Williams syndrome: ophthalmological examination and review of systemic manifestations

Novel ophthalmic findings and deep phenotyping in Williams-Beuren syndrome

BACKGROUND/AIMS

To characterise the ocular manifestations of Williams-Beuren syndrome (WBS) and compare these to patients with isolated elastin mediated supravalvular aortic stenosis (SVAS).

METHODS

Fifty-seven patients with a diagnosis of WBS and five with SVAS underwent comprehensive ophthalmic evaluation at the National Institutes of Health from 2017 to 2020, including best-corrected visual acuity, slit-lamp biomicroscopy, optical biometry, dilated fundus examination, optical coherence tomography and colour fundus imaging.

RESULTS

Mean age of the 57 WBS patients was 20.3 years (range 3-60 years). Best-corrected visual acuity ranged from 20/20 to 20/400 with mean spherical equivalent near plano OU. Twenty-four eyes (21.8%) had an axial length (AL) less than 20.5 mm and 38 eyes (34.5%) had an AL measuring 20.5-22.0 mm. Stellate iris and retinal arteriolar tortuosity were noted in 30 (52.6%) and 51 (89.5%) WBS patients, respectively. Novel retinal findings in WBS included small hypopigmented retinal deposits (OD 29/57, OS 27/57) and broad foveal pit contour (OD 44/55, OS 42/51). Of the five patients with SVAS, none had stellate iris or broad foveal pit contour while 2/5 had retinal arteriolar tortuosity.

CONCLUSION

WBS is a complex multisystem genetic disorder with diverse ophthalmic findings that differ from those seen in isolated elastin mediated SVAS. These results suggest other genes within the WBS critical region, aside from ELN, may be involved in observed ocular phenotypes and perhaps broader ocular development. Furthermore, retinal arteriolar tortuosity may provide future insight into systemic vascular findings in WBS.

Ophthalmic characteristics and retinal vasculature changes in Williams syndrome, and its association with systemic diseases

BACKGROUND

We aim to characterise the ophthalmic findings and retinal vasculature changes in patients with WS, and to analyse the correlation between ophthalmic manifestations and the associated systemic diseases.

METHODS

This retrospective case-control study included 27 WS patients and 28 age-matched healthy participants. Stellate pattern of iris, central macular thickness (CMT), foveal width, retinal vessel diameter, superficial vascular density (SVD) of macula and foveal avascular zone (FAZ) were compared between WS patients and healthy participants.

RESULTS

Twenty-five patients (93%) had the classic stellate iris presentation. Compared with healthy controls, WS patients had decreased CMT, increased foveal width and a lower SVD of macula (all P < 0.001). Significantly decreased mean retinal arterial (117.9 ± 9.9 µm vs. 133.0 ± 6.7 µm in WS and controls, respectively; p < 0.001) and venous (158.9 ± 11.2 µm vs. 174.0 ± 8.0 µm in WS and controls, respectively; p < 0.001) outer diameters, as well as mean arterial wall thickness (11.2 ± 1.3 µm vs. 12.2 ± 0.8 µm in WS and controls, respectively; p < 0.01) were found in WS. Stellate iris grading was significantly associated with CMT, foveal width, retinal vessel diameter (all p < 0.05), and a significant increase in the odds of having hypertension (Odds ratio (OR), 5.63; P < 0.05). The severity of stellate iris in WS seemed to have the trend of increasing risk of having pulmonary stenosis, tricuspid regurgitation and mitral regurgitation.

CONCLUSIONS

This study provides the first in vivo evidence reflecting current knowledge on vessel morphology in WS patients that deficient circumferential growth is the predominant pathophysiologic changes resulting from elastin deficiency. The ophthalmic characteristics may serve as a complementary tool to diagnose and follow-up patients suffering from WS.

Ophthalmological manifestations in 6 patients diagnosed with Williams-Beuren syndrome and literature review

Medical history of 6 patients diagnosed with Williams-Beuren Syndrome (SWB) in pediatric age was revised. All the patients presented characteristic elf facies and cardiovascular abnormalities. All presented good visual acuity, except one case of unilateral amblyopia. The most frequent refractive error was hyperopia (n = 6; 100%) and astigmatism (n = 5; 83.3%). Ocular motility alterations were found in 2 patients (1 case of exophoria with hyperfunction of right inferior oblique and another of congenital endotropia with bilateral hyperfunction of inferior oblique). On the cognitive function, 66.7% (n = 4) had visoperceptive disorders. Other findings were epicanthus (n = 6; 100%) and congenital obstruction of the nasolacrimal duct with unilateral epiphora (n = 1; 16.7%). SWB is a rare disorder with complex ophthalmological and systemic manifestations. For this reason, ophthalmological follow-up of these children is recommended.

Updates on congenital lacrimal drainage anomalies and their association with syndromes and systemic disorders: A major review

BACKGROUND

To review and update the syndromic and non-syndromic systemic associations of congenital lacrimal drainage anomalies.

METHODS

The authors performed a PubMed search of all articles published in English on congenital lacrimal drainage anomalies (CLDA). The current review provides an update from January 2017 to August 2020 on all CLDA associated with clinical syndromes or non-syndromic systemic disorders. The update intends to appraise the readers on all papers that were published in the interim 3-year period since the publication of the previous major review by authors (1933-2016). Patients with specific syndromes or systemic disorders were then reviewed. Pertinent cross-references from each of the short-listed articles were also included. Data reviewed include syndromic descriptions, systemic details, demographics, lacrimal presentations, management, and outcomes.

RESULTS

There have been significant new updates. Eleven new syndromes have been added to the list of syndromic associations, of which three were suspects. Among the new syndromic associations, three (PHACE, Williams-Beuren, and Peter's plus syndromes) described CLDA details in depth. Several new non-syndromic systemic conditions with associated CLDA also came to light, the foremost amongst them being proboscis lateralis, diprosopus dirrhinus, cerebral palsy, and NGLY-1 related disorders. Although familial presentations have been reported, the inheritance patterns are unclear for most anomalies. Surgical challenges in these patients are distinct, and a thorough pre-operative assessment, including detailed imaging when indicated, may facilitate good outcomes. Two updated tables reflecting the summary of syndromic and non-syndromic systemic associations are provided to capture the details at a glance.

CONCLUSION

It is not very uncommon to find CLDA in syndromic or non-syndromic systemic disorders. Diagnosis of a craniofacial syndrome should prompt the physician to look out for CLDA. Similarly, a diagnosis of multiple CLDA should alert the examiner for the possible presence of associated systemic anomalies.

Lacrimal drainage system anomalies in Williams-Beuren syndrome

Williams-Beuren syndrome is a rare multi-system disorder affecting 1:10000 to 1:20000 live-births. The cause is de novo contiguous gene deletion on the long arm of chromosome 7 (7q11.23). It typically manifests with dysmorphic facies and predominantly involves the connective tissues, cardiovascular and nervous systems. The published literature reveals that lacrimal drainage anomalies are exceptionally rare and not much is known of those reported. The present case describes multiple lacrimal drainage anomalies in a child with Williams-Beuren syndrome.

Vision in children with autism spectrum disorder: a critical review

Autism spectrum disorder (ASD) is a common neurodevelopmental condition with approximately 1-2 per cent prevalence in the population. The condition has lifelong effects for the individual and family, and early intervention and management helps maximise quality of life and outcomes. Many studies of vision in ASD have attempted to link the behavioural and sensory deficits in ASD with underlying visual processing. From this work, it is clear that individuals with ASD 'see' and process the world differently, but there remain gaps in our understanding. This review will summarise our current knowledge of key aspects of visual functions and the optometric profile of ASD. This includes findings regarding visual acuity and contrast sensitivity, refractive error, eye movements, binocular vision, near visual functions and retinal structure in ASD. From this, a pattern of knowledge emerges for children with ASD: we should expect normal visual acuity; there will likely be atypical eye movements and susceptibility for subtle visuo-motor deficits, there is an increased prevalence of strabismus; an increased likelihood of astigmatism and possibly other refractive errors; attention, crowding and task complexity will likely be problematic; and retinal structure and function may be compromised. Bringing this together, these findings highlight that further work is necessary, not only to understand how higher-level functions link to behaviours, but also to ensure there is a sound understanding of the building-blocks of vision to fully grasp the profile of visual processing as a whole in ASD. This review will give a translational viewpoint for clinicians, and underline the benefits of comprehensive vision care in ASD.

ROD-CONE DYSTROPHY ASSOCIATED WITH WILLIAMS SYNDROME

PURPOSE

To describe a case of rod-cone dystrophy associated with Williams syndrome.

METHODS

This is an observational case report. The medical history was assessed. Examination included ophthalmoscopy, slit-lamp biomicroscopy, fundus autofluorescence imaging, optical coherence tomography, full-field and multifocal electroretinography, and fluorescence in situ hybridization for genetic testing.

RESULTS

A 14-year-old Asian Indian girl with characteristic facies and heart murmur, and with findings on ophthalmoscopy, slit-lamp biomicroscopy, fundus autofluorescence imaging, optical coherence tomography, full-field electroretinography, and multifocal electroretinography consistent with panretinal rod-cone dystrophy, has been reported. Fluorescence in situ hybridization revealed only 1 copy of the elastin gene on Chromosome 7, confirming the diagnosis of Williams syndrome in this patient.

CONCLUSION

The authors report the first case of a patient with ophthalmic findings characteristic for rod-cone dystrophy in the setting of genetically confirmed Williams-Beuren syndrome.

Critical care of patients with paediatric valvar cardiac disease

Valvar cardiac disease accounts for a large percentage of heart lesions in the paediatric population. There are a variety of congenital and acquired valvar lesions produced by different mechanisms that produce unique physiologies. With the development of more advanced cardiac interventional procedures and congenital cardiac surgery techniques, most of these lesions can be repaired in a single or multi-stage approach. Given the potential for significant symptomatology before intervention, it is imperative to review the critical care management of paediatric valvar heart disease. The purpose of this article is to provide an overview of the current critical care management of valvar cardiac disease. We approach each cardiac valve individually in order to review the pathophysiology caused by valve dysfunction (obstruction and incompetence) and elaborate on the most frequent diagnoses, specific cardiac physiology, potential for other organ system associations, and perioperative management.