Fundus morphology assessed by digital image analysis in children with fetal alcohol syndrome

Vision outcomes in children with fetal alcohol spectrum disorders

BACKGROUND

Previous studies demonstrated that children with Fetal Alcohol Spectrum Disorders (FASD) are more likely to have vision impairments. However, existing human clinical and epidemiological investigations are few and include limited sample sizes. This study aimed to explore the association between ophthalmologic abnormalities and FASD in a sample of 5-7 year old children in the general population.

METHODS

This was a cross-sectional study nested in a larger study intended to estimate the prevalence of FASD in San Diego, California, conducted between 2012 and 2014. Prenatal exposure to alcohol, dysmorphology examinations, and a neurobehavioral testing battery were collected for each child and an FASD diagnosis was assigned. Parents of participating children were asked to release their child's vision screening or diagnostic records.

RESULTS

Vision records were obtained for 424 participants in the larger prevalence study. Of these, 53 children were classified as having FASD. A statistically significant association was found between FASD and a diagnosis of strabismus; 5/42 (11.9%) of children who were classified as having FASD had strabismus compared to 6/290 (2.1%) of children who were not classified as having FASD (p = .01). All five cases of strabismus in the FASD group occurred in 19 children classified as having partial fetal alcohol syndrome (pFAS). No association was found between FASD and vision impairment (p = .23), refractive errors (p = .66), glasses/contact lens prescription (p = .30), or having one or more ophthalmological abnormalities (p = .97).

CONCLUSIONS

An association between strabismus and FASD, specifically partial FAS, suggests that the effect of alcohol exposure on risk of strabismus must be severe enough to result in facial features consistent with FASD. This emphasizes the importance of vision screening in children with FASD.

Path analysis of the impact of prenatal alcohol on adult vascular function

BACKGROUND

The vascular system may be particularly vulnerable to prenatal alcohol exposure (PAE). Alterations in angiogenesis and epigenetic changes to vascular development have been implicated as a probable mechanism for this vulnerability.

METHODS

We assessed the long-term impact of prenatal alcohol exposure (PAE) on adult vascular health using a prospective cohort first identified while in utero. Participants with no PAE (n = 37, mean age = 36.7 [SD = 1.6] years) were compared to participants with PAE (n = 51, mean age = 36.3 [SD = 1.7] years). Their vascular health was assessed by arterial blood pressure (BP) and peripheral arterial tonometry, which yields an index of endothelial function (reactive hyperemia index) and a measure of arterial stiffness (augmentation index). Blood samples were collected to assess cholesterol levels and insulin resistance (glucose, hemoglobin A1C, and insulin). Path analysis was used to examine the direct and indirect effects of PAE on vascular health after adjusting for other known physical outcomes.

RESULTS

Participants with a history of PAE weighed less, trended towards being shorter, had smaller body mass, and had more alcohol-related dysmorphic features than those without PAE. Path analysis suggested that the impact of PAE on BP was through its indirect relationships with height, body mass index, and dysmorphic features and resulted in protective effects relative to the Contrast group who were disproportionately overweight. PAE was also found to have a direct negative effect on endothelial function. An index of total alcohol-related dysmorphic features was negatively had both a direct effect on arterial stiffness and an indirect effect on endothelial function.

CONCLUSIONS

Prenatal alcohol exposures' impact on vascular function is not independent of other common physical and environmental factors but endothelial function and arterial stiffness seemed most compromised after controlling for these other factors. Level of alcohol-related dysmorphic features seems to be predictive of more adverse effects than endothelial function and vascular stiffness.

Visual Function and Fundus Morphology in Relation to Growth and Cardiovascular Status in 10-Year-Old Moderate-to-Late Preterm Children

PURPOSE

To study visual function and ocular fundus morphology in relation to growth, metabolic status, and blood pressure in moderate-to-late preterm (MLP) children at 10 years of age.

DESIGN

Prospective cohort study.

METHODS

In this population-based observational study, nonsyndromic MLP children born in Gothenburg, Sweden, were examined neonatally in the years 2002-2003 concerning length, weight, head circumference, and insulin-like growth factor I (IGF-I). At 10 years of age, 33 children (10 girls) were examined regarding previously mentioned variables, and regarding visual acuity, refraction, fundus morphology, IGF binding protein 3, leptin, adiponectin, and blood pressure. An age- and sex-matched control group consisted of 28 children (9 girls).

RESULTS

Myopia was more commonly found in MLP children than in controls (P = .004, 95% CI 1.8 to 49.8). The MLP group had smaller optic disc area (P = .01, 95% CI -0.5 to -0.1), smaller rim area (P = .001, 95% CI -0.5 to -0.2), fewer branching points (P = .0001, 95% CI -5.7 to -2.1), and higher index of tortuosity of arteries (P = .03, 95% CI 0.002 to 0.03) and veins (P = .02, 95% CI 0.003 to 0.02). Refraction correlated with IGF-I (P = .0005, r_s = 0.60 in right eye, and P = .002, r_s = 0.55 in left eye) at 10 years of age. Tortuosity of arteries at assessment correlated with neonatal IGF-I levels (P = .03, r_s = -0.39). Tortuosity of veins correlated with a leptin/adiponectin ratio at assessment (P = .04, r_s = 0.37).

CONCLUSION

The findings suggest that being born MLP is associated with myopia, smaller optic disc and rim areas, and abnormal retinal vascularization. Furthermore, metabolic status and growth factors seem to have an impact on ocular development.

Fetal alcohol syndrome

Alcohol is a physical and behavioural teratogen. Fetal alcohol syndrome (FAS) is a common yet under-recognized condition resulting from maternal consumption of alcohol during pregnancy. While preventable, FAS is also disabling.Although FAS is found in all socioeconomic groups in Canada, it has been observed at high prevalence in select First Nations and Inuit communities in Canada.This statement addresses FAS prevention, diagnosis, early identification and management for health care professionals.Prevention of FAS must occur at two levels. Primary prevention involves eliminating FAS through classroom or community education, and encouraging women to avoid consuming alcohol before conception and throughout pregnancy. Secondary prevention involves identifying women who are drinking while pregnant and reducing their consumption. This statement describes a variety of screening strategies including Tolerance-Annoyance, Cut Down, Eye Opener (T-ACE). Medical practitioners should recommend abstinence starting with the first prenatal visit. Prompt referral for alcohol treatment is recommended for pregnant individuals who are unable to stop drinking alcohol.This statement describes the diagnosis of FAS, partial or atypical FAS, alcohol-related birth defects and alcohol-related neurodevelopmental disorder. With a history of in-utero alcohol exposure, a diagnosis of FAS should be considered with current or previous growth deficiency, select facial abnormalities involving the upper lip and eyes, and neurodevelopmental abnormalities. These features are best quantified with the use of a four-digit diagnostic method.Strategies for early identification of possible alcohol-related abnormalities are outlined.Intervention focuses on optimizing development, managing behavioural difficulties and providing appropriate school programming. Of prime importance is earliest possible childhood intervention to prevent secondary disabilities that may result from delay while awaiting a definitive diagnosis of FAS.

Eye malformations in children with heavy alcohol exposure in utero

OBJECTIVE

To determine whether children who do not develop fetal alcohol syndrome (FAS) despite heavy alcohol exposure are at risk for eye abnormalities.

STUDY DESIGN

We screened 9628 pregnant women and identified 101 women who were drinking >/= 2 oz of absolute alcohol per day and 101 nondrinking control women. We followed 43 exposed and 55 control offspring between age 4 and 9 years, performing masked standardized ophthalomologic examinations.

RESULTS

The groups did not differ in their rates of impaired visual acuity, refractory errors, ptosis, epicanthal folds, or short palpebral fissures. Biomicroscopy examination was normal in all exposed subjects; cataracts were detected in 2 control subjects (4%) but in no exposed subjects. Arterial tortuosity was seen in 7 exposed subjects (16%) and in 8 control subjects (15%). Optic nerve hypoplasia was not detected in any subject.

CONCLUSIONS

Previous research has found that children with FAS have a high incidence of serious ophthalmologic defects; our data indicate that the risk is limited to children with FAS and does not extend to children exposed to high levels of alcohol prenatally who do not develop FAS. Eye examinations are unlikely to clarify the diagnosis in children suspected of having alcohol-related damage.

Concurrent dietary administration of D-SAL and ethanol diminishes ethanol's teratogenesis

BACKGROUND

SAL (SALLRSIPA) is a peptide fragment of activity-dependent neurotrophic factor. Both L- and D-SAL diminish ethanol's pathogenesis, however, the D-peptide is protease resistant, and can therefore be effectively administered in a diet. The present study tested the hypothesis that D-SAL provided in a liquid diet containing ethanol will prevent ethanol-induced teratogenicity in mice.

METHODS

Following an ethanol acclimation period, female C57Bl/6J mice were withdrawn from the ethanol, bred, and then returned during gestational days (GD) 7 and 8 to a control liquid diet or one containing 4.8% ethanol alone or in combination with 5.6 microg/ml D-SAL. At these doses, the mice received approximately 75 microg of D-SAL on each day and achieved peak blood-alcohol concentrations on GD 8 that ranged from 148-162 mg/dl. On GD 14, the fetuses were examined for the presence of ocular abnormalities including microphthalmia and irregularly shaped pupils, teratogenic effects known to result from this ethanol exposure paradigm.

RESULTS

Dietary D-SAL reduced the incidence of ocular defects in ethanol-exposed fetuses from 29 to 10% in the right eyes and from 21 to 7.5% in the left eyes; levels similar to those observed in pair-fed controls. In addition to decreasing their incidence, D-SAL also reduced the severity of the ocular defects.

CONCLUSIONS

These results demonstrate that oral D-SAL can prevent ethanol-induced ocular defects. Because ocular defects are commonly associated with CNS damage, oral D-SAL may also prove valuable in preventing ethanol-induced brain defects.

Maternal oral intake mouse model for fetal alcohol spectrum disorders: ocular defects as a measure of effect

BACKGROUND

This work was conducted in an effort to establish an oral intake model system in which the effects of ethanol insult that occur during early stages of embryogenesis can be easily examined and in which agents that may modulate ethanol's teratogenicity can be readily tested in vivo. The model system described utilizes the alcohol deprivation effect to obtain teratogenic levels of maternal ethanol intake on days 7 and 8 of pregnancy in C57Bl/6J mice. Ocular defects including microphthalmia and uveal coloboma, which have previously been shown to result from ethanol administered by gavage or via intraperitoneal injection on these days, served as the developmental end point for this study. The ocular defects are readily identifiable and their degree of severity is expected to correlate with concurrently developing defects of the central nervous system (CNS).

METHODS

Female C57Bl/6J mice were maintained on an ethanol-containing (4.8% v/v) liquid diet for 14 days and then mated during a subsequent abstinence period. Mice were then reexposed to ethanol on days 7 and 8 of pregnancy only. Control as well as ethanol-exposed dams were killed on their 14th day of pregnancy. Fetuses were then weighed, measured for crown rump length, photographed, and analyzed for ocular abnormalities. Globe size, palpebral fissure length, and pupil size and shape were noted for both the right and left eyes of all fetuses and informative comparisons were made.

RESULTS

This exposure paradigm resulted in peak maternal blood alcohol concentrations that ranged from 170 to 220 mg/dL on gestational day (GD) 8. Compared with the GD 14 fetuses from the normal control group, the pair-fed, acquisition controls, as well as the ethanol-exposed fetuses, were developmentally delayed and had reduced weights. Confirming previous studies, comparison of similarly staged control and treated GD 8 embryos illustrated reductions in the size of the forebrain in the latter. Subsequent ocular malformations were noted in 33% of the right eyes and 25% of the left eyes of the 103 GD 14 ethanol-exposed fetuses examined. This incidence of defects is twice that observed in the control groups. Additionally, it was found that the palpebral fissure length is directly correlated with globe size.

CONCLUSIONS

The high incidence of readily identifiable ocular malformations produced by oral ethanol intake in this model and their relevance to human fetal alcohol spectrum disorders (FASD) makes this an excellent system for utilization in experiments involving factors administered to the embryo that might alter ethanol's teratogenic effects. Additionally, the fact that early ethanol insult yields ocular and forebrain abnormalities that are developmentally associated allows efficient specimen selection for subsequent detailed analyses of CNS effects in this in vivo mammalian FASD model.

Effects of embryonic exposure to ethanol on zebrafish visual function

Across a variety of species, including humans, it has been shown that embryos exposed to ethanol display eye abnormalities as well as deficiencies in visual physiology and behavior. The purpose of this study was to examine the effects of embryonic exposure to ethanol on visual function in zebrafish. Visual function was assessed physiologically, via electroretinogram (ERG) recordings, and behaviorally, by measuring visual acuity with the optomotor response. Zebrafish larvae were exposed to 1.5% ethanol at various times during development, including the period of maximal eye development. The results show that ethanol effects on visual function were most pronounced when exposure occurred during eye development. ERG recordings from ethanol-exposed larvae differed from normal subjects both in shape of the response waveform and in visual thresholds under both light and dark adaptation; the differences were more pronounced under lower levels of adaptation. Also, ethanol-exposed larvae displayed lower visual acuity as determined from the optomotor response. These results indicate embryonic ethanol exposure affects visual function particularly when exposure occurs during eye development. In addition, these findings illustrate the usefulness of the zebrafish as a viable animal model for studying Fetal Alcohol Syndrome (FAS).

Optic nerve morphology may reveal adverse events during prenatal and perinatal life--digital image analysis

OBJECTIVE

To evaluate optic nerve morphology in children with various conditions caused by adverse events during prenatal and/or perinatal life and to investigate whether optic nerve morphology can reveal brain lesions associated with these conditions, as well as provide insight into the etiology and timing of the prenatal and perinatal damage.

METHODS AND PATIENTS

A digital image analysis technique was used to analyze fundus photographs. One hundred healthy Swedish individuals of various ages from childhood to adolescence constituted a reference group. The following patient groups were chosen to represent various clinical conditions affecting the newborn or fetus at different stages of development: children born preterm (N = 39), children with fetal alcohol syndrome (FAS [N = 16]), children with periventricular leukomalacia (PVL [N = 17]), and children with septo-optic dysplasia (SOD [N = 6]).

RESULTS

Preterm children without known brain lesions demonstrated normal optic disk morphology but abnormal retinal vascular pattern; children born preterm with an acquired brain lesion late in gestation (PVL) demonstrated normal disk size with enlarged cups in addition to the abnormal vascular pattern. Children with prenatal alcohol exposure (FAS) had a subnormal optic disk area with increased tortuosity of both arteries and veins, whereas children born at term with an early acquired brain lesion (SOD) had a markedly reduced optic disk area with isolated tortuosity of the retinal veins.

CONCLUSIONS

Evaluation of optic nerve morphology, by digital image analysis, demonstrated that differences in ocular fundus morphology were correlated with differences in etiology and timing of the adverse event occurring in prenatal and perinatal life. In addition, digital image analysis may be a helpful tool for understanding variations in optic nerve and retinal vessel morphology and their relationship with central nervous pathology.

The clinical and morphologic spectrum of optic nerve hypoplasia

PURPOSE

The purpose of this study was to characterize the clinical and morphologic spectrum of all children referred for optic nerve hypoplasia to a tertiary referral hospital in Sweden during a 9-year period.

SUBJECTS AND METHODS

A retrospective review was undertaken of the charts of 117 children (age range, 0.25-16 years), treated at the Children's Hospital, Göteberg between 1988 and 1996, after the diagnosis of optic nerve hypoplasia. Ocular fundus morphologic condition was evaluated by digital image analysis of fundus photographs in 50 children, and neuroimaging was performed in 57 children.

RESULTS

Of the 117 children with optic nerve hypoplasia, 66 (56%) were boys and 51 (44%) were girls. Preterm birth occurred in 24 (20%), and 14 (12%) were born small for gestational age. Additional diagnoses, such as fetal alcohol syndrome, septo-optic dysplasia, perinatal adverse events, and neuropsychiatric disorders, were made in 88%; 7% had unilateral optic nerve hypoplasia. Most of the children had small optic disc, cup, and neuroretinal rim areas, as well as retinal vascular abnormalities; 75% were visually impaired, and a high incidence of nystagmus and strabismus was found among these children.

CONCLUSION

This study indicates that optic nerve hypoplasia has a wide clinical and morphologic spectrum and is associated with a broad range of disorders of the central nervous system. It is suggested that differences in the etiology and timing of the lesion as well as associated lesions may explain this spectrum of optic nerve hypoplasia in children.

Eye size in healthy Swedish children and in children with fetal alcohol syndrome

PURPOSE

This study set out to collect reference data for normal ocular growth and to study the teratological effects of alcohol on eye development.

METHODS

Eye size was studied in 92 healthy Swedish children (age 1 month to 16 years) as reference and in 13 children (age 1.4 months to 17 years) with fetal alcohol syndrome (FAS) using ultrasonographic axial length measurements. Another three children with FAS were evaluated by clinical examination only.

RESULTS

The control group demonstrated a marked increase in total axial length during the first 2 years of life. Girls with FAS had a shorter total axial length (p = 0.045) than their controls. Both boys and girls with FAS demonstrated a relatively smaller vitreous body than the controls, p = 0.015 and 0.068, respectively. Three children with FAS had severe structural anomalies.

CONCLUSION

The observations support previous studies indicating that alcohol has an adverse effect on growth and configuration of the eye.