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Stemmer-Rachamimov AO, Kozanno L, Plotkin SR, Jordan JT, Rd Rizzo JF. Histologic correlates of "Choroidal abnormalities" in Neurofibromatosis type 1 (NF1). Acta Neuropathol 2024; 147:71. [PMID: 38607446 DOI: 10.1007/s00401-024-02724-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 04/13/2024]
Abstract
Neurofibromatosis type 1 (NF1) is a rare autosomal dominant disorder characterized by proliferation of cells from neural crest origin. The most common manifestations are cutaneous, neurologic, skeletal and ocular. The distinction of NF1 from other syndromes with multiple café-au-lait macules may be difficult in the pediatric age group, and ocular findings, especially Lisch nodules (i.e., melanocytic hamartomas on the irides), are a useful, early diagnostic tool. In recent years, novel ocular manifestations descriptively referred to as "choroidal abnormalities", choroidal "hyperpigmented spots" and "retinal vascular abnormalities" have been recognized in NF1. Choroidal abnormalities (CA) appear as bright patchy nodules that can be best detected with near-infrared ocular coherence tomography imaging (NIR-OCT). Because of their high specificity and sensitivity for NF1, CA have been added as an ocular diagnostic criterion of NF1 as an alternative to Lisch nodules. Although CA are important ocular diagnostic criteria for NF1, the histologic correlates are controversial. We present the postmortem ocular pathology findings of an NF1 patient for whom clinical notes and ocular imaging were available. Findings in this patient included choroidal hyperpigmented spots on funduscopy and retinal vascular abnormalities, both of which have been reported to be closely associated with CA. Histologic examination of the eyes showed multiple clusters of melanocytes of varying sizes in the choroid. Pathologic review of 12 additional postmortem eyes from 6 NF1 patients showed multiple, bilateral choroidal melanocytic aggregates in all eyes. These findings suggest that the CA seen on NIR-OCT and the hyperpigmented spots seen clinically in NF1 patients are manifestations of multifocal choroidal melanocytic clusters, consistent with choroidal melanocytic hamartomas. Lisch nodules, often multiple, were present in all eyes with morphology that differed from the choroidal hamartomas. As such, although CA and Lisch nodules are melanocytic hamartomas, there are clear phenotypical differences in their morphologies.
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Affiliation(s)
- Anat O Stemmer-Rachamimov
- Department of Pathology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 20114, USA.
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.
| | - Liana Kozanno
- Department of Pathology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 20114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
| | - Scott R Plotkin
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
- Department of Neurology and Cancer Center, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 20114, USA
| | - Justin T Jordan
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
- Department of Neurology and Cancer Center, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 20114, USA
| | - Joseph F Rd Rizzo
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
- Neuro-Ophthalmology Service, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA, 02114, USA
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Estrela T, Truong S, Garcia A, He J, Ying GS, Devakandan K, Reginald YA, Fisher MJ, Liu GT, Ullrich NJ, Avery RA, Heidary G. The Relationship Between Choroidal Abnormalities and Visual Outcomes in Pediatric Patients With NF1-Associated Optic Pathway Gliomas. J Neuroophthalmol 2024; 44:5-9. [PMID: 38252486 PMCID: PMC10922160 DOI: 10.1097/wno.0000000000002075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND Choroidal abnormalities (CAs) visualized on near-infrared reflectance (NIR) imaging are a new diagnostic criterion for neurofibromatosis type 1 (NF1), but the association between the presence of CAs and visual function remains unknown. This study evaluated the relationship between visual acuity (VA) with the presence, number, or total area of CAs visualized by NIR in children with NF1-associated optic pathway gliomas (NF1-OPGs). METHODS Patients (<18 years) enrolled in a prospective longitudinal study of children with NF1-associated OPGs from 3 institutions were eligible if they had optical coherence tomography (OCT) of the macula (Heidelberg Spectralis) with ≥1 year of follow-up. The central 30° NIR images were reviewed by 2 neuro-ophthalmologists who manually calculated the number and total area of CAs. VA (logMAR) was measured using a standardized protocol. Cross-sectional associations of presence, number, and total area of CAs with VA, retinal nerve fiber layer thickness (RNFL), and ganglion cell-inner plexiform layer thickness were evaluated at the first and most recent visits using regression models. Intereye correlation was accounted for using generalized estimating equations. RESULTS Eighty-two eyes of 41 children (56% female) were included. The mean ± SD age at the first OCT was 10.1 ± 3.3 years, with a mean follow-up of 20.4 ± 7.2 months. At study entry, CAs were present in 46% of eyes with a mean number of 2.1 ± 1.7 and a mean total area of 2.0 ± 1.7 mm 2 per eye. At the most recent follow-up, CAs were present in 48% of eyes with a mean number of 2.2 ± 1.8 lesions and a mean total area of 2.3 ± 2.1 mm 2 per eye. Neither VA nor OCT parameters at first and follow-up visits were associated with the presence, number, or total area of CAs (all P > 0.05). CONCLUSIONS CAs are prevalent but not ubiquitous, in children with NF1-OPGs. Although CAs are a diagnostic criterion for NF1, their presence and size do not appear to be associated with visual function.
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Affiliation(s)
- Tais Estrela
- Neuro-Ophthalmology Department, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA
| | - Saprina Truong
- Departments of Ophthalmology and Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Arielle Garcia
- Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jocelyn He
- Center for Preventive Ophthalmology and Biostatistics, Department of Ophthalmology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gui-Shuang Ying
- Center for Preventive Ophthalmology and Biostatistics, Department of Ophthalmology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Michael J. Fisher
- Division of Neuro-Oncology Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Grant T. Liu
- Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Ophthalmology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicole J. Ullrich
- Departments of Ophthalmology and Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert A. Avery
- Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Ophthalmology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gena Heidary
- Neuro-Ophthalmology Department, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA
- Departments of Ophthalmology and Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Mallone F, Alisi L, Lucchino L, Di Martino V, Nebbioso M, Armentano M, Lambiase A, Moramarco A. Insights into Novel Choroidal and Retinal Clinical Signs in Neurofibromatosis Type 1. Int J Mol Sci 2023; 24:13481. [PMID: 37686284 PMCID: PMC10488231 DOI: 10.3390/ijms241713481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 08/20/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
Neurofibromatosis type 1 (NF1) is a rare inherited neurocutaneous disorder with a major impact on the skin, nervous system and eyes. The ocular diagnostic hallmarks of this disease include iris Lisch nodules, ocular and eyelid neurofibromas, eyelid café-au-lait spots and optic pathway gliomas (OPGs). In the last years, new manifestations have been identified in the ocular district in NF1 including choroidal abnormalities (CAs), hyperpigmented spots (HSs) and retinal vascular abnormalities (RVAs). Recent advances in multi-modality imaging in ophthalmology have allowed for the improved characterization of these clinical signs. Accordingly, CAs, easily detectable as bright patchy nodules on near-infrared imaging, have recently been added to the revised diagnostic criteria for NF1 due to their high specificity and sensitivity. Furthermore, subclinical alterations of the visual pathways, regardless of the presence of OPGs, have been recently described in NF1, with a primary role of neurofibromin in the myelination process. In this paper, we reviewed the latest progress in the understanding of choroidal and retinal abnormalities in NF1 patients. The clinical significance of the recently revised diagnostic criteria for NF1 is discussed along with new updates in molecular diagnosis. New insights into NF1-related neuro-ophthalmic manifestations are also provided based on electrophysiological and optical coherence tomography (OCT) studies.
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Affiliation(s)
| | | | | | | | | | | | - Alessandro Lambiase
- Department of Sense Organs, Sapienza University of Rome, 00161 Rome, Italy; (F.M.); (L.A.); (L.L.); (V.D.M.); (M.N.); (M.A.); (A.M.)
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de Rivas MO, Gabás JM, Cabeza MÁT, Floría OE, Latorre RH, Moscarda EN, Clavería JA, Rivasés GP, Puyuelo JA. Choroidal Hyperreflective Nodules Detected by Infrared Reflectance Images Are a Diagnostic Criterion for Neurofibromatosis Type 1 Patients Excluding Those with High Myopia. Diagnostics (Basel) 2023; 13:diagnostics13071348. [PMID: 37046566 PMCID: PMC10093036 DOI: 10.3390/diagnostics13071348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/22/2023] [Accepted: 03/29/2023] [Indexed: 04/08/2023] Open
Abstract
Neurofibromatosis type 1 (NF1) is one of the central nervous system’s most common autosomal dominant conditions. The diagnosis is based on the clinical diagnostic criteria and/or a molecularly confirmed mutation in the NF1 gene. This study investigated the possibility of substantiating choroidal nodules as a diagnostic criterion for the disease, including patients affected with and without high myopia. A cross-sectional study was carried out in 60 eyes of 30 adult patients diagnosed with NF1. A total of 30 healthy individuals of equivalent age and sex served as control. The Spectralis HRA+OCT MultiColor (Heidelberg Engineering GmbH, Heidelberg, Germany) evaluated the presence of choroidal abnormalities with near-infrared reflectance imaging. Secondly, the presence of iridian Lisch nodules was evaluated by slit lamp examination. Near-infrared reflectance imaging showed the presence of choroidal hyperreflective nodules in 83% of the patients diagnosed with NF1, while these choroidal abnormalities were not observed in any control subject. The patients diagnosed with NF1 associated with high myopia were the only ones who did not present the characteristic choroidal disorders. Therefore, when excluding patients diagnosed with high myopia, choroidal nodules were more frequent than Lisch nodules in a statistically significant proportion. Hyperreflective nodules detected by near-infrared reflectance imaging are as regular as Lisch nodules or even significantly more frequent when excluding high myope patients. Our observation of the mutual exclusion of choroidal hyperreflective nodules and high myopia in the NF1 patients seems a novel and interesting remark.
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Affiliation(s)
- Marta Orejudo de Rivas
- Department of Ophthalmology, Lozano Blesa University Clinic Hospital, 50009 Zaragoza, Spain
| | - Javier Mateo Gabás
- Department of Ophthalmology, Lozano Blesa University Clinic Hospital, 50009 Zaragoza, Spain
- Aragon Health Research Institute (IIS Aragon), 50009 Zaragoza, Spain
| | - Miguel Ángel Torralba Cabeza
- Aragon Health Research Institute (IIS Aragon), 50009 Zaragoza, Spain
- Department of Internal Medicine, Lozano Blesa University Hospital, 50009 Zaragoza, Spain
| | - Olivia Esteban Floría
- Department of Ophthalmology, Lozano Blesa University Clinic Hospital, 50009 Zaragoza, Spain
- Aragon Health Research Institute (IIS Aragon), 50009 Zaragoza, Spain
| | - Raquel Herrero Latorre
- Department of Ophthalmology, Lozano Blesa University Clinic Hospital, 50009 Zaragoza, Spain
| | - Eva Núñez Moscarda
- Department of Ophthalmology, Lozano Blesa University Clinic Hospital, 50009 Zaragoza, Spain
| | | | | | - Javier Ascaso Puyuelo
- Department of Ophthalmology, Lozano Blesa University Clinic Hospital, 50009 Zaragoza, Spain
- Aragon Health Research Institute (IIS Aragon), 50009 Zaragoza, Spain
- School of Medicine, Department of Surgery, University of Zaragoza, 50009 Zaragoza, Spain
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Mallone F, Lucchino L, Giustini S, Lambiase A, Moramarco A. An update on choroidal abnormalities and retinal microvascular changes in neurofibromatosis type 1. Orphanet J Rare Dis 2022; 17:223. [PMID: 35698197 PMCID: PMC9195315 DOI: 10.1186/s13023-022-02369-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 05/29/2022] [Indexed: 11/30/2022] Open
Abstract
Neurofibromatosis Type 1 (NF1) is a rare neurocutaneous disorder transmitted in an autosomal dominant fashion, mainly affecting the nervous system, the eye and skin. Ocular diagnostic hallmarks of NF1 include iris Lisch nodules, optic gliomas, orbital and eyelid neurofibromas, eyelid café-au-lait spots. In recent years, a new ocular sign represented by choroidal abnormalities (CAs) has been characterized in NF1. The CAs, identified with near-infrared reflectance, have been reported with a frequency of up to 100% in NF1, and have recently been added to the actual diagnostic criteria for NF1. The present Letter to the journal is intended to provide an update on features and clinical significance of CAs in NF1. Moreover, the relation with other ocular manifestations recently described in NF1 including hyperpigmented spots and retinal microvascular abnormalities is discussed.
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Affiliation(s)
- Fabiana Mallone
- Department of Sense Organs, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy
| | - Luca Lucchino
- Department of Sense Organs, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy
| | - Sandra Giustini
- Department of Dermatology and Venereology, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Alessandro Lambiase
- Department of Sense Organs, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Antonietta Moramarco
- Department of Sense Organs, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy
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