Surgical treatment of advanced chronic angle closure glaucoma in Weill-Marchesani syndrome

Weill-Marchesani syndrome 4 caused by compound heterozygosity of a maternal submicroscopic deletion and a paternal nonsense variant in the ADAMTS17 gene: A case report

Purpose

To retrospectively report a case of Weill-Marchesani syndrome 4 (WMS4) with compound heterozygous variants of ADAMTS17 gene.

Observations

The patient was a 7-year-old boy with progressively worsening eyesight and intermittent elevated intraocular pressure (IOP) for two years. His IOPs were temporarily controlled using anti-glaucoma drugs. At presentation he had a shallow anterior chamber, lens subluxation, spherophakia and extensive synechial angle closure with high myopia in both eyes. Ultrasound biomicroscopy (UBM) identified thickened zonule fibers and anteriorly rotated, flat and slender ciliary processes, both of which worsened and were accompanied by obvious iris bombe after miosis. Gene testing showed compound heterozygosity of a maternal submicroscopic deletion on chromosome 15q26.3 (0.774 Mb) affecting the sequences of ADAMTS17, LYSMD4 and CERS3 as well as a paternal nonsense variant (c.1051_1053delAAGinsTAA, P.K351X) in the ADAMTS17 gene in the proband. The diagnosis of WMS4 was confirmed by genetic testing. Phacoemulsification (Phaco), intraocular lens (IOL) implantation, and irido-zonulo-hyaloid-vitrectomy (IZHV) combined with Ahmed Glaucoma Valve (AGV) implantation as a staged or one-stage surgery effectively lowered IOP, deepened ACD, improved visual acuity, and resolved the configuration of the ciliary processes in both eyes.

Conclusion and Importance

Recessive ADAMTS17 variants are associated with WMS4. We report here compound heterozygous variants in ADAMTS17 causing WMS4, and anatomically highlighted the possible pathophysiology for its clinical phenotype. A modified surgical approach with Phaco, IOL implantation, and IZHV combined with AGV implantation could be used to treat these complicated cases.

Fibrin Glue-Assisted Intraocular Lens Fixation in Weill-Marchesani Syndrome

PURPOSE:

To report visual and intraocular pressure (IOP) outcomes of 4 eyes in 2 patients with Weill Marchesani Syndrome having ocular fearures of spherophakia and secondary glaucoma who underwent fibrin glue assisted intrascleral fixation of intraocular lens (IOL).

METHODS:

Detailed anterior and posterior segment evaluation assessing best corrected visual acuity (BCVA), IOP, central corneal thickness was done in all. Lensectomy, vitrectomy with glued Intrascleral fixation of 3 piece intraocular lens was done. Post operative BCVA and IOP were assessed.

RESULTS:

Visual acuity and IOP control improved post-operatively.

CONCLUSIONS:

Glued IOL implantation is an effective method to visually rehabilitate and control glaucoma in patients with Weill Marchesani Syndrome.

Outcomes of lensectomy and risk factors for failure in spherophakic eyes with secondary glaucoma

PURPOSE

To report the outcomes of lensectomy in spherophakic eyes with subluxated or dislocated crystalline lenses and secondary glaucoma.

METHODS

Lensectomy was performed in 52 eyes, 36 eyes with lens subluxation and 16 eyes with lens dislocation with secondary glaucoma from 1991 to 2016. Glaucoma was diagnosed based on intraocular pressure (IOP) ≥22 mm Hg and/or glaucomatous optic disc damage. Complete success was defined as IOP ≥5 and ≤21 mm Hg without antiglaucoma medications (AGMs) or surgery, and eyes needing oral AGM or surgical intervention for IOP control or those with complication causing loss of light perception were considered failure.

RESULTS

Median (IQR) age at lensectomy was 12 (6-18) years, and median spherical equivalent was -14.5D (-23.7to -13). Median follow-up was 30.6 (5.4-103.4) months. Median logMAR (logarithm of minimal angle of resolution) visual acuity improved from 0.95 (0.6-1.8) to 0.4 (0.2-1.3) after lensectomy (p=0.01). Median IOP decreased from 22 mm Hg (17-31) to 14 mm Hg (11-19) at final follow-up (p=0.01). Median number of AGM decreased from 2 (2-3) to 1 (0-2) at final follow-up (p<0.0001), and glaucoma surgery was needed in four eyes (7.7% eyes). Complete success probability was 69% at 1 year and 51% at 5 years. Younger age (<6 years), higher presenting IOP (>32 mm Hg) and larger cup to disc ratio at presentation were found to be significant risk factors for failure.

CONCLUSION

Lensectomy was effective in controlling IOP in close to half of all eyes with spherophakia and secondary glaucoma, 40% eyes needed AGM and only 7.7% eyes needed glaucoma surgery for IOP control. In this cohort, younger age, higher IOP and larger cup to disc ratio at presentation were risk factors for poor glaucoma control after lensectomy.

Isolated Microspherophakia Presenting with Angle-Closure Glaucoma

We report a case of 13-year-old girl presenting to our clinic with blurred vision in both eyes. Ophthalmic examination revealed high myopia and angle-closure glaucoma due to pupillary block caused by small, spherical crystalline lenses. Treatment approaches to glaucoma in patients with microspherophakia are discussed in this case report.

Lensectomy, vitrectomy, and transvitreal ciliary body photocoagulation as primary treatment for glaucoma in microspherophakia

Microspherophakia is a rare, bilateral developmental anomaly of the crystalline lens. It can occur in isolation or as a component of a familial disorder. It has been associated with the Weill-Marchesani syndrome and Marfan syndrome. Angle clousure glaucoma can occur in microspherophakia and is the primary cause of visual loss. We describe the management of 2 sisters with bilateral microspherophakia and advanced angle closure glaucoma.

Weill-Marchesani syndrome with advanced glaucoma and corneal endothelial dysfunction: a case report and literature review

BACKGROUND

To report the diagnostic features and management strategy of a rare case of Weill-Marchesani syndrome with advanced glaucoma and corneal endothelial dysfunction.

CASE PRESENTATION

A patient presented with advanced glaucoma with an intraocular pressure of 49 mmHg in the left eye, and subsequently received trabeculectomy to control the intraocular pressure. Surprisingly, slit lamp examination through the dilated pupil revealed a dislocated microspherophakic lens almost touching the corneal endothelium. A microspherophakic lens was confirmed by anterior segment optical coherence tomography. Weill-Marchesani syndrome was then diagnosed by ocular examinations, and was accompanied by systemic abnormalities, including brachymorphia and brachydactyly. Corneal endothelial microscopy showed severe corneal endothelial dysfunction, and lens extraction and intraocular lens implantation were subsequently performed to prevent further endothelial damage. At the 1-year follow-up visit, the patient had well-controlled intraocular pressure, transparent cornea, and normal anterior chamber depth, while the intraocular lens remained correctly in place.

CONCLUSIONS

Weill-Marchesani syndrome could be diagnosed by microspherophakia, high myopia, secondary glaucoma, and systemic abnormalities such as brachymorphia and brachydactyly. Removal of the microspherophakia is recommended to control intraocular pressure and improve vision. Advanced glaucoma in Weill-Marchesani syndrome should be treated with combined glaucoma surgery and lens extraction.

Human eye development is characterized by coordinated expression of fibrillin isoforms

PURPOSE

Mutations in human fibrillin-1 and -2, which are major constituents of tissue microfibrils, can affect multiple ocular components, including the ciliary zonule, lens, drainage apparatus, cornea, and retina. However, the expression pattern of the three human fibrillins and an integral microfibrillar component, MAGP1, during human eye development is not known.

METHODS

We analyzed sections from human eyes at gestational weeks (GWs) 6, 8, and 11 and at 1 and 3 years of age with antibodies specific for each human fibrillin isoform or MAGP1, using immunofluorescence microscopy.

RESULTS

During embryonic development, each fibrillin isoform was detected in vascular structures bridging the ciliary body and the developing lens, hyaloid vasculature, and retina. In addition, they were present in the developing corneal basement membranes and lens capsule. MAGP1 codistributed with the fibrillin isoforms. In contrast, the juvenile zonule was composed of fibrillin-1 microfibrils containing MAGP1, but fibrillin-2 was absent and fibrillin-3 was only sparsely detected.

CONCLUSIONS

Fibrillin-1, -2, and, unique to humans, fibrillin-3 are found in various ocular structures during human embryonic eye development, whereas fibrillin-1 dominates the postnatal zonule. We speculate that vasculature spanning the ciliary body and lens, which elaborates fibrillin-2 and -3, may provide an initial scaffold for fibrillin assembly and zonule formation.

Visual outcome and incidence of glaucoma in patients with microspherophakia

INTRODUCTION

A number of ocular complications have been reported in microspherophakia. The literature however is limited to small case reports and the incidence of these complications is largely unknown. Our study describes a series of patients who presented to our hospital from 1998 to 2008.

MATERIAL AND METHODS

Data on the clinical and surgical findings of patients presented to us from 1998 to 2008 with microspherophakia were retrieved from the medical records and the results analyzed.

RESULTS

Thirty-six eyes of 18 patients were reviewed. The mean age at presentation was 16±10 years. All patients had varying degrees of lenticular myopia with a mean of -11.07±5.03 D. Glaucoma developed in 16 eyes (44.4%). Half of them had high IOP at presentation. Despite medical and surgical management IOP remained high in five eyes at the last follow-up. Sixteen eyes (44.4%) required lensectomy for dislocated crystalline lens. Lensectomy did not have any impact on the intraocular pressures. Homocysteinuria was the most common systemic association noted.

CONCLUSION

Microspherophakia is associated with a high incidence of lenticular myopia, subluxation of the crystalline lens and glaucoma. Management of glaucoma is difficult with the IOP remaining high in spite of combined medical and surgical management.

Glaucoma in microspherophakia: presenting features and treatment outcomes

PURPOSE

To report the clinical features, management, and treatment outcomes of glaucoma in microspherophakia.

METHODS

Medical records of 159 eyes of 80 subjects with microspherophakia were reviewed. The clinical features at presentation, presence of glaucoma, methods of treatment, and their outcomes were noted. Glaucoma was diagnosed based on intraocular pressure (IOP)≥22 mm Hg on 2 different occasions and/or glaucomatous optic disc damage. Angle closure was defined as occludable angles >270 degrees with or without presence of peripheral anterior synechiae.

RESULTS

Glaucoma was diagnosed in 81 eyes (51%). The mean age of subjects was 20±13 years, mean refractive error was -13.5±5.5, the mean IOP was 27.7±11.1 mm Hg. IOP≥22 mm Hg was present in 84% of eyes, disc damage in 59% of the eyes, 75% eyes had angle closure, and 25% had open angle on gonioscopy. Subluxation of crystalline lens was seen in 53 eyes and 14 eyes had dislocation of the lens; systemic associations were present in 21 subjects (3 Marfan syndrome, 18 Weill-Marchesani syndrome). Nine eyes out of 51 and 2 out of 16 eyes responded to medical treatment and laser iridotomy, respectively. Of the 48 eyes that required surgical intervention, 24 eyes underwent trabeculectomy. Complete success probability of trabeculectomy was 86% [95% confidence interval (CI), 63%-95%] at 6 months, 77% (95% CI, 53%-90%) at 1 year, which was maintained till 7 years, and reduced to 61% (95% CI, 26%-84%) at 8 years. Nearly 20% of eyes at presentation and 30% of the eyes at last follow-up were blind due to glaucoma.

CONCLUSIONS

More than half of the eyes with microspherophakia in this series presented with glaucoma; angle closure was the predominant form of glaucoma. Blindness due to glaucoma in microspherophakia was 20% to 30%.

Scleral-fixated intraocular lens implantation in microspherophakia

Background:

In microspherophakia, abnormal laxity of the lenticular zonules leads to development of a spherical lens and possible subluxation. We evaluated long-term results of lens removal with scleral-fixated intraocular lens (SFIOL) implantation in microspherophakia.

Materials and Methods:

Case series. SF IOLs were implanted in four consecutive patients with bilateral microspherophakia (eight eyes [three with pupillary block and secondary glaucoma who underwent immediate surgery and five with only subluxation who underwent elective surgery]). Post-operative best-corrected visual acuity (BCVA), intraocular pressure (IOP) and lens position were evaluated periodically from day 1 to 18 months.

Results:

All patients were females (mean age 28 ± 7.03 years). In group 1 eyes (three eyes that presented with pupillary block), the mean BCVA improved from 0.008 decimals (preoperative) to 0.50 decimals (final post-operative visit); in group 2 eyes (the other five eyes), the mean BCVA improved from 0.12 ± 0.21 decimals to 0.73 ± 0.14 decimals. The preoperative mean IOP (54.53 ± 7.33 mmHg) in group 1 eyes was significantly (P = 0.03) higher than that (16 ± 4.30 mm Hg) in group 2 eyes. At final post-operative visit, the mean IOP (11.67 ± 2.88 mmHg) in group 1 eyes was not significantly different from that in group 2 eyes (13.0 ± 3.08 mmHg). All SFIOLs were well- centred at the final visit. None of the patients encountered any peroperative or postoperative complications.

Conclusions:

SFIOLs may be an option for surgical management of microspherophakia.

Outcomes of trabeculectomy in microspherophakia

PURPOSE

To report the outcomes of trabeculectomy in eyes with glaucoma in microspherophakia.

MATERIALS AND METHODS

In a retrospective non-comparative case series, we analyzed 29 eyes of 18 patients with glaucoma in microspherophakia, who underwent primary trabeculectomy between 1998 and 2012. Success was defined as complete if the intraocular pressure (IOP) was ≤ 21 and > 5 mm Hg without any antiglaucoma medication and qualified if IOP ≤ 21 and >5 mm Hg with or without antiglaucoma medications. Eyes not falling into qualified success criteria were labeled as failure.

RESULTS

The median age at the time of trabeculectomy was 23 years (inter quartile range: 12, 28). The mean IOP reduced from 31.1 ± 8.6 mm Hg to 14.6 ± 4.4 mm Hg after trabeculectomy over a median follow up of 77 months (P < 0.001). The probability of complete success was 96% (95% CI: 77-99%) at one year, 88% (95% CI: 67-96%) at 2 years, which was maintained till 7 years and decreased to 79% (95% CI: 50-92%) at 8 years. The probability of qualified success was 100% till 7 years and decreased to 90% (95% CI: 47-98%) at 8 years. The median number of postoperative medications reduced from 2 to 0 postoperatively (P < 0.001) . Five eyes (21%) developed post-operative shallow anterior chamber (AC) requiring anterior chamber reformation, with 2 of these eyes needing lensectomy for resolution of this complication.

CONCLUSION

Primary trabeculectomy had good success rate in glaucoma associated with microspherophakia. Post-operative shallow AC was a frequent complication needing additional intervention.

Biometric and corneal topographic characteristics in patients with Weill-Marchesani syndrome

PURPOSE

To determine the biometry of ocular structures and corneal topographic characteristics in patients with Weill-Marchesani syndrome.

SETTING

Department of Ophthalmology, Shiraz University of Medical Sciences, Shiraz, Iran.

METHODS

Patients with Weill-Marchesani syndrome (syndrome group) and age-matched normal subjects (control group) were evaluated. All had a complete ocular examination including refraction and analysis using Fourier transformation, slitlamp biomicroscopy, pachymetry, keratometry, and ocular biometry. The following A-scan parameters were measured: anterior chamber depth (ACD), lens thickness, axial length (AL), lens-AL factor, and relative lens position (RLP). Corneal topography examinations were performed in the syndrome group only.

RESULTS

The syndrome group comprised 7 female patients and the control group, 20 female subjects. The syndrome group had statistically significantly higher myopia and corneal astigmatism than the control group (P<.0001). Oblique astigmatism was common in the syndrome group, showing a strong right-left specificity (right eyes' axes in the 135-degree meridian, left eyes' axes in the 45-degree meridian). The syndrome group had a statistically significantly shorter AL, shallower ACD, thicker lens, higher calculated lens power, and a higher lens-AL factor (P<.0001). However, there was no statistically significant difference in RLP (P = .32). The syndrome group also had statistically significantly thicker corneas and higher keratometry values (P<.0001).

CONCLUSION

Characteristic ocular findings in patients with Weill-Marchesani syndrome were a steep, thick cornea with a strong right-left specificity of corneal astigmatism; a thick lens; a short AL; and a shallow ACD.

[Rare complication in microspherophakia surgery: early capsular contraction]

INTRODUCTION

Microspherophakia is characterized by a decreasing equatorial diameter of the crystalline lens and a relative spherical shape objectivized by an increase in the diameter of the anteroposterior axis. This rare abnormality, leading to severe glaucoma and lenticular myopia, can be sporadic or inherited.

OBSERVATION

We report the case of an 18-year-old woman with a history of bilateral angle-closure glaucoma consulting for recurring painful episodes with no relief from medical treatment. The clinical examination showed idiopathic microspherophakia, confirmed by crystalline lens diameter measures with B-scan biometry, associated with secondary glaucoma due to pupillary blockage even though bilateral iridotomy was achieved. A lens extraction was performed with a bag implantation, with no complications. Seven days after surgery, visual acuity dropped to 10/10 with no refractive error, but a major capsular contraction and a superior haptic luxation were noted. After a new surgery to reposition the haptic, at the end of 3 months the visual acuity was 10/10 without refractive error or hypertony.

CONCLUSION

This report is an example of a rare crystalline lens disease that required lens extraction. Postoperative complications raise the problem of implantation in this pathology because of the small capsular bag diameters and the high rate of bag contraction. Using a capsular tension ring may prevent this complication but a ring was not placed in this case because of a particular anatomic condition (small bag).

Phacomorphic glaucoma: case and review

Phacomorphic glaucoma is a lens-induced secondary angle closure glaucoma that may occur as a result of mature cataract formation. A patient with markedly asymmetric cataract and anterior chamber depth was referred after the development of significant eye pain and elevated intraocular pressure that did not respond to topical antiglaucoma medications. The presence of an asymmetric mature lens, angle closure, and intraocular pressure elevation in the affected eye led to the diagnosis of phacomorphic glaucoma. Because the patient was systemically ill, physically frail, and had poor vision in the affected eye since birth, secondary to strabismic amblyopia, initial therapy was medically directed toward pain management. Cycloplegia, corticosteroids, and aqueous suppressants successfully ameliorated the patient's intraocular pressure and adequately controlled pain. However, progression to phacolysis and subsequent failure of pain management necessitated referral for lens extraction. The diagnosis and mechanism of phacomorphic glaucoma is discussed along with a review of current treatment modalities.

Central corneal thickness in patients with Weill-Marchesani syndrome

PURPOSE

To investigate whether central corneal thickness (CCT) is affected in patients with Weill-Marchesani syndrome (WMS) and to focus on its clinical significance.

DESIGN

Case-control study.

METHODS

Complete ocular examination was performed in case and control groups, and then the lowest reading of ten pachymetry measurements of the central cornea was taken as CCT.

RESULTS

All participants, case and controls, were female and age matched (P = .7). The mean of central corneal thickness in twelve eyes of six patients with WMS was thicker (631.5 +/- 25.9 microns) than 40 eyes of 20 normal persons (535.8 +/- 25.9 microns) in the control group (P < .0001).

CONCLUSIONS

Increased CCT seems to be a previously unrecognized aspect of WMS. This may lead to overestimation of intraocular pressure by applanation tonometers. Therefore, unusually thick CCT should be considered in interpreting the Goldmann tonometric reading in diagnosis and management of glaucoma in this rare syndrome.

Weill-Marchesani syndrome and secondary glaucoma associated with ectopia lentis

Weill-Marchesani syndrome (WMS) is a rare systemic connective tissue disorder with the systemic features of short stature, short and stubby hands and feet and stiff joints, especially in the hands. Occasionally, it is associated with heart defects and mental retardation. The main ocular features of WMS are microspherophakia (small and spherical crystalline lens), ectopia lentis (a displaced or malpositioned lens), severe myopia and glaucoma. Rare findings include asymmetric axial lengths associated with presenile vitreous liquefaction. A 14-year-old patient with WMS, who developed a secondary glaucoma and suffered visual loss from the ocular features of WMS, is described. The clinical findings and its successful management are also reported.