Prevalence of strabismus and risk factors in adults born preterm with and without retinopathy of prematurity: results from the Gutenberg Prematurity Eye study

AIM

The purpose of this study was to assess the prevalence of strabismus and nystagmus and to analyse associated factors in preterm and full-term infants in adulthood.

METHODS

The Gutenberg Prematurity Eye Study is a retrospective cohort study with a prospective ophthalmological examination of participants born preterm and full-term (aged 18-52 years). Perinatal data were carefully assessed for risk factors and comprehensive ophthalmological examinations were conducted. The association between strabismus and nystagmus was assessed by analysing 16 different perinatal and actual risk factors in multivariable analysis. Participants were grouped into full-term controls (gestational age (GA) at birth ≥37 weeks), preterm participants without retinopathy of prematurity (ROP) and GA 33-36 weeks (group 2), GA 29-32 weeks (group 3), GA ≤28 weeks (group 4), non-treated ROP (group 5) and treated ROP (group 6).

RESULTS

In total, 892 eyes of 450 preterm and full-term individuals (mean age: 28.6 years, SD: ± 8.6 years, 251 females) were included. Strabismus was observed in 2.1% (3/140), 6.6% (9/137), 17.4% (16/92), 11.1% (2/18), 27.1% (13/48) and 60% (9/15) of participants and nystagmus in 0.7% (1/140), 1.5% (2/137), 4.3% (4/92), 5.6% (1/18), 10.4% (5/48) and 26.7% (4/15) of participants in the respective groups. In the multivariable regression model, strabismus was associated with GA (OR=0.90; p=0.046), anisometropia ≥1.5 diopter (OR=3.87; p=0.003), hypermetropia ≥2 diopter (OR=9.89; p<0.001) and astigmatism ≥1.5 diopter (OR=2.73; p=0.017). Esotropia was more frequent than exotropia and hypermetropia/hypometropia. Most strabismus cases occurred within the first 10 years of life. The strongest predictor associated with nystagmus was perinatal adverse events (OR=15.8; p=0.002).

CONCLUSION

Low GA and refraction of the eye are independent risk factors for strabismus, which typically occurs in the first 10 years of life. Perinatal adverse events are the most important factors for the presence of nystagmus in adulthood.

Proof-of-concept and Randomized, Placebo-controlled Trials of an FcRn Inhibitor, Batoclimab, for Thyroid Eye Disease

CONTEXT

Inhibition of the neonatal fragment crystallizable receptor (FcRn) reduces pathogenic thyrotropin receptor antibodies (TSH-R-Ab) that drive pathology in thyroid eye disease (TED).

OBJECTIVE

We report the first clinical studies of an FcRn inhibitor, batoclimab, in TED.

DESIGN

Proof-of-concept (POC) and randomized, double-blind placebo-controlled trials.

SETTING

Multicenter.

PARTICIPANTS

Patients with moderate-to-severe, active TED.

INTERVENTION

In the POC trial, patients received weekly subcutaneous injections of batoclimab 680 mg for 2 weeks, followed by 340 mg for 4 weeks. In the double-blind trial, patients were randomized 2:2:1:2 to weekly batoclimab (680 mg, 340 mg, 255 mg) or placebo for 12 weeks.

MAIN OUTCOME

Change from baseline in serum anti-TSH-R-Ab and total IgG (POC); 12-week proptosis response (randomized trial).

RESULTS

The randomized trial was terminated because of an unanticipated increase in serum cholesterol; therefore, data from 65 of the planned 77 patients were analyzed. Both trials showed marked decreases in pathogenic anti-TSH-R-Ab and total IgG serum levels (P < .001) with batoclimab. In the randomized trial, there was no statistically significant difference with batoclimab vs placebo in proptosis response at 12 weeks, although significant differences were observed at several earlier timepoints. In addition, orbital muscle volume decreased (P < .03) at 12 weeks, whereas quality of life (appearance subscale) improved (P < .03) at 19 weeks in the 680-mg group. Batoclimab was generally well tolerated, with albumin reductions and increases in lipids that reversed upon discontinuation.

CONCLUSIONS

These results provide insight into the efficacy and safety of batoclimab and support its further investigation as a potential therapy for TED.

A Multicenter, Single-Blind, Case-Control, Immunohistochemical Study of Orbital Tissue in Thyroid Eye Disease

Background: Thyroid eye disease (TED) involves several pathogenic pathways and a battery of infiltrating mononuclear cells, cytokines, and chemokines in the orbit. Revealing the main molecules, which play a major role in the pathogenesis of TED, will help developing novel treatment strategies. Methods: In a multicenter, single-blind, case-control study, 60 tissue samples were collected during orbital decompression (44 TED patients) or non-TED related oculoplastic (16 controls) surgeries. Formalin-fixation and paraffin embedding preserved orbital tissue. Tissue sections were immunostained with 18 antibodies by the micro-polymer labeling technique. Immunostaining slides were scanned by Panoramic Desk and blindly evaluated by a user-independent viewer software. Results: Marked lymphocyte infiltration was observed in orbital tissue specimens of patients with clinically active TED (n = 22) and to a much lesser extent in inactive cases (n = 22), while it was absent in controls. Increased vascularity was noted in all samples, with orbital congestion in specimens of clinically active TED. Tissue fibrosis was present in TED samples but not in controls. Immunohistochemistry of orbital tissue clearly differentiated between TED and controls, as well as between active and inactive TED. In contrast to controls and with the exception of cluster of differentiation 20 (CD20), 17 out of 18 antibodies were highly expressed in orbital connective tissue of TED patients. Especially, thyrotropin receptor (TSH-R), insulin-like growth factor 1 receptor (IGF-1R), CD40, cluster of differentiation 40 ligand (CD40L), CD3, CD68, interleukin-17A (IL-17A), IL-23A, IL-1β, IL-4, regulated on activation, normal T cell expressed and secreted (RANTES), macrophage chemoattractant protein 1 (MCP-1), IL-16, and B cell activating factor (BAFF) were overexpressed in clinically active TED (all p < 0.001). Also, the expression of CD40L, IL-17A, IL-23A, IL-6, IL-1β, RANTES, and BAFF was very high (TED/control ratio >3), moderate (ratio >2), and low in active (p < 0.001), inactive TED and controls, respectively. The expression of TSH-R, IGF-1R, CD40, CD40L, CD3, CD68, CD20, IL-17A, IL-23A, RANTES, MCP-1, and BAFF positively and significantly correlated with both serum TSH-R stimulatory antibody concentrations and clinical activity scores while it negatively correlated with TED duration. Orbital irradiation decreased TSH-R (p < 0.001) and IGF-1R expression (p = 0.012); in contrast, neither smoking, age, nor gender did impact immunohistochemical staining. Conclusions: Adaptive and cell-mediated immunity, overexpression of TSH-R/IGF-1R and CD40/CD40L are the relevant pathomechanisms in TED. Targeting these key players in the active phase of the disease offers specific and novel treatment approaches.

Anterior Chamber Angle in Adults Born Extremely, Very, and Moderately Preterm with and without Retinopathy of Prematurity-Results of the Gutenberg Prematurity Eye Study

Purpose: To determine whether prematurity and associated factors affect the anterior chamber angle (ACA) width in adulthood. Methods: The Gutenberg Prematurity Eye Study (GPES) is a retrospective cohort study with a prospective ophthalmologic examination of adults (age 18–52 years) in Germany. All participants were examined with Scheimpflug imaging (Pentacam HR, Oculus Optikgeräte GmbH, Wetzlar, Germany) using linear regression analysis to assess the associations of ACA in the different sectors with gestational age (GA), birth weight, birth weight percentile, retinopathy of prematurity (ROP), ROP treatment, placental insufficiency, preeclampsia, and breastfeeding. Results: In total, 516 eyes of 319 preterm and full-term individuals (aged 28.9 ± 8.8 years, 188 females) were examined. ROP treatment was associated with smaller ACA width in the nasal (B = −9.6 [95%CI: −14.7; −4.5] degree; p < 0.001) and temporal positions (B = −11.5 [95%CI: −17.7; −5.3] degree; p = 0.001), whereas non-treated individuals with ROP had an unaltered ACA width, as did individuals with low gestational age without ROP. Conclusion: Advanced stages of ROP following treatment with laser- and cryocoagulation lead to a smaller ACA width until adulthood, and hence may increase the risk of angle closure in later life.

[Alterations of the anterior segment of the eye caused by exposure to UV radiation]

BACKGROUND

By identifying diseases of the anterior segment of the eye associated with exposure to UV light, recommendations for action can be derived.

AIM

After reading this review, the reader should be familiar with UV light-associated diseases of the anterior segment of the eye.

METHOD

Using a selective literature search, UV light-associated diseases of the anterior segment of the eye were identified and protective mechanisms are described.

RESULTS

The UV light-associated lesions of the anterior segment of the eye include basal cell and squamous cell carcinomas, malignant melanoma of the eyelids and conjunctiva, pterygium, keratoconjunctivitis photoelectrica and climatic droplet keratopathy as well as cortical cataract.

CONCLUSION

Eyeglasses for filtering UV light, sunglasses and special safety glasses, such as welding helmets and wearing headgear protect against UV light exposure to the anterior segment of the eye and the associated diseases.

Prevalence and Time Trends in Myopia Among Children and Adolescents

BACKGROUND

Myopia (near-sightedness) is increasing worldwide, especially in Asia. The aim of this study was to describe trends in the prevalence of myopia in Germany.

METHODS

We analyzed data from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS; baseline survey 2003-2006, N = 17 640; wave 2, 2014-2017, N = 15 023). The presence of myopia was determined from a parent questionnaire and validated by the use of a visual aid. The population prevalence of myopia was calculated. Based on the KiGGS wave 2 data, potential risk factors for myopia were identified by means of logistic regression.

RESULTS

The prevalence of myopia at the age of 0-17 years in Germany was 11.6% (95% confidence interval [11.0; 12.2]) in the period 2003-2006 and 11.4% [10.7; 12.2] in 2014-2017. No age group of either sex exhibited a relevant, statistically significant change in the prevalence of myopia. In the adjusted model (adjusted for age, sex, family socioeconomic status, family history of migration), no association was found between myopia and use of digital media. More time spent reading books was associated with myopia: reading for more than 2 h/day showed an odds ratio of 1.69 [1.3; 2.2].

CONCLUSION

The prevalence of myopia in children and adolescents in Germany has remained virtually unchanged over a period of approximately 10 years. Changes in media consumption, such as the increased use of smartphones in this age group, have therefore had no detectable impact on the development of myopia, at least not so far. Future studies should investigate the influences of further increases in media use and examine the long-term effects.

The Prevalence of Visual Impairment in the Adult Population

BACKGROUND

The distribution of visual impairment is an indicator of the health status of the population and for the frequency of diseases of the eye.

METHODS

The Gutenberg Health Study (GHS) is a population-based cohort study in Germany concerning adults aged 35 to 74. 15 010 subjects from the Mainz-Bingen region underwent general medical and ophthalmological examination, with measurement of the distance-corrected visual acuity in each eye separately. As per the World Health Organization criteria, visual impairment was defined as an acuity below 0.3 in the better eye, and blindness as an acuity below 0.05. All patients who were found to be visually impaired or blind underwent further individual study with clinical history-taking, split-lamp examination, and fundus photography.

RESULTS

Data from 14 687 subjects were evaluated. The mean age of the partici- pants was 55.0 years (standard deviation, 11.1 years). The prevalence of visual im- pairment was 0.37% (95% confidence interval [0.28; 0.49]) (n = 55) and was higher in women (0.44%) than in men (0.31%). Blindness was present in 0.05% [0.03; 0.11] (n = 8) of the subjects. The prevalence of visual impairment from age 65 on- ward was 0.79%, three times higher than in the younger age groups. 54.5% of the visually impaired subjects had multiple underlying ophthalmological pathologies.

CONCLUSION

The causes of visual impairment are manifold. Loss of vision is often the combined effect of multiple pathological factors. The etiology of visual impair- ment is thus a more complex matter than is commonly assumed.

Association of Low Birth Weight With Altered Corneal Geometry and Axial Length in Adulthood in the German Gutenberg Health Study

Importance

Low birth weight is associated with altered ocular organ development in childhood, including the morphology of the eye. However, no population-based data exist about this association in adulthood.

Objective

To evaluate whether low birth weight has a long-term association with anterior segment anatomy and axial length in adulthood.

Design, Setting, and Participants

The Gutenberg Health Study is a population-based, observational cohort study in Germany. All participants underwent ocular biometry. Among the participants with follow-up and self-reported birth weight available, associations were assessed between low birth weight and anterior segment anatomy and axial length using multivariable linear regression analysis with adjustment for age and sex. In patients with phakia, anterior chamber depth and lens thickness were also examined. Data for this study were collected from April 27, 2012, through April 28, 2017, and analyzed from January through April 2018.

Exposures

Low birth weight.

Main Outcomes and Measures

Corneal curvature, central corneal thickness, white-to-white distance, anterior chamber depth, lens thickness, and axial length.

Results

Overall, 11 294 eyes of 7120 participants were included (52.4% female; mean [SD] age, 56.2 [10.3] years). Most of the participants were white (98.6%). After adjustment for age and sex, an association was found between a lower birth weight and steeper corneal curvature (β = 0.005 mm/100 g; 95% CI, 0.005-0.006 mm/100 g; P < .001), smaller white-to-white distance (β = 0.006 mm/100 g; 95% CI, 0.005-0.007 mm/100 g; P < .001), thinner central corneal thickness (β = 0.327 μm/100 g; 95% CI, 0.229-0.425 μm/100 g; P < .001), and shorter axial length (β = 0.006 mm/100 g; 95% CI, 0.003-0.010 mm/100 g; P < .001). However, anterior chamber depth and lens thickness were not associated with low birth weight in participants with phakia (10 510 eyes of 5279 participants).

Conclusions and Relevance

These analyses demonstrate an association between low birth weight and altered ocular geometry in adults aged 40 to 80 years, suggesting that birth weight and associated factors are crucial in anatomical ocular morphologic development. Retinopathy of prematurity and its treatment may affect ocular anatomy but could not be further analyzed in this study.

Intact Visuospatial Cognition in Amblyopia: Results From the Gutenberg Health Study

PURPOSE

To determine whether amblyopia interferes with cognitive functions requiring visuospatial processing, measured by the Tower of London (ToL) test.

METHODS

The current study was based on a sub-cohort from the population-based Gutenberg Health Study and included 1,569 participants aged 35 to 44 years. Amblyopia was defined as a visual acuity of 0.63 or worse (worse eye) in the presence of an amblyogenic factor; prevalence was 5%. There were three groups: participants with amblyopia (n = 78), participants with a visual acuity of 0.63 or worse (worse eye) without amblyopia (n = 65), and participants with a visual acuity of better than 0.63 (worse eye) (n = 1,426). Visuospatial planning ability was measured by the ToL test (touch-screen version), and the performance score ranged from 0 to 24, depending on the number of correctly solved problems. The authors used linear regression models to investigate the association between amblyopia and ToL test scores, adjusting for age, sex, and socioeconomic status.

RESULTS

The mean ± standard deviation of ToL test performance was 15.31 ± 3.29 in participants with a visual acuity of better than 0.63, 14.56 ± 3.76 in the amblyopic group, and 15.14 ± 3.65 in participants with a visual acuity of 0.63 or worse without amblyopia. In a linear regression model, sex, and socioeconomic status significantly predicted planning performance (P <.0001), whereas amblyopic status did not (P = .20).

CONCLUSIONS

Amblyopia may affect visuospatial perception, but no such relationships could be found for higher cognitive functions that strongly depend on visuospatial processing. Thus, in adulthood, individuals with amblyopia are unaffected in their visuospatial cognitive abilities, as required by the ToL test. [J Pediatr Ophthalmol Strabismus. 2019;56(6):397-401.].

Health-related quality of life and mental health in children and adolescents with strabismus - results of the representative population-based survey KiGGS

Background

To estimate the effect of strabismus (squinting) on mental health and health-related quality of life aspects in children and adolescents.

Methods

Data from the German Health Interview and Examination Survey for Children and Adolescents KiGGS (2003–2006 baseline survey; N = 14,835, aged 3 to 17 years, 49% girls) were examined. The presence of strabismus was derived by parental questionnaire, and health-related quality of life and mental health were investigated with the KINDL-R and Strengths and Difficulties Questionnaire. Associations between strabismus and outcomes were analyzed using multivariable linear and logistic regression models.

Results

Of 12,989 children without missing data, 579 children (4.5% of the sample) were reported to have strabismus. Children with strabismus had lower scores in the parent-reported KINDL-R total scale (adjusted beta = − 1.02; 95%CI: -1.86 to − 0.18; p = 0.018) and sub-scale ‘friends’ (adjusted beta = − 2.18; 95%CI: -3.56 to -0.80; p = 0.002) compared to children without strabismus. The presence of strabismus was also associated with more mental health problems like ‘hyperactivity/inattention’ (adjusted OR = 1.50; 95%CI: 1.14 to 1.98; p = 0.005), and ‘peer problems’ (adjusted OR = 1.35; 95%-CI: 1.05 to 1.74; p = 0.018) as reported by parents.

Conclusions

Strabismus in children and adolescents is associated with lower health-related quality of life.

Electronic supplementary material

The online version of this article (10.1186/s12955-019-1144-7) contains supplementary material, which is available to authorized users.

Recommendation for ophthalmic care in German preschool health examination and its adherence: Results of the prospective cohort study ikidS

Background

Each child in Germany undergoes a preschool health examination including vision screening and recommendations for further ophthalmic care. This study investigated the frequency of and adherence to these recommendations.

Methods

A population-based prospective cohort study was performed in the area of Mainz-Bingen (Rhineland-Palatinate, Germany). All preschoolers were examined at the statutory preschool health examination, which includes vision testing (Rodenstock vision screener) with available correction in the last preschool year. Based on the results, recommendations for further ophthalmic care were given to the parents. Six weeks prior to school entry, parents were surveyed concerning ophthalmic health care visits, diagnoses, and treatments. Ophthalmic care recommendation frequency and its adherence were investigated using logistic regression analysis adjusted for potential confounders.

Results

1226 children were included in this study, and 109 children received a recommendation for ophthalmic care based on the preschool health examination. At the follow-up, 84% of children who had received a recommendation had visited an ophthalmologist within the preceding year compared to 47% of children who had not received a recommendation. The recommendation for ophthalmic care was clearly associated with a higher number of ophthalmological visits (odds ratio = 7.63; 95% confidence interval: 3.96–14.7). In a subgroup analysis, adherence to a recommendation was lower in children with migrant background (OR = 2.26; 95%-CI: 0.64–7.90, compared to: OR = 11.6; 95%-CI: 4.95–27.4) and in those with low socio-economic status.

Conclusions

Adherence to preschool recommendations for ophthalmic care is high in German preschoolers. However, a migrant background and low socio-economic status may reduce this adherence.

Association of low birth weight with myopic refractive error and lower visual acuity in adulthood: results from the population-based Gutenberg Health Study (GHS)

Purpose

Low birth weight (BW) is linked to impaired organ development in childhood, including altered ocular morphological and functional development. The aim of this study was to evaluate whether low BW has long-term effects on visual acuity and refraction in adulthood.

Methods

The Gutenberg Health Study is a population-based, observational cohort study in Germany, including 15 010 participants aged between 35 and 74 years. These participants were divided into three different BW groups (low: <2500 g; normal: between 2500 and 4000 g; and high: >4000 g). Best-corrected visual acuity and objective refraction were examined. We used multivariable linear regression models with adjustment for age, sex, socioeconomic status and self-reported glaucoma, age-related macular degeneration, corneal disease and cataract to assess associations between BW and the main outcome measures, best-corrected visual acuity, spherical equivalent and astigmatism.

Results

Overall, 8369 participants reported their BW. In a multivariable analysis, an association for low BW with spherical equivalent (B=−0.28 per dioptre, P=0.005) and best-corrected visual acuity (B=0.02 logarithm of the minimum angle of resolution, P=0.006) compared with normal BW was observed. For participants with high BW, an association was observed with spherical equivalent (B=0.29 per dioptre, P<0.001), while none with visual acuity.

Conclusions

Our data demonstrated that low BW is linked to visual acuity and refractive long-term outcomes long after childhood. Individuals with low BW are more likely to have lower visual acuity and a higher myopic refractive error in adulthood. Adults with high BW are more likely to have a more hyperopic refractive error.

[Prevalence and Risk Factors of Myopia in Children and Adolescents in Germany - Results of the KiGGS Survey]

Purpose To determine the population prevalence and risk factors of myopia in children and adolescents in Germany. Methods The prevalence of myopia in Germany was computed using data from the 2003-2006 German Health Interview and Examination Survey for Children and Adolescents (N=17 640, 49% girls). Status of myopia was derived from parental questionnaire responses for myopia and the use of spectacles. Potential risk factors were identified using directed acyclic graphs and evaluated using multivariable logistic regression analysis. Results The population prevalence of myopia in the age group 3-17 years was estimated at 13.3% (95%-confidential interval 12.6-14.0%). In the age group 3-10 years, myopia was positively associated with age (per 2 years: OR=1.78 [1.59; 2.00]) and negatively associated with male gender (OR=0.73 [0.57; 0.95]), but neither with leisure-time activities nor with media use. In the age group 11-17 years, attending a High School was positively associated with myopia (OR=1.69 [1.32; 2.16]), while regular physical activity (OR=0.67 [0.53; 0.84]) was negatively associated. Media use was not associated. Conclusions In Germany, myopia is one of the most frequent chronic medical conditions among children and adolescents. Girls, adolescents, and pupils attending a Gymnasium are at higher risk of developing myopia while being physically active may be protective.

The prevalence of amblyopia in Germany: data from the prospective, population-based Gutenberg Health Study

BACKGROUND

Amblyopia is due to insufficient development of the visual system in early childhood and is a major source of lifelong impairment of visual acuity. Too little is known about the prevalence of amblyopia in Germany and the frequency of its various causes.

METHODS

The Gutenberg Health Study of the University of Mainz Faculty of Medicine is an ongoing population-based, prospective, monocentric cohort study with 15 010 participants aged 35 to 74. All participants are examined for the presence of ocular, cardiovascular, neoplastic, metabolic, immunologic, and mental diseases. 3227 participants aged 35 to 44 underwent ophthalmological examination from 2007 to 2012. Amblyopia was defined as impaired visual acuity in the absence of any organic pathology capable of explaining the condition, and in the presence of a known risk factor for amblyopia.

RESULTS

Amblyopia, when defined as a visual acuity less than or equal to 0.63, was present in 182 participants (5.6%, 95% confidence interval [CI] 4.9-6.5%), 120 of whom had a visual acuity less than or equal to 0.5 (3.7%, 95% CI 3.3-5.2%). A narrower definition of amblyopia requiring, in addition, an interocular difference in acuity of at least two lines yielded slightly lower prevalence figures: 5.0% (95% CI 4.2-5.8%) and 3.7% (95% CI 3.1-4.4%), respectively. The causes of amblyopia (visual acuity ≤ 0.63) were anisometropia (different refractive strengths of the two eyes) in 49% of participants, strabismus (a squint) in 23%, both of these factors in 17%, and visual deprivation in 2%. 3 patients (2%) had relative amblyopia due to a traumatic cataract sustained in early childhood. 7% of the participants with amblyopia had binocular amblyopia.

CONCLUSION

This study yielded a prevalence figure of 5.6% for amblyopia in Germany-a higher figure than in other, comparable population-based studies, which have generally yielded figures of ca. 3% for visual acuity ≤ 0.63. The distribution of the causes of amblyopia is similar across studies.

Charles Bonnet's syndrome: not only a condition of the elderly

PURPOSE

To investigate whether the experience of visual hallucinations, namely Charles Bonnet's syndrome, in psychologically healthy people is a phenomenon solely of elderly, visually impaired people.

METHODS

In a prospective controlled study, four groups of subjects (total 324) were formed: age ≤40 years, no visual impairment; age ≤40 years, visually impaired; age >40 years, no visual impairment; age >40 years, visually impaired. Visual impairment was defined as best-corrected visual acuity ≤0.3 (Snellen) in the better-seeing eye. Each group consisted of 81 subjects. Visual hallucinations were defined as complex visual perceptions. After ruling out psychiatric causes for visual hallucinations or medication related to the experience of visual hallucinations, affected subjects underwent a detailed interview about their visual hallucinations.

RESULTS

The prevalence of visual hallucinations among young subjects with visual impairment was 4.9 %; among the elderly visually impaired subjects, it was 6.2 %. The difference was not statistically significant. No subject without visual impairment experienced visual hallucinations.

CONCLUSIONS

Charles Bonnet's syndrome is not limited to elderly people suffering from visual impairment, though there tends to be a higher prevalence of visual hallucinations in this group.

[Charles Bonnet's syndrome: clinical insights in a fascinating disease]

Even mentally and cognitively healthy people can experience visual hallucinations. These are called Charles Bonnet's syndrome, named after the Swiss scientist, who first described such perceptions in the 18th century. Usually patients possess insight in the unreality of their visual experiences. The definitions of CBS are not consistent. Visual impairment or blindness is not part of every definition, but often is associated with CBS. Ophthalmologists should be aware of this syndrome, since its prevalence is high among blind or visually impaired people: patients often are reluctant to admit their hallucinatory experiences, because of the fear of being stigmatised. Possibly women are affected more often than men. CBS is well investigated in the elderly, but also young people might experience visual hallucinations. Hallucinatory contents commonly are persons, with varying duration of the hallucinations. Most patients experience more than one hallucinatory episode. CBS is best investigated in patients suffering from AMD. Neuroimaging studies suggest that cerebral abnormalities, mainly in the occipital cortex, might also play a role in the pathogenesis of CBS. Many patients do not require (drug) treatment, since education itself is helpful in most cases. The pathophysiology remains unclear, but there are a couple of theories.

Ependymal tissue in microphthalmia with cyst

PURPOSE

To report the nature of the contents of a cyst associated with microphthalmia and optic nerve coloboma in a male infant.

DESIGN

Clinicopathologic report.

CASE REPORT

A male infant in good general health presented with a massively swollen, protruded left lower eyelid since birth. The globe was not identifiable. MRI disclosed a microphthalmic globe in the upper nasal orbit and an orbital cystic mass consisting of various compartments. Examination of the fellow eye showed a large optic nerve coloboma. As the protrusion of the left lower eyelid was progressive, aspiration of the cyst was performed twice. Finally, the cyst was removed surgically due to repeated filling.

RESULTS

Examination of the aspirated fluid showed resemblance to cerebrospinal fluid (CSF). During surgery, the cyst was not found to communicate with the cerebrospinal fluid system. However, tissue resembling choroidal plexus lined the wall of the cyst that was adherent to the optic nerve. Histological evaluation of the tissue revealed ependymal cells.

DISCUSSION

The presence of CSF in microphthalmic cysts does not necessarily imply a connection to the CNS, but may be due to local CSF production by ectopic ependymal cells.