The management of orbital cysts associated with congenital microphthalmos and anophthalmos

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

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

Managing a Case of a Congenital Cystic Eyeball: Case Report with Review of Literature

A congenital cystic eyeball is an extremely rare condition, with only 52 cases reported in the literature to date. An orbital cyst replaces the eyeball which occurs due to the complete or partial failure in invagination of the primary optic vesicle during the fourth week of gestation. We discuss a case of a congenital cystic eyeball in a 14-year-old female who presented to us for a cosmetic blemish due to a large swelling in the right eyelid with the absence of a right eyeball since birth. She underwent removal of the cyst followed by an orbital implant and later prosthesis. Diagnosis of the congenital cystic eyeball was made based on the clinical and ultrasound B-scan features, intraoperative findings, and histopathology report. This article adds one more case to the existing literature on the congenital cystic eyeball. Orbital implant with prosthesis after excision of the cyst provided definitive diagnosis and a good cosmetic outcome in our case.

The Management of Congenital Microphthalmia With Orbital Cyst: A Case Series

PURPOSE

To describe a series of patients treated for congenital microphthalmia associated with orbital cyst and recommend a management protocol.

METHODS

This retrospective case series comprised 6 patients (7 eyes) who attended an oculoplastic tertiary medical center from 2001 to 2018. Clinical, treatment, and outcome data were collected from the electronic files. Main outcome measures were preservation of vision and cosmetic appearance.

RESULTS

Four patients were diagnosed at birth. Six cysts were located inferiorly and one superiorly. Two patients had a visual potential of light perception or better in the affected eye. In 4 eyes, the cyst was initially retained and the eye was fitted with a custom-made conformer. In 1 eye, the fornices were too shallow for a conformer, warranting fornix reconstruction and cyst excision. Early surgery was required in 1 eye for an expanded cyst and large orbit volume, and in another eye the cyst had overgrown the orbit, causing bone erosion and remodeling. Cosmetic results were good in 3 of the eyes in which the cyst was retained in early childhood, stimulating orbital growth.

CONCLUSIONS

Congenital microphthalmia with orbital cyst is rare. Management should focus on preserving visual potential, especially in unilateral cyst cases when the other eye is also microphthalmic. Otherwise cosmetic symmetry is the main concern; cyst retention combined with ocular conformers may stimulate socket expansion. The authors found that, in most cases, if treated early, enucleation was avoidable during cyst excision. Early assessment, meticulous follow-up, and individually tailored treatment are warranted. [J Pediatr Ophthalmol Strabismus. 2022;59(3):192-199.].

Novel mutation in TENM3 gene in an Iranian patient with colobomatous microphthalmia

This investigation revealed a homozygous c.5069-1G>C variation in TENM3 gene although has not been reported for its pathogenicity and can be considered as a novel mutation. The present finding can be used for genetic diagnosis and detection of carriers in the family and other patients with similar disease manifestations.

Therapeutic Strategies in 103 Children with Congenital Microphthalmos

INTRODUCTION

Congenital microphthalmos can either occur alone (simple microphthalmos) or be associated with other ocular malformations, such as sclerocornea or cataract (complex microphthalmos). As this is a rare condition, there are no uniform recommendations for treatment.

MATERIAL AND METHODS

Retrospective case series of 103 patients or a total of 114 eyes with congenital microphthalmos, with reporting of age, sex, visual acuity, pupil reaction, axial length, horizontal width of the palpebral fissure, type of therapy performed and complications.

RESULTS

All patients would have been able to be fitted with a prosthesis primarily. The size of the palpebral fissure depended on the underlying findings: "bilateral microphthalmos" < "microphthalmos and healthy fellow eye" < "microphthalmos and fellow anophthalmos". In order to assess visual (residual) function in an infant in the first weeks or months of life, the pupillary response is of the upmost importance in deciding on therapy, especially in unilateral disease, and as assessed with the indirect light response of the healthy eye. In about half of the cases, conservative prosthetic treatment was sufficient. After the successful initial fitting of a prosthesis, the prosthesis was enlarged according to the ocularist's instructions. If the eye length difference was so large that symmetry could not be achieved even with a double-walled prosthesis, volume filling with retrobulbar implanted self-swelling pellet expanders (osmed GmbH, Ilmenau) was offered. In almost one third of the patients, no surgical therapy or prosthetic treatment was performed. The reason for this was usually the presence of minimal visual function of the microphthalmos - ranging from light perception to hand movements.

CONCLUSIONS

In the case of visual function of the microphthalmos, surgical measures should not be indicated or only with extreme caution, since the preservation of the existing visual acuity must be regarded as having priority over the cosmetic findings. In cases of asymmetry or underdeveloped palpebral fissure, therapy can be started early in the first year of life without fear of resulting complications.

Treatment strategies and long-term outcomes in patients with congenital microphthalmia-anophthalmia with cyst

BACKGROUND/AIMS

Microphthalmia and anophthalmia are rare conditions, which represent ocular maldevelopment; both may be associated with orbital cysts. Current literature recommends retention to stimulate orbital growth during socket rehabilitation but does not illustrate their potential to deform the periocular tissues. This study aims to illustrate the long-term outcomes when other elements, such as forniceal and lid development, are also considered when formulating bespoke treatment plans for patients.

METHODS

Retrospective case series of 78 patients attending a single prosthetics clinic between 1988 and 2020. Clinical and surgical notes, radiological imaging, clinical photographs and patient/doctor satisfaction questionnaires were used to report patient outcomes and natural history data.

RESULTS

89 sockets of 78 patients (11 bilateral) were included; average age of presentation being 2.8 years (9 days to 29.5 years). Cysts were clinically detected (48%) or were incidental findings (52%). The mean follow-up time was 7.2 years (6 months to 28 years). Cysts in 46% of sockets underwent surgical excision while the remainder were retained. Satisfaction surveys were obtained for 75 patients, with cosmetic outcomes rated as 'excellent' or 'good' in 90% of cases by physicians and 97% of cases by patients or guardians.

CONCLUSION

The favourable long-term outcomes in this study have resulted from bespoke plans which considered periocular tissue development, regional orbital growth and orbital volume replacement. The authors contemplate cyst excision if the prosthetic fitting or retention is impeded by the cyst as this often heralds the increased risk of long-term periocular distortion.

Microphthalmia and orbital cysts in DiGeorge syndrome

We report the case of a 4-month-old boy diagnosed with DiGeorge syndrome with novel ocular features. The patient was diagnosed through genetic testing, with a noted 22q11.2 deletion, and had the additional clinical findings of cardiac anomalies, Hirschsprung's disease, and intracranial microhemorrhages. Eye findings included bilateral microphthalmia, persistent fetal vasculature, chorioretinal coloboma, and a unilateral orbital cyst. Given no known additional inciting exposures, a dysgenic mechanism resulting in failed closure of developmental fissures associated with the chromosomal deletion likely gave rise to these combined pathologies.

Anophthalmic Socket Syndrome: Prevalence, Impact and Management Strategies

Anophthalmic socket syndrome determines functional deficits and facial deformities, and may lead to poor psychological outcomes. This review aims to comprehensively evaluate the features of the syndrome, based on literature review and authors’ clinical and surgical experience. An electronic database (PubMed,MEDLINE and Google Scholar) search of all articles written in English and non-English language with abstract translated to English on anophthalmic socket syndrome was performed. Data reviewed included demographics, presentations, investigations, management, complications and outcomes. Different types of orbital implants were evaluated; the management of implant exposure was examined; different orbital volume enhancement procedures such as secondary implantation, subperiosteal implants and the use of fillers in anophthalmic patients were described; the problems related to socket contraction were outlined; the treatment options for chronic anophthalmic socket pain and phantom eye syndrome were assessed; the most recent advances in the management of congenital anophthalmia were described. Current clinical evidence does not support a specific orbital implant; late exposure of porous implants may be due to pegging, which currently is seldom used; filler absorption in the orbit appears to be faster than in the dermis, and repeated treatments could be a potential source of inflammation; socket contraction results in significant functional and psychological disability, and management is challenging. Patients affected by anophthalmic socket pain and phantom eye syndrome need specific counseling. It is auspicable to use a standardized protocol to treat children affected by clinical congenital anophthalmia; dermis fat graft is a suitable option in these patients as it helps continued socket expansion. Dermis fat graft can also address the volume deficit in case of explantation of exposed implants and in contracted sockets in both children and adults. Appropriate clinical care is essential, as adequate prosthesis wearing improves the quality of life of anophthalmic patients.

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.

Ocular coloboma-a comprehensive review for the clinician

Typical ocular coloboma is caused by defective closure of the embryonal fissure. The occurrence of coloboma can be sporadic, hereditary (known or unknown gene defects) or associated with chromosomal abnormalities. Ocular colobomata are more often associated with systemic abnormalities when caused by chromosomal abnormalities. The ocular manifestations vary widely. At one extreme, the eye is hardly recognisable and non-functional—having been compressed by an orbital cyst, while at the other, one finds minimalistic involvement that hardly affects the structure and function of the eye. In the fundus, the variability involves the size of the coloboma (anteroposterior and transverse extent) and the involvement of the optic disc and fovea. The visual acuity is affected when coloboma involves disc and fovea, or is complicated by occurrence of retinal detachment, choroidal neovascular membrane, cataract, amblyopia due to uncorrected refractive errors, etc. While the basic birth anomaly cannot be corrected, most of the complications listed above are correctable to a great extent. Current day surgical management of coloboma-related retinal detachments has evolved to yield consistently good results. Cataract surgery in these eyes can pose a challenge due to a combination of microphthalmos and relatively hard lenses, resulting in increased risk of intra-operative complications. Prophylactic laser retinopexy to the border of choroidal coloboma appears to be an attractive option for reducing risk of coloboma-related retinal detachment. However, a majority of the eyes have the optic disc within the choroidal coloboma, thus making it difficult to safely administer a complete treatment.

Case report: Unilateral optic nerve aplasia and developmental hemi-chiasmal dysplasia with VEP misrouting

Purpose

To describe the trans-occipital asymmetries of pattern and flash visual evoked potentials (VEPs), in an infant with MRI findings of unilateral optic nerve aplasia and hemi-chiasm dysplasia.

Methods

A child with suspected left cystic microphthalmia, left microcornea, left unilateral optic nerve aplasia, and hemi-chiasm underwent a multi-channel VEP assessment with pattern reversal, pattern onset, and flash stimulation at the age of 16 weeks.

Results

There was no VEP evidence of any post-retinal visual pathway activation from left eye with optic nerve aplasia. The VEP trans-occipital distribution from the functional right eye was skewed markedly across the midline, in keeping with significant misrouting of optic nerve fibres at the chiasm. This was supported by the anatomical trajectory of the optic chiasm and tracts seen on MRI.

Conclusion

This infant has chiasmal misrouting in association with unilateral optic nerve aplasia and unilateral microphthalmos. Chiasmal misrouting has not been found in patients with microphthalmos or anophthalmos, but has been reported after early eye loss in animal models. Our findings contribute to our understanding of the discrepancy between the visual pathway physiology of human unilateral microphthalmia and animal models.

Classification for treatment urgency for the microphthalmia/anophthalmia spectrum using clinical and biometrical characteristics

PURPOSE

Current clinical classifications do not distinguish between the severity of the MICrophthalmia/Anophthalmia (MICA) spectrum with regard to treatment urgency. We aim to provide parameters for distinguishing mild, moderate and severe MICA using clinical and biometrical characteristics.

METHODS

We performed a single-centre, cross-sectional analysis of prospective cohort of 58 MICA children from September 2013 to February 2018 seen at the Amsterdam University Medical Center, The Netherlands. All patients with a visible underdeveloped globe were included. We performed full ophthalmic evaluation including horizontal palpebral fissure length, axial length by ultrasound and/or MRI measurements, paediatric and genetic evaluation. Cases were subdivided based on clinical characteristics. Biometrical data were used to calculate the relative axial length (rAL) and the relative horizontal palpebral fissure length (rHPF) compared with the healthy contralateral eye for unilateral cases.

RESULTS

In previously untreated patients, a strong correlation exists between rAL and rHPF, distinguishing between severe, moderate and mild subjects using rAL of 0-45%, 45-75% and 75%-100%, respectively. Clinical subgroups were randomly dispersed throughout the scatterplot.

CONCLUSION

Current classifications lack clinical implications for MICA patients. We suggest measuring eyelid length and axial length to classify the severity and determine treatment strategy. The 'severe' group has obvious asymmetry and abnormal socket configuration for which therapy should quickly be initiated; the 'moderately' affected group has normal socket anatomy with a microphthalmic eye with disturbing asymmetry for which treatment should be initiated within months of development; the 'mild' group has a slightly smaller axial length or less obvious eyelid asymmetry for which reconstructive correction is possible, but expansive conformer treatment is unnecessary.

Bilateral microphthalmos with bilateral orbital cysts: individualising the treatment according to the visual potential. A case report

The case is presented of a 3-month-old infant diagnosed with microphthalmos and orbital cysts. Magnetic Resonance Imaging revealed a bilateral microphthalmia with a moderate right cyst and a severe left cyst. Visual potential of the right eye was uncertain. Non-surgical treatment was decided. At the age of 2 years old, physical examination showed a significant decrease of the cysts and visual acuity of hand movements due to the residual vision of his right eye. Microphthalmos with orbital cyst is a rare congenital anomaly. Cysts tend to enlarge with time. At the moment, no standard protocol for the management of this pathology has been described. Unlike in our patient, visual acuity in these patients is usually of no-light perception. The observation could be an alternative in severe cases, since there is a possibility of spontaneous reduction, displacement, or regression of the cysts.

Congenital Microphthalmia with Intraorbital Cyst: A Rare Case Report

Microphthalmia is considered to be the most common congenital malformation of the eye after congenital cataract. However, its association with intraorbital cyst is considered to be very rare. Most of the lesions are still misdiagnosed as orbital tumor and teratomas as there is a general paucity of data reported in literature. Herein, we report a rare case of congenital microphthalmia with intraorbital cyst in an eight-month-old male patient.

Orbital conjunctival epithelial cyst mimicking cyst with microphthalmos

Orbitopalpebral cysts are most commonly associated with microphthalmic eyes (microphthalmos with cyst). We report a 15-year-old girl with a large orbitopalpebral cyst in the absence of associated microphthalmos. The patient presented with a massive swelling involving the left lower eyelid overhanging the left cheek and occupying much of the left orbital cavity. The globe was not visible on clinical examination. No history of trauma or surgery preceding the development of the cyst was reported by the patient or her father. Imaging showed a small eyeball displaced superiorly along the anterior part of the orbital roof. On excision of the cyst, a normal-sized globe with a cataractous lens was noted. Histopathological examination revealed the cyst to be of conjunctival origin.

Congenital Microphthalmia with Orbital Cyst: A Case Series

Microphthalmos results from incomplete invagination of the optic vesicle or closure of the embryonic fissure. We present three patients with unilateral congenital microphthalmia with cyst. None of them had vision in the affected eye since birth. There was gradually increasing left eye orbital mass encroaching towards lower fornix and lower eyelid ectropion. On examination and investigations, patients had large orbital cyst with microphthalmia pushing the eyeball superiorly and posteriorly in affected orbit. Microphthalmic globe with cyst was surgically excised and histopathologically studied. Orbital cavity was big enough to occupy the conformer and the prosthetic eye after 6 weeks. Diagnosis was confirmed as large communicating orbital cyst with microphthalmia without systemic association in all the patients. None of the mothers of patients had regular antenatal check up. All the parents had consanguineous marriage. Antenatal check up with ultrasound at 14 to16 weeks of pregnancy is important for genetic counselling. Targeted abdominal ultrasound examination of pregnant women focused on the orbital region of foetus is recommended, in mothers who have children with congenital eye anomalies. Keywords: congenital anomaly; cyst; eye; microphthalmos.

Management of congenital microphthalmos and anophthalmos with orbital cyst

PURPOSE

To study the effects of an individualized treatment approach to children with congenital microphthalmos and anophthalmos.

METHODS

Patients with congenital microphthalmos or anopthalmos with orbital cysts who were referred to Beijing Tongren Hospital between July 2009 and July 2017 were included in this retrospective case series study. For patients ≤6 years of age, the cyst was retained to promote orbital development unless a prosthesis could not be fitted at all or disproportionate orbital growth was detected. Hydrogel orbit expanders were implanted initially if orbital volume was poor. For patients >6 years of age, the cyst was removed if it caused cosmetic problems or unsatisfactory prosthesis fitting. Eyelid procedures were performed after puberty to improve appearance.

RESULTS

The study included 26 orbits of 24 patients. Of the 14 patients ≤6 years, 3 underwent cyst excision, 8 were treated with conformers only, and 3 had hydrogel orbit expander implantation initially. Of the 10 patients >6 years, 1 had the cyst removed, 5 had eyelid surgeries without removing the cyst, 3 wore an artificial eye without any surgery, and 1 used no prosthesis. During the follow-up period (range, 6 months to 8 years), 23 patients had a good cosmetic outcome and were eventually able to retain an ocular prosthesis; 1 patient could not wear prostheses but refused further treatment. No procedure-related complications were noted.

CONCLUSIONS

The individualized treatment of congenital microphthalmos and anophthalmos with orbital cysts depends on the patient's age at presentation, the growth pattern of the cyst, and the volume of the affected orbit.

Fibrin glue-assisted excision of a large recurrent microphthalmic cyst

Microphthalmic cysts are rare. Although small cysts can be left in situ to promote orbital expansion, large cysts require drainage or surgical excision. Complete surgical excision is notoriously difficult, and incomplete excision may result in cyst reformation. We describe a novel method of using fibrin glue to aid successful complete removal of a large recurrent microphthalmic cyst in a 6-year-old child who previously had multiple drainage and surgical attempts.

Management of Congenital Clinical Anophthalmos with Orbital Cyst: A Kinshasa Case Report

An early developmental lack of the optic vesicle can result in congenital anophthalmia, defined as a complete absence of the eye, which can be distinguished from congenital microphthalmos, where ocular rudiments are present. Here, a rare pediatric case of congenital clinical anophthalmos with orbital cyst in the left orbit is reported. The patient was a 14-month-old girl with no other congenital defects who underwent surgical and prothetic management in St. Joseph's Hospital Kinshasa, Democratic Republic of the Congo (DRC). Surgery was carried out under general anesthesia. The cyst was punctured and its wall fully excised. Near the orbital apex pigmented elements representing iris, ciliary body, and choroidal or retinal remnants were found. The specimens were fixed in formalin for histological examination. Surgical cyst removal including socket deepening for an artificial eye was performed. Postoperative wound healing was uneventful and a satisfactory cosmetic outcome was achieved in all follow-up examinations. Histological examination revealed rudimentary ocular structures similar to degenerated lens tissue with a typical, PAS-positive capsule. Additionally, pigmented epithelial structures, which seem to be of ciliary body, iris, and choroidal or retinal-type epithelium origin, could be detected, prompting the final diagnosis, microphthalmia with dominant cyst formation.

Characteristics and management of congenital anophthalmos and microphthalmos at a tertiary eye hospital

Purpose: The purpose of the study is to evaluate demographic data and outcomes of the management of congenital anophthalmia/microphthalmia. Methods: This retrospective, descriptive, cross-sectional study evaluated patients with congenital anophthalmia/microphthalmia managed from 2004 to 2014 at a tertiary hospital in Saudi Arabia. Data were collected on patient age, gender, cause, orbital status, laterality, systemic comorbidities, ocular evaluation, and management (type of surgery, type of orbital implant, and complications). The main outcome measure was the ability to hold the prosthesis. Results: The study sample was composed of 513 eyes/sockets of 365 patients. Two-hundred and seventeen (59.4%) patients were unilateral cases. Forty-one (8%) sockets were due to congenital anophthalmia and 471 (92%) were due to microphthalmia. There were 73.2% isolated cases and 28.5% with systemic involvement. Systemic involvement was more common in bilateral cases. The most commonly associated conditions were central nervous disorders. One-hundred and nineteen (46.7%) cases had parental consanguinity. Two hundred and eighteen eyes/sockets (163 patients) underwent surgery including conjunctival flap (38; 17.4%), evisceration (38; 17.4%), enucleation (16; 7.3%), or procedures to improve the anophthalmic socket volume (45; 20.6%). Volume enhancing procedures included polymethylmethacrylate orbital implants (26; 57.8%), expanders (11; 24.4%), integrated hydroxyapatite or polyethylene implants (2; 4.4%), and dermis-fat graft (6; 13.3%). In most cases, clinical or surgical management resulted in a successful outcome. Conclusion: Anophthalmia/Microphthalmia was detected in 36.5 patients/year. The majority had isolated microphthalmia. Good outcomes were achieved with clinical or surgical management in the majority of cases.

Cyst Excision and Globe Preservation in a Case of Microphthalmos With a Large Orbital Cyst and Visual Potential

Congenital microphthalmos belongs to a spectrum of diseases ranging from true anophthalmos to congenital clinical anophthalmos to microphthalmos. These conditions are frequently associated with an orbitopalpebral cyst, and pathologically, this represents a failure in the closure of the embryonic fissure at the 7-14 mm stage of gestation. The cyst develops as an outpouching from the eyeball and is generally helpful as it provides a stimulus for the orbit to expand. The general management guideline is to retain the cyst till it provides a stimulus for the orbit to expand and then to consider aspiration and sclerotherapy once orbital expansion is achieved. However, in eyes that have visual potential, sclerotherapy is contraindicated. The authors present an unusual case of a mildly microphthalmic eye with visual potential and a communicating cyst that was excised with a good result. The challenges faced in the excision of the communicating cyst with a wide pedicle and the management of the case are highlighted.

Adenocarcinoma of Pigmented Ciliary Epithelium in a Child With Aicardi Syndrome and Congenital Microphthalmia With Cyst

A 5-year-old girl with Aicardi syndrome and microphthalmia with cyst of the OD presented with progressive enlargement of the cyst causing pain. Microophthalmia with inferior cyst (35 × 25 × 12 mm) was noted at birth, and Aicardi syndrome was diagnosed at 10 months by the presence of the classic triad of callosal agenesis, infantile spasms, and chorioretinal lacunae. She underwent enucleation with cyst resection, and subsequent reconstruction with a dermis fat graft. Histopathologic study revealed adenocarcinoma of the pigmented ciliary epithelium. Full-body metastatic workup was negative. Adenocarcinoma of the pigmented ciliary epithelium is an extremely rare eye tumor with only 4 documented cases in the literature, none arising in a microophthalmic eye with cyst. Aicardi syndrome is also a rare disease that has been associated with increased incidence of malignancy and ocular abnormalities, but has never been described in association with microophthalmia with cyst or with adenocarcinoma of the pigmented ciliary epithelium. Herein, the authors present a review of the case and relevant literature.

[Palpebral malformations in children]

Palpebral malformations can be isolated or associated with a craniofacial disorder. Their assessment is based on clinical examination; additional investigations are mainly done to characterize craniofacial syndromes. In case of extrapalpebral lesions or complex craniofacial pathology, genetic testing must be performed. Some isolated malformations will only need a simple follow-up; others must have specific treatment, undertaken following a precise timing, taking into account child and anatomical structures' growth and the possible consequences of the malformation on the eye and child's sight (degree of urgency). When dealing with these malformations, there are two main risks to be taken into consideration: corneal irritation due to lagophtalmos and amblyopia owing to visual axis obstruction, anisometropia or strabismus.

Gene mapping in an anophthalmic pedigree of a consanguineous Pakistani family opened new horizons for research

Clinical anophthalmia is a rare inherited disease of the eye and phenotype refers to the absence of ocular tissue in the orbit of eye. Patients may have unilateral or bilateral anophthalmia, and generally have short palpebral fissures and small orbits. Anophthalmia may be isolated or associated with a broader syndrome and may have genetic or environmental causes. However, genetic cause has been defined in only a small proportion of cases, therefore, a consanguineous Pakistani family of the Pashtoon ethnic group, with isolated clinical anophthalmia was investigated using linkage mapping. A family pedigree was created to trace the possible mode of inheritance of the disease. Blood samples were collected from affected as well as normal members of this family, and screened for disease-associated mutations. This family was analyzed for linkage to all the known loci of clinical anophthalmia, using microsatellite short tandem repeat (STR) markers. Direct sequencing was performed to find out disease-associated mutations in the candidate gene. This family with isolated clinical anophthalmia, was mapped to the SOX2 gene that is located at chromosome 3q26.3-q27. However, on exonic and regulatory regions mutation screening of the SOX2 gene, the disease-associated mutation was not identified. It showed that another gene responsible for development of the eye might be present at chromosome 3q26.3-q27 and needs to be identified and screened for the disease-associated mutation in this family.

Digital Evaluation of Orbital Cyst Associated with Microphthalmos: Characteristics and Their Relationship with Orbital Volume

Purpose

To study the characteristics of orbital cyst associated with microphthalmos in a group of Chinese patients, and to analyze the relationship between orbital cyst and orbital volume.

Design

Cross-sectional comparative study.

Participants

120 patients who were diagnosed as unilateral clinical blind microphthalmos, in which 20 patients had orbital cyst in the affected eye.

Method

Participants had computed tomography (CT) scan. CT images were analyzed with a computer-aided software.

Main Outcome Measures

Volume and position of orbital cyst, microphthalmic to contralateral ratio (MCR) of orbital volume, height and depth and orbital rim displacement.

Results

38.1% of the cysts located anterior to or at the equator of the globe, 75% of which located infratemporally and all of which were outside the muscle cone. Most (84.6%) of the posterior cysts were inside the muscle cone. The anterior cysts were larger than the posterior cysts (p = 0.005). MCR of orbital volume (p<0.001), height (p = 0.004) and width (p = 0.043) were significantly higher in patients with orbital cyst than controls. For patients with orbital cyst, larger cyst-plus-globe volume of the affected eye was associated with higher MCR of orbital volume (r = 0.630, p = 0.003). Patients with large cyst-plus-globe volume had higher MCR of orbital volume (p = 0.002), height (p = 0.014), width (p = 0.005) and depth (p = 0.002) and less displacement in inferior (p = 0.004) orbital rim, compared with patients with small cyst-plus-globe volume, but the differences between patients with small cyst-plus-globe volume and patients without cyst were not significant.

Conclusions

Microphthalmic eyes with large cyst-plus-globe volume showed better similarity with the contralateral eyes, comparing with microphthalmic eyes without orbital cyst or with small cyst-plus-globe volume. It suggested that the existence of orbital cysts (especially large cysts) in microphthalmic eyes might play a positive role in the orbital development.

3D Orbital Reconstruction in a Patient with Microphthalmos and a Large Orbital Cyst-A Case Report

BACKGROUND

Orbital cysts are rare developmental anomalies that can occur in microphthalmic and anophthalmic patients. Such cysts can promote orbital growth and subsequently markedly increase the size of the orbit, which is commonly underdeveloped in these patients. Cyst removal is therefore generally dissuaded (at least) in the first 5 years.

CLINICAL CASE

A 6-year-old boy with a microphthalmos and a cyst developed protrusion of his prosthetic eye and a swelling of the lower eyelid. MRI showed a large cyst causing distortion of the right orbit. Due to the expansive orbital growth and subsequent misfitting of the prosthesis, cystectomy and orbital floor reconstruction was performed using 3D technology.

CONCLUSION

3D imaging and printing enables exact delineation of orbital cysts and the adjacent bony structures. Furthermore it offers the possibility to plan an individual surgical approach and to design and fabricate a custom fit orbital floor implant.

Proliferation and arrest: the genetics of orbital disorders

PURPOSE OF REVIEW

Oculoplastic genetic diseases can be divided into eyelid, lacrimal, and orbital disorders. The purpose of this review is to develop a rational approach to the categorization of genetic diseases that affect the orbit and review the most recent developments.

RECENT FINDINGS

Genetic disorders that affect the orbit can simply be divided into whether they cause proliferation or arrest of orbital structures. Proliferative conditions include vascular, neural, bony, mesenchymal, and lymphoid. Conditions that cause arrest can be subcategorized into whether they cause soft tissue or bony arrest of development. The genetics of many of these conditions have been elucidated and novel treatments, based on the molecular defects, have been utilized with some success.

SUMMARY

Molecular advances may result in substitution of a molecular categorization scheme for the one proposed in this manuscript. Delineation of the underlying molecular causes of these disorders will result in earlier, less invasive procedures than those that are currently employed.

Recommendations for post-adaption care of an ocular prosthesis: A review

An ocular prosthesis must be maintained in a suitable state of cleanliness, fit and preservation. Otherwise its functioning may be compromised, leading to a variety of diseases. However, there is a lack of consensus on the care of such prostheses. This review assembles and attempts to update existing knowledge in this area and discusses the most appropriate care regimes.

Severe microphthalmos with cyst and unusually huge dermolipoma

PURPOSE

The purpose of this study was to report an unusual case of severe microphthalmos, together with an orbital cyst and huge ocular surface dermolipoma.

METHODS

This is a clinical report relating clinical features as well as imaging and histopathologic findings, along with surgical management of the patient.

RESULTS

A 5-month-old Chinese male infant was referred, with 2 large masses in the left eye that were present since birth. Ocular examination results revealed a complete absence of any eye structures in the left orbit. In its place were 2 large masses between the left upper and lower palpebral fissure. One was a 3 × 3 × 2.5-cm spherical red tumor with a smooth surface. The other was a large solid spherical tumor, 4 × 4 × 5 cm, covered with normal skin located in the temporal region and attached to the red mass by a pedicle. Orbital magnetic resonance imaging examination findings confirmed that no eye structures were present in the left orbit. However, a cystic lesion was found in the left orbit, with a low signal on T1-weighted imaging and high signal on T2-weighted imaging, and another huge spherical heterogeneous mass was located "outside" the left orbit. Anterior orbitotomy by conjunctival incision was performed under general anesthesia. A spherical cystic mass of 1.5 × 1.5 × 1.6 cm, a small eye of 0.7 × 0.7 × 0.6 cm, and a huge dermolipoma were removed completely. Pathologic examination results confirmed the diagnosis of severe microphthalmos, together with orbital dermoid cyst and dermolipoma.

CONCLUSIONS

This rare case demonstrates that severe microphthalmos with a cyst may be completely covered by conjunctiva and associated with an unusually huge dermolipoma.

Congenital cystic eye associated with a low-grade cerebellar lesion that spontaneously regressed

Background

Congenital cystic eye is an exceedingly rare ocular malformative disease, originated from the failure in the invagination of the optic vesicle during the fetal period and it can be associated with other ocular and non-ocular abnormalities. Diagnosis is based on clinical, radiological and histological features.

Case presentation

We report a case of a congenital cystic eye associated with a cerebellar lesion accidentally detected at magnetic resonance imaging. Biopsy of the mass has not been performed due to parental rejection. Based on radiologic features and absence of clinical signs, a low-grade glioma diagnosis was hypothesized, but histological characterization was not obtained. Follow-up neuro-imaging 6 months after diagnosis showed that intracranial lesion spontaneously regressed without any treatment.

Conclusion

Our report stresses the importance of early MRI in children with ocular malformations, in order to detect associated intracranial defects, also of non-malformative origin. Additionally, we debate the clinic-radiological features of the intracranial lesions that could allow a wait-and-see policy. We also recommend a strict clinical and neuro-imaging follow-up for these lesions. Finally, biological mechanisms at the base of spontaneous regression of the brain lesions are discussed.

The use of self-inflating hydrogel expanders in pediatric patients with congenital microphthalmia in China

PURPOSE

To report the results of enlarging orbital volume in consecutive cases of severe congenital microphthalmia by means of solid hydrophilic tissue expanders.

METHODS

The medical records of consecutive patients with congenital microphthalmia who underwent the placement of a hydrogel expander were retrospectively reviewed. Main outcome measures were orbital tissue expansion, prosthetic retention, and patient family satisfaction.

RESULTS

A total of 17 patients were included in the study. All patients were able to retain an ocular prosthesis. The horizontal palpebral length increased from 71.3% of the contralateral unaffected eye to 85.4% of the contralateral unaffected eye. The expansion of orbital volume was assessed in seven patients. The volume of the microphthalmic orbits was expanded from 74.7% of the contralateral unaffected orbits to 83.5% of the contralateral unaffected orbits. Aesthetic results were satisfactory to both physicians and patient families. The following complications were noted in two patients: inferior migration of a spherical expander occurred in one case; a hemispheric expander was removed by the patient in another case.

CONCLUSIONS

Hydrogel implants can successfully expand the dimensions of the conjunctival sac and the orbit in cases of severe congenital microphthalmia.

Congenital anophthalmia: current concepts in management

PURPOSE OF REVIEW

The introduction of hydrogel socket and orbital expanders has modified the approach towards the rehabilitation of congenital anophthalmia. This study highlights the most recent advances for the treatment of congenital anophthalmia based on personal experience and the review of recent literature.

RECENT FINDINGS

Hydrogel socket expanders may be positioned as an out-patient procedure with topical anaesthesia, using cyanoacrylate glue as opposed to temporary tarsorraphy. Increased orbital volume has been confirmed by computed tomography (CT) scan or magnetic resonance imaging (MRI) following early dermis-fat graft in children with congenital anophthalmia. An orbital tissue expander made of an inflatable silicone globe sliding on a titanium T-plate and secured to the lateral orbital rim appears to be effective to stimulate orbital bone growth and development.

SUMMARY

Congenital anophthalmia has a complex cause with both genetic and environmental factors involved. The ideal treatment is simultaneous expansion of the eyelids, socket and orbital bones, and it should begin after birth as soon as possible. Socket expansion with self-inflating expanders is a useful technique, although custom-made conformers may produce similar results. Dermis-fat grafts are another reasonable option as an orbital implant, following adequate lid and socket expansion.

Congenital cystic eye: from prenatal diagnosis to therapeutic management and surgical treatment

Only 28 cases of congenital cystic eye have been reported in the literature. The main issue in such cases is differential diagnosis between this malformation and different cystic malformations and masses of the orbital cavity and eyeball, the most common of which is microphthalmia with cyst. Both malformations arise from incomplete closure of the fetal optic vesicle in different stages of embryonic development. We present a case of congenital cystic eye, associated with coloboma and corneal dermoid of the fellow eye and with left brachiocephaly, discussing differential diagnosis with microphthalmia with cyst and illustrating the treatment we planned and performed. The patient first underwent a surgical excision of the left corneal dermoid, then a resection of the right orbital cyst. The last step was to perform a craniotomy and cranial vault remodeling. All the operations were planned and performed using a team approach. The team comprised an ophthalmologist, a plastic surgeon, and a neurosurgeon, and the result was a successful outcome.

Managing epibulbar choristoma with microphthalmos

A 3-year-old boy had a large epibulbar choristoma with microphthalmos of his left eye. He received simple partial tumor excision due to significant local mechanical erosion and disfiguring appearance. The cosmetic outcome was satisfactory.

Anophthalmia and microphthalmia

Anophthalmia and microphthalmia describe, respectively, the absence of an eye and the presence of a small eye within the orbit. The combined birth prevalence of these conditions is up to 30 per 100,000 population, with microphthalmia reported in up to 11% of blind children. High-resolution cranial imaging, post-mortem examination and genetic studies suggest that these conditions represent a phenotypic continuum. Both anophthalmia and microphthalmia may occur in isolation or as part of a syndrome, as in one-third of cases. Anophthalmia/microphthalmia have complex aetiology with chromosomal, monogenic and environmental causes identified. Chromosomal duplications, deletions and translocations are implicated. Of monogenic causes only SOX2 has been identified as a major causative gene. Other linked genes include PAX6, OTX2, CHX10 and RAX. SOX2 and PAX6 mutations may act through causing lens induction failure. FOXE3 mutations, associated with lens agenesis, have been observed in a few microphthalmic patients. OTX2, CHX10 and RAX have retinal expression and may result in anophthalmia/microphthalmia through failure of retinal differentiation. Environmental factors also play a contributory role. The strongest evidence appears to be with gestational-acquired infections, but may also include maternal vitamin A deficiency, exposure to X-rays, solvent misuse and thalidomide exposure. Diagnosis can be made pre- and post-natally using a combination of clinical features, imaging (ultrasonography and CT/MR scanning) and genetic analysis. Genetic counselling can be challenging due to the extensive range of genes responsible and wide variation in phenotypic expression. Appropriate counselling is indicated if the mode of inheritance can be identified. Differential diagnoses include cryptophthalmos, cyclopia and synophthalmia, and congenital cystic eye. Patients are often managed within multi-disciplinary teams consisting of ophthalmologists, paediatricians and/or clinical geneticists, especially for syndromic cases. Treatment is directed towards maximising existing vision and improving cosmesis through simultaneous stimulation of both soft tissue and bony orbital growth. Mild to moderate microphthalmia is managed conservatively with conformers. Severe microphthalmia and anophthalmia rely upon additional remodelling strategies of endo-orbital volume replacement (with implants, expanders and dermis-fat grafts) and soft tissue reconstruction. The potential for visual development in microphthalmic patients is dependent upon retinal development and other ocular characteristics.

A practical guide to the management of anophthalmia and microphthalmia

Congenital anophthalmia and microphthalmia are rare developmental defects of the globe. They often arise in conjunction with other ocular defects such as coloboma and orbital cyst. They may also be part of more generalised syndromes, such as CHARGE syndrome. Anophthalmia, microphthalmia, and coloboma are likely to be caused by disturbances of the morphogenetic pathway that controls eye development, either as a result of primary genetic defect, or external gestational factors, including infection or drugs that can influence the smooth processes of morphogenesis. The ophthalmologist is often the primary carer for children with anophthalmia and microphthalmia, and as such can coordinate the multidisciplinary input needed to offer optimal care for these individuals, including vision and family support services. They are able to assess the vision and maximise the visual potential of the child and they can also ensure that the cosmetic and social impact of anophthalmia or microphthalmia is minimised by starting socket expansion or referring to a specialist oculoplastics and prosthetics unit. A coordinated approach with paediatrics is necessary to manage any associated conditions. Genetic diagnosis and investigations can greatly assist in providing a diagnosis and informed genetic counselling.

Ethanolamine Oleate Sclerotherapy Versus Simple Cyst Aspiration in the Management of Orbitopalpebral Cyst Associated With Congenital Microphthalmos

PURPOSE

To evaluate the efficacy of ethanolamine oleate (EO) sclerotherapy in the management of orbitopalpebral cysts associated with congenital microphthalmos, and compare it with simple cyst aspiration.

METHODS

Retrospective, interventional comparative case series of 12 orbitopalpebral cysts of 8 patients associated with congenital microphthalmos. Five cysts were treated with simple aspiration and 7 cysts with EO sclerotherapy. Cyst resolution was the main outcome measure.

RESULTS

Five cysts underwent aspiration alone at a median age of 12 weeks. One (20%; 95% CI, 0%-55.1%) of these 5 showed complete resolution. Seven cysts (6 patients) underwent aspiration combined with EO sclerotherapy at a median age of 30 weeks (3 had recurred following prior cyst aspiration). Postsclerotherapy, 6 eyes (85.7%; 95% CI, 59.8%-100%) showed complete cyst resolution (p = 0.072, Fisher exact test). The mean follow-up was 8.8 months (range, 3-23 months). In the EO group, 1 cyst (14.3%) required repeat sclerotherapy and another cyst showed partial resolution at 6 weeks. The number needed to treat with sclerotherapy to prevent 1 recurrence was 2 (1-5, 95% CI). No procedure-related complications were noted.

CONCLUSIONS

Simple aspiration of orbitopalpebral cyst is associated with a high recurrence rate and should be reserved for early prognostication of visual potential in the microphthalmic eye. Minimally invasive EO sclerotherapy provides a rapid, effective, and uncomplicated treatment modality for definitive therapy, and should be preferred in cases with no visual prognosis in the microphthalmic eye demonstrating adequate bony orbital expansion.

Management of congenital unilateral proptosis from an orbital epithelial cyst by cyst aspiration

A rare cause of axial proptosis, orbital epithelial cysts are presumed to be of conjunctival origin if the wall is composed of nonkeratinized squamous epithelium (especially if goblet cells are present). These cysts can occur at any age and are typically surgically resected if symptomatic. The subject of this report is the management of a congenital orbital epithelial cyst by needle aspiration in a newborn with ipsilateral esotropia and severe unilateral proptosis.

Injectable self inflating hydrogel pellet expanders for the treatment of orbital volume deficiency in congenital microphthalmos: preliminary results with a new therapeutic approach

BACKGROUND/AIM

Children with congenital microphthalmos are usually able to wear an eye prosthesis but the cosmetic aspect is determined by the size of the orbital volume deficiency. Instead of using a ball shaped standard hydrogel expander or a regular orbital implant, which would necessitate enucleation of the microphthalmic eye, this study investigates the feasibility of volume augmentation with injectable pellet expanders, as formerly suggested for acquired anophthalmos in adults only.

METHOD

The pellet expander is made from a self inflating hydrogel that takes up water by osmosis (dry state: length 8 mm, diameter 2 mm, volume 0.025 ml; in vitro hydrated state after around 1 day: length 15 mm, diameter 4 mm, volume 0.24 ml; swelling capacity: 9.6-fold). This report concerns six patients (two girls and four boys) aged between 4 months and 42 months with unilateral microphthalmos who were treated by injection of 4-14 pellet expanders into the retrobulbar orbital tissue. Volume augmentation was 1-3.5 ml. The pellets were injected using a customised trocar and placed behind the microphthalmos directed into the intraconal space.

RESULTS

The increasing orbital volume was noticeable within 2 days and was confirmed by ultrasonography and magnetic resonance imaging. The final result can be anticipated by the volume augmentation effect produced by the amount of saline solution injected in the orbital apex region. All patients were fitted with an artificial eye, which was subsequently enlarged every 3-5 months. Anophthalmic enophthalmos was fully compensated with this technique. No complications have been encountered to date.

CONCLUSIONS

Orbital volume augmentation with injectable self inflating hydrogel expander pellets is apparently a safe, quick, and minimally invasive technique for various indications in orbital reconstructive surgery-for example, to treat an enophthalmic appearance in microphthalmos and congenital or acquired anophthalmos.

Anterior coloboma with macrophthalmos and cyst

Coloboma is one of the congenital ocular malformations presenting important diagnostic and therapeutic problems, especially in infants. Coloboma can be associated with microphthalmia frequently and macrophtalmia rarely. However, the association of coloboma, macrophthalmia, and orbital cyst was not reported previously in the literature. A case of coloboma associated with macrophtalmia and cyst was presented, and MR findings of this anomaly was defined with emphasis to the importance of radiologic examinations in the diagnosis of some congenital ocular malformations.

Gorlin syndrome: the PTCH gene links ocular developmental defects and tumour formation

AIM

To identify a gene linking microphthalmia with cyst with early onset medulloblastoma.

METHODS

Mutation analysis of the PTCH gene.

RESULTS

A mutation in exon 10 of the PTCH gene was identified, confirming a diagnosis of Gorlin syndrome.

CONCLUSIONS

This is the first genetically identified mutation giving rise to microphthalmia with cyst and provides a valuable link in the eye developmental gene pathway.