessitate examination of the anatomical characteristics, which can result from the disproportional size of intraocular tissues despite structural normality. These include a small anterior chamber depth, scleral thickening and anomalies of the vein plexus, which are predisposing factors for the formation of angle-closure glaucoma. The resulting therapeutic challenges in the nanophthalmic eye can be countered with iridectomy, lensectomy, vitrectomy and cyclophotocoagulation. The definition, genetics and clinical findings of nanophthalmos are discussed with a focus on the complication of glaucoma and its treatment.

Clinical features of posterior microphthalmic and nanophthalmic eyes

AIM

To clinically differentiate nanophthalmos (NO) and posterior microphthalmos (PM) and to explore the mechanisms related to papillomacular folds (PMF).

METHODS

Medical records of 34 unrelated patients with microphthalmos (54 eyes) from April 2009 to October 2017 were retrospectively reviewed.

RESULTS

Fourteen eyes of 7 unrelated patients with NO and PM were included in the study. The presenting age of the NO cohort was significantly higher compared with the PM cohort (NO: 27±16y; PM: 3.7±0.6y). PMF was more likely to occur in cases with PM than in NO (25% in NO, 100% in PM). The anatomic features of PMF from optical coherence tomography (OCT) included: ganglion cell layer, inner plexiform layer, inner nuclear layer, outer plexiform layer and outer nuclear layer. In eyes without an apparent PMF (these were all NO eyes), rudimentary fovea without a foveal pit was noted. Four eyes that were NO developed angle closure glaucoma. Three NO eyes developed exudative retinal detachment and were successfully treated with lamellar sclerectomy.

CONCLUSION

Posterior segment changes are pervasive both in PM and NO. Complications like angle closure glaucoma and exudative retinal detachment are likely to occur in eyes with NO but not with PM. Detailed OCT analysis found that PMF was partially a neural retinal issue, suggesting that redundancy of retinal issues involved only inner retinal layers.

Absent Foveal Pit, Also Known as Fovea Plana, in a Child without Associated Ocular or Systemic Findings

The purpose of this report is to describe a case of bilateral foveal hypoplasia in the absence of other ophthalmological or systemic manifestations. We characterize the case of a 9-year-old Caucasian male who underwent full ophthalmologic examination, including functional measures of vision and structural measurements of the eye. Best corrected visual acuity was 0.50 logMAR in the right eye and 0.40 logMAR in the left eye. Ophthalmoscopy revealed a lack of foveal reflex that was further investigated. Optical coherence tomography (OCT) confirmed the absence of foveal depression (pit). OCT images demonstrated the abnormal structure of retina in a region in which we expected a fovea; these findings were decisive to determine the cause of reduced acuity in the child.

Phthisis Bulbi-a Clinicopathological Perspective

Phthisis bulbi denotes end-stage eye disease characterized by shrinkage and disorganization of the eye with the resultant functional loss. The major factors associated with the pathogenesis of phthisis are hypotony, deranged blood-ocular barriers, and inflammation. Common causes include trauma, surgery, infection, inflammation, malignancy, retinal detachment, and vascular lesions. A phthisical globe shows a small squared off shape, opaque and thickened cornea, thickened sclera, neovascularization of iris, cataract, cyclitic membrane, ciliochoroidal detachment, and retinal detachment. Microscopic features include internal disorganization, inflammatory reaction, a reactive proliferation of various cells, calcification, and ossification. Early treatment of the causative etiology is the best strategy available to avoid an eye from going into phthisis. A phthisical eye has no visual potential and cosmetic rehabilitation or symptomatic relief of pain remains the mainstay in the management. The authors present a comprehensive review of the etiopathogenesis, pathology, clinical features, and management of the end-stage ocular disease.

Nanophthalmos: A Review of the Clinical Spectrum and Genetics

Nanophthalmos is a clinical spectrum of disorders with a phenotypically small but structurally normal eye. These disorders present significant clinical challenges to ophthalmologists due to a high rate of secondary angle-closure glaucoma, spontaneous choroidal effusions, and perioperative complications with cataract and retinal surgeries. Nanophthalmos may present as a sporadic or familial disorder, with autosomal-dominant or recessive inheritance. To date, five genes (i.e., MFRP, TMEM98, PRSS56, BEST1, and CRB1) and two loci have been implicated in familial forms of nanophthalmos. Here, we review the definition of nanophthalmos, the clinical and pathogenic features of the condition, and the genetics of this disorder.

Clinical features of posterior microphthalmos associated with papillomacular fold and high hyperopia

BACKGROUND

The aim was to evaluate the characteristic clinical features of posterior microphthalmos.

METHODS

Medical records of four patients (eight eyes) between the ages of three and 31 years with posterior microphthalmos were reviewed retrospectively. Thorough ocular examinations were performed, including visual acuity, intraocular pressure, ocular alignment, axial length, cycloplegic refraction, slitlamp biomicroscopy of the anterior segment and fundus and spectral-domain optical coherent tomography (SD-OCT).

RESULTS

All subjects had presented with high hyperopia (+11.0 to +15.75 D) and retinal papillomacular folds in both eyes. They also had reduced bilateral axial length (15.55-18.61 mm), with foreshortening of the posterior segment and a relatively normal anterior segment. Papillomacular retinal folds involving the inner retinal layers and sparing the outer retinal layers, along with the absence of foveal depression, were confirmed by macular SD-OCT. In three patients, we found esodeviations associated with posterior microphthalmos and one of these required strabismic surgery. Concomitant optic nerve hypoplasia and a newly-developed neurosensory retinal detachment were found in one patient.

CONCLUSION

Posterior microphthalmos is a developmental arrest of ocular growth. In addition to high hyperopia and retinal papillomacular folds, various types of esotropia, optic disc hypoplasia and neurosensory retinal detachment may accompany posterior microphthalmos. In particular, children with posterior microphthalmos require early appropriate management of the high refractive error and resultant esotropia.

High-hyperopia database, part I: clinical characterisation including morphometric (biometric) differentiation of posterior microphthalmos from nanophthalmos

PURPOSE To characterise and differentiate posterior microphthalmos (PM) and nanophthalmos (NO) using morphometric parameters.Patients and methodsConsecutive case database of patients with hyperopia >+7.00 D sphere was analysed retrospectively for clinical and biometric characterisation. Thirty-eight consecutive high-hyperopic subjects (75 eyes) with axial lengths <20.5 mm underwent uniform comprehensive ocular evaluation. Twenty-five subjects were diagnosed as PM and 13 as NO based on the horizontal corneal diameter. Parameters analysed included visual acuity, refraction, horizontal corneal diameter, anterior chamber depth, lens thickness, axial length, fundus changes, and associated ocular pathology.

PRIMARY OUTCOME MEASURES

ocular biometry difference between PM and NO.

SECONDARY OUTCOME MEASURES

differences in associated ocular pathologies between PM and NO.RESULTS Hyperopia ranged from +7 to +17 D and was similar in the two groups. Lens thickness was statistically more in NO than in PM group (4.53±0.75 mm vs 3.82±0.48 mm, P <0.001), whereas anterior chamber depth was more in the PM than in NO group (3.26±0.36 mm, vs 2.59±0.37 mm, P<0.001). NO had higher association with angle-closure glaucoma (66.7% vs 0%) and pigmentary retinopathy (38.5 vs 8.0%) but lesser association with macular folds (0% vs 24%) as compared with PM. NO was associated with poorer visual acuity.CONCLUSION PM and NO have significant differences in lens thickness, anterior chamber depth, prevalence of glaucoma, pigmentary retinopathy, macular pathology, and visual acuity while being similar in hyperopic refraction.

Microphthalmia in a case of Edward syndrome

AIM

To present an infant of trisomy 18 (Edwards Syndrome) with unilateral microphthalmia.

METHODS

A female infant who was born at 41 weeks of gestation had been diagnosed with Edwards Syndrome (ES). On ophthalmic examination, microphthalmia, microcornea, optic disc coloboma, and persistent hyaloid artery were determined in the left eye. In addition, abnormalities in the ears, hands, feet, and cardiovascular system were present.

DISCUSSION

With this case report, we aimed to highlight the relationship between ocular disgenesis and chromosomal disorders and the importance of prenatal testing and genetic counseling for parents.

Posterior microphthalmia and nanophthalmia in Tunisia caused by a founder c.1059_1066insC mutation of the PRSS56 gene

Congenital microphthalmia (CMIC) is a common developmental ocular disorder characterized by a small, and sometimes malformed, eye. Posterior microphthalmia (PM) and nanophthalmia are two rare subtypes of isolated CMIC characterized by extreme hyperopia due to short axial length and elevated lens/eye volume ratio. While nanophthalmia is associated with a reduced size in both anterior and posterior segments, PM involves a normal-size anterior chamber but a small posterior segment. Several genes encoding transcription and non-transcription regulators have been identified in different forms of CMIC. MFRP gene mutations have, for instance, been associated with nanophthalmia, and mutations in the recently identified PRSS56 gene have been linked to PM. So far, these two forms of CMIC have been associated with 9 mutations in PRSS56. Of particular interest, a c.1059_1066insC mutation has recently been reported in four Tunisian families with isolated PM and one Tunisian family with nanophthalmia. Here, we performed a genome-wide scan using a high density single nucleotide polymorphism (SNP) array 50 K in a large consanguineous Tunisian family (PM7) affected with PM and identified the same causative disease mutation. A total of 24 polymorphic markers spanning the PRSS56 gene in 6 families originating from different regions of Tunisia were analyzed to investigate the origin of the c.1059_1066insC mutation and to determine whether it arose in a common ancestor. A highly significant disease-associated haplotype, spanning across the 146 kb of the 2q37.1 chromosome, was conserved in those families, suggesting that c.1059_1066insC arose from a common founder. The age of the mutation in this haplotype was estimated to be around 1,850 years. The identification of such 'founder effects' may greatly simplify diagnostic genetic screening and lead to better prognostic counseling.

Spectral domain optical coherence tomography finding in posterior microphthalmos

An eight-year-old boy presented with decreased vision in both eyes. At presentation, the visual acuity was 6/60 in both eyes with high plus spheres. Anterior segment examination was normal. Fundus examination and spectral domain optical coherence tomography were consistent with posterior microphthalmos and showed an elevated foveal contour and fold in the outer plexiform layer. External limiting membrane, photoreceptor and retinal pigment epithelium were not involved in the fold. To the best of our knowledge this is the first such case report with optical coherence tomography imaging of the retinal layer involved in a case of posterior microphthalmos.

Longitudinal change in aphakic refraction after early surgery for congenital cataract

PURPOSE

To characterize the longitudinal changes of refraction in aphakic eyes after early surgery for congenital cataract and to evaluate longitudinally measured aphakic refraction (individual vs group mean) as a noninvasive indicator of postoperative disturbances in ocular development.

METHODS

Records of children who had cataract surgery during their first year of life between 1980 and 1995 were obtained from a prospective, population-based study of congenital cataract. Only children with regular follow-up were included. Postoperative aphakic refraction was calculated at the corneal plane. Data were obtained up to 36 months of age.

RESULTS

The study included 28 children (49 eyes) who underwent surgery at a median age of 2.8 months (range, 0-9 months). The decrease of aphakic refraction at the corneal plane followed a logarithmic trend (R(2) = 0.95). A total of 36 eyes followed this pattern, with no growth in 8 eyes and an increased growth rate in 1 eye with uncontrolled glaucoma and 4 eyes of 2 children with Down syndrome.

CONCLUSIONS

Most aphakic eyes follow a predictable, logarithmic change in refraction in the first 3 years of life, Longitudinal monitoring of refraction may prove to be a useful, noninvasive screening method for early detection of disturbances in aphakic eye growth.

Hereditary High Hypermetropia in the Faroe Islands

PURPOSE

To characterize the phenotype of two families with high hypermetropia from the Faroe Islands.

METHODS

Ophthalmologic evaluation including ultrasound oculometry and anthropometric measurements.

RESULTS

Of the 40 examined family members, 15 individuals (8 males, 7 females; ages: 6-77 years; mean: 36.5 years) had small deep-set eyes with high hypermetropia (median: + 16.5 D; range: + 7.75 to + 22), short axial eye length (< 21 mm), and a thickened eye wall. The median corrected visual acuity was 0.4 (0.2-0.9). Ocular complications included angle-closure glaucoma in six eyes, uveal effusion in three eyes, cataract in two eyes, and esotropia with amblyopia in three eyes. An emergency case of uveal effusion and retinal detachment after Yag iridotomy eventually responded to systemic corticosteroids and scleral resection surgery with a slow visual recovery. No associated ocular or systemic malformations were found in the series. In addition to the two examined families, six smaller Faroese families with high hypermetropia are briefly reported.

CONCLUSIONS

The study highlights the signs and symptoms of a rare hereditary phenotype characterized by a short axial length mainly confined to the posterior segment of the eye, a shallow anterior chamber, and a thickened eye wall. The morphological characteristics predispose for sight-threatening complications such as angle-closure glaucoma, chorioretinal pathology including uveal effusion, and amblyopia. Regular ophthalmic follow-up is therefore of obvious importance in families known to have small eyes/high hypermetropia. An endemic high prevalence in the Faroe Islands suggests the presence of a founder effect, and further genetic research would probably indicate pseudodominant rather than dominant transmission

A genome-wide linkage scan in Tunisian families identifies a novel locus for non-syndromic posterior microphthalmia to chromosome 2q37.1

Posterior microphthalmia (PM) is a relatively rare autosomal recessive condition with normal anterior segment and small posterior segment resulting in high hyperopia and retinal folding. It is an uncommon subtype of microphthalmia that has been mostly reported to coexist with several other ophthalmic conditions and to occur in sporadic cases. The membrane-type frizzled-related protein (MFRP) is the only gene so far reported implicated in autosomal recessive, non-syndromic and syndromic forms of PM. Here, we performed a clinical and genetic analysis using six consanguineous families ascertained from different regions of Tunisia and affected with non-syndromic PM that segregates as an autosomal recessive trait. To identify the disease-causing defect in these families, we first analysed MFRP gene, then some candidate genes (CHX10, OPA1, MITF, SOX2, CRYBB1-3 and CRYBA4) and loci (MCOP1, NNO1 and NNO2) previously implicated in different forms of microphthalmia. After exclusion of these genes and loci, we performed a genome-wide scan using a high density single nucleotide polymorphism (SNP) array 50 K in a large consanguineous pedigree. SNP genotyping revealed eight homozygous candidate regions on chromosomes 1, 2, 3, 6, 15, 17 and 21. Linkage analysis with additional microsatellite markers only retained the 2q37.1 region with a maximum LOD score of 8.85 obtained for D2S2344 at theta = 0.00. Further investigations are compatible for linkage of four more families to this region with a refined critical interval of 2.35 Mb. The screening of five candidate genes SAG, PDE6D, CHRND, CHRNG and IRK13 did not reveal any disease-causing mutation.

Rapid measurement of corneal diameter in children: validation of a clinic-based digital photographic technique

Measuring corneal diameter is often difficult in infants, but its importance in certain circumstances cannot be overstated. Most available techniques for obtaining corneal diameter measurement are threatening to the child: the gold standard measurement technique relies on calipers and a ruler and necessitates general anesthesia for most children under the age of 7 years. Consequently, this important element of the pediatric eye examination is often not performed in clinic. We describe and prospectively validate a digital photographic technique for measuring corneal diameter, which is easy to perform, quick, nonthreatening, and provides an accurate corneal diameter measurement.

Severe microcornea with anterior segment malformation in a mother and her son

A male infant with microcornea, anterior segment dysgenesis and congenital cataracts, but with a normal ocular posterior segment is reported. His mother also had extreme microcornea, no useful vision from birth, but had globes of grossly normal size.

Pervasive ocular anomalies in posterior microphthalmos

BACKGROUND

Posterior microphthalmos is a relatively rare condition that has been reported to coexist with several other ophthalmic conditions. However, to the best of the authors' knowledge, there are no previous reports that have found posterior microphthalmos and refractive, binocular, retinal, and neurologic considerations, along with a possible hereditary component. The following report documents the coexistence of posterior microphthalmos with severe hyperopia, esotropia, macular folds, and optic nerve hypoplasia in a pair of siblings.

CASE REPORT

A 9-year-old Hispanic girl presented for a comprehensive eye examination. Best-corrected visual acuity (VA) was reduced in both eyes with poorer VA in the right eye. Binocular testing found a small angle constant right esotropia (ET). On dilated fundus examination, a peculiar, elevated, dolphin-shaped folding of the macula was identified, the right eye greater than the left eye, that extended toward an anomalous optic nerve head in both eyes (OU), presumed to be a disc hypoplasia. The patient's brother, who also exhibited severe hyperopia and ET, presented with a similar acuity reduction, a nearly identical folded macular appearance, the right eye more so than the left eye, and a probable optic nerve hypoplasia. Pachymetry, ultrasonography, and ocular coherence tomography imaging of both siblings found thickened corneas in the presence of posterior microphthalmos OU and macular folds affecting only the retina, leaving the choroid and sclera unaffected.

CONCLUSIONS

Posterior microphthalmos may exist in the presence of ocular anomalies along with refractive, binocular, retinal, neurologic, and genetic considerations. In this case, optical coherence tomography provided information on the internal morphology of the macular folds, which helped direct the differential diagnosis. The similar presentation among siblings supports a hereditary component that warrants further investigation.

Microphthalmos: clinical and ultrasonographic findings

We analyzed ocular and ultrasonographic findings of microphthalmos and associated ocular and systemic pathologies in 27 microphthalmic eyes. A high incidence of consanguinous marriages (26%) was present among the parents of patients. Associated systemic abnormalities were growth retardation, congenital rubella, cleft lip and palate, facial hemangioma, inguinal hernia, clinodactyly, Hurler syndrome, Goltz-Gorlin syndrome and Hallermann-Streiff syndrome. A variety of ocular/systemic abnormalities were encountered. Early ultrasonographic diagnosis and description of other ocular and systemic pathologies are essential.

Modified flexible iris retractor to retract superior iris and support inferior capsule in eyes with iris coloboma and inferior zonular deficiency

Flexible nylon iris retractors are a useful adjunct to cataract surgery in cases of small pupil and subluxated lenses. A modification is presented of the standard application of iris hooks to retract the superior iris and support the inferior capsule during phacoemulsification in cases of iris coloboma with inferior zonular deficiency. Three iris hooks are applied to retract the iris, and 2 iris hooks are applied to the inferior capsule margin to support the crystalline lens in that quadrant. Clear corneal temporal phacoemulsification is then performed with adequate pupillary diameter and capsular support.

Oculometric Characteristics of Extreme Hypermetropia in Two Faroese Families

PURPOSE

To describe and analyze the oculometric features of small eyes with high hypermetropia in two Faroese families, with emphasis on refractive components.

METHODS

Members of the two families (N=40; age, 1 to 77 years), including 15 cases of extreme hypermetropia (+7.5 to +19.25 D), had an ophthalmic evaluation including refractometry, keratometry, and axial ocular measurements using A-scan ultrasound. Eye-wall thickness was assessed using B-scan. Nonparametric statistics were used, mainly the Mann-Whitney U test.

RESULTS

In the two families, there were six and nine probands, respectively, with hypermetropia more than +7 D and short eyes as defined by axial eye lengths <21 mm. The median corrected visual acuity was 0.4 (range, 0.2 to 0.9). Gross fundus abnormalities were not observed. All 15 had a short posterior segment with a thick eye wall and a relatively thick lens. Furthermore, steep and rather small corneas were present. In one of the families, 70% of the affected had a corneal curvature radius of < or =7.0 mm. Five probands from family 2 were labeled as possibly affected because of hypermetropia and borderline axial length findings (21 to 22 mm). The remaining 20 subjects had visual acuity and oculometric findings within physiologic limits.

CONCLUSIONS

The axial measurement features in our series of highly hypermetropic eyes mainly presented as an extension downward from the hypermetropic bottom line of the normal distribution. The axial shortness of the eyes was primarily the result of a short posterior eye segment ("posterior microphthalmos"). A steep cornea was a feature in most small eyes in our series, particularly in one family branch.

The management of orbital cysts associated with congenital microphthalmos and anophthalmos

AIMS

To study the management of the orbital cysts present in a group of patients with anophthalmos and microphthalmos.

METHODS

A retrospective study of 34 patients (40 orbits) treated for orbital cyst associated with microphthalmos and anophthalmos.

RESULTS

The two largest treatment groups comprised 17 orbits (42.5%) where the cyst was removed surgically and 17 orbits (42.5%) where the cyst was retained and conformers were used. The remaining cases comprised two orbits (5%) where the cyst was aspirated initially; two orbits (5%) with large cysts which will need to be excised after further orbital growth; one orbit (2.5%) in which a silicone expander was used initially, and one orbit (2.5%) in which a mildly microphthalmic eye had some vision and was monitored but required no surgery.

CONCLUSION

In this study 33 out of 34 patients had a good cosmetic result which illustrates that the orbital cyst in microphthalmos or anophthalmos performs a useful role in socket expansion and that the majority of patients with this condition can expect a good cosmetic outcome.

Posterior segment changes associated with posterior microphthalmos

PURPOSE

To characterize and analyze the posterior segment ocular involvement in patients with posterior microphthalmos.

DESIGN

Retrospective observational case series.

PARTICIPANTS

Eighteen patients (8 sporadic cases and 10 siblings from 5 different families) between the age of 4 and 36 years with posterior microphthalmos.

METHODS

Records of patients with posterior microphthalmos over a 5-year-period were reviewed, including clinical, fundus photographic, fluorescein angiographic, and ultrasonographic findings, and management.

RESULTS

All patients had bilateral foreshortening of the posterior ocular segment (range, 7--11.2 mm) with associated high hyperopia (range, +12.00--+19.00 diopters) and normal or slightly smaller than normal anterior segment dimensions. Visual acuity ranged from 20/200 to 20/40. Inheritance of this syndrome was compatible with an autosomal recessive pattern. Posterior segment changes included bilateral elevated papillomacular retinal fold (13 patients, 72.2%); fine retinal folds (6 patients, 33.3%); chorioretinal folds (11 patients, 61.1%); uveal effusion syndrome (3 patients, 16.7%); pigmentary retinopathy (4 patients, 22.2%), including retinitis punctata albescens in 1 patient; absence or marked reduction of the capillary-free zone (18 patients, 100%); crowded optic discs (18 patients, 100%); and sclerochoroidal thickening on ultrasonography (18 patients, 100%). Two patients with uveal effusion were successfully treated with scleral surgery.

CONCLUSION

A wide variety of congenital or acquired posterior segment changes may be encountered in patients with posterior microphthalmos. Although high hyperopia and elevated papillomacular retinal fold are the main causes of visual impairment, other chorioretinal changes, such as pigmentary retinopathy, chorioretinal folds and uveal effusion syndrome, should be considered as causes of visual disturbance in patients with posterior microphthalmos. Early ultrasonographic diagnosis, close follow-up, and appropriate management are mandatory to improve or maintain visual function in such patients.

Ocular colobomata

Ocular colobomata present diagnostic and therapeutic challenges in patients of all ages, but especially in young children. The "typical" coloboma, caused by defective closure of the fetal fissure, is located in the inferonasal quadrant, and it may affect any part of the globe traversed by the fissure from the iris to the optic nerve. Ocular colobomata are often associated with microphthalmia, and they may be idiopathic or associated with various syndromes. Types and severity of complications vary depending on the location and size of the colobomata. This article reviews the pathogeneses, categorization, genetic bases, differential diagnoses and management of ocular coloboma.

Phacoemulsification and intraocular lens placement in eyes with cataract and congenital coloboma: visual acuity and complications

PURPOSE

To evaluate the safety and complications of phacoemulsification in a series of patients with congenital coloboma and cataract.

SETTING

University-based hospital practice.

METHODS

A retrospective review was conducted of consecutive patients who had coloboma and cataract and had phacoemulsification between January 1987 through December 1998. Complications and visual acuity 2 months postoperatively were assessed.

RESULTS

Mean age of 7 cases at the time of surgery was 41.6 years +/- 11.1 (SD). Visual acuity improved in 6 of 7 eyes; 1 eye had no change. Six eyes had no serious complications. In 1 eye, a retinal detachment was observed postoperatively, but there was no loss in visual acuity. Another patient developed postoperative monocular diplopia from exposure of the intraocular lens (IOL) edge within the inferonasally located corectopia associated with the coloboma. Nonsurgical treatment was unsuccessful, but this symptom resolved after surgical pupilloplasty.

CONCLUSIONS

The results of this small case series affirm that clinically significant cataract develops at a younger age in eyes with congenital coloboma than in eyes with typical age-related nuclear sclerotic cataract. Monocular diplopia, a potential complication after cataract surgery in these eyes, can be managed by pupilloplasty. The improved vision in this study indicates that phacoemulsification and IOL placement are safe and beneficial in patients with typical congenital coloboma and cataract.

Visual acuity in children with coloboma: clinical features and a new phenotypic classification system

OBJECTIVE

The aims of this study were to describe the clinical features and biometric findings in the eyes of children with coloboma and to develop a classification of coloboma that correlates with visual function.

DESIGN

Retrospective observational case series.

PARTICIPANTS

One hundred thirteen children and young adults (48 female, 65 male) aged 0 to 20 years with 196 eyes having coloboma.

METHODS

Children with coloboma were recruited from schools for the blind, integrated education programs, schools for the mentally handicapped, community-based rehabilitation services, and hospital clinics in Andhra Pradesh, India, between January 1998 and January 1999. Visual function was assessed, including distance and near visual acuity (VA), and navigational vision. The corneal diameter and axial length of eyes were measured wherever possible.

MAIN OUTCOME MEASURES

Anatomic site of coloboma, association with microcornea and/or microphthalmos, VA, presence of navigational vision and reading vision.

RESULTS

Of 196 eyes with colobomatous malformations, 11 had microphthalmos with cyst, and 185 eyes had coloboma (associated with microcornea in 155 eyes and with a normal corneal diameter in 30). Microphthalmos was present in 72 of the 185 eyes with coloboma, of which 71 of 72 also had microcornea. The prognosis for vision depended on the phenotype of the better eye. Microphthalmos with cyst had the worst prognosis (VA < 3/60, 100%; reading and navigational vision, 0%). Microcornea with microphthalmos had a worse prognosis than microcornea without microphthalmos (VA < 3/60: 66.7% vs. 23.3%; unable to read N10: 66.7% vs. 34.1 %; no navigational vision: 30.6% vs. 6.73%). Simple coloboma (no microcornea or microphthalmos) had the best prognosis (VA < 3/60: 6.7%; able to read N10: 93.3%; navigational vision: 100%). A corneal diameter <6 mm had a poor visual prognosis, whereas a corneal diameter >10 mm had a good prognosis.

CONCLUSIONS

A phenotypic classification of coloboma is proposed, which in this study showed a good correlation with visual acuity, reading, and navigational vision. Microphthalmos with cyst had the worst prognosis, coloboma with microcornea and microphthalmos a poor prognosis, coloboma with only microcornea had an intermediate prognosis, and simple coloboma had the best prognosis.

Ophthalmological and intracranial anomalies in patients with clinical anophthalmos

PURPOSE

To better describe the clinical and neuroimaging spectrum of abnormalities in clinical anophthalmos.

METHODS

We performed a retrospective review of all 17 patients admitted to the King Khaled Eye Specialist Hospital with clinical anophthalmos over a 15 year period who had a complete ophthalmological examination documented and received computed tomographic (CT) imaging of the orbits and brain.

RESULTS

Patients with clinical anophthalmos had a high incidence of developmental abnormalities involving both eyes (15/17 patients, 88%), the brain (12/17 patients, 71%) and the body (7/12, 58%). The incidence of central nervous system anomalies reached 100% in patients with bilateral small optic nerves on CT scan.

CONCLUSIONS

Patients with clinical anophthalmos share a similar constellation of neurological, somatic and neuroradiological abnormalities as patients with microphthalmos, septo-optic dysplasia and clinical optic nerve hypoplasia. This fact may provide insight into developmental abnormalities of the afferent visual system and brain.