ITPR1-associated spinocerebellar ataxia with craniofacial features-additional evidence for germline mosaicism

Inositol 1,4,5-triphosphate receptor type 1 (ITPR1) is an endoplasmic reticulum-bound intracellular inositol triphosphate receptor involved in the regulation of intracellular calcium. Pathogenic variants in ITPR1 are associated with spinocerebellar ataxia (SCA) types 15/16 and 29 and have recently been implicated in a facial microsomia syndrome. In this report, we present a family with three affected individuals found to have a heterozygous missense c.800C > T (predicted p.Thr267Met) who present clinically with a SCA29-like syndrome. All three individuals presented with varying degrees of ataxia, developmental delay, and apparent intellectual disability, as well as craniofacial involvement-an uncommon finding in patients with SCA29. The variant was identified using clinical exome sequencing and validated with Sanger sequencing. It is presumed to be inherited via parental germline mosaicism. We present our findings to provide additional evidence for germline mosaic inheritance of SCA29, as well as to expand the clinical phenotype of the syndrome.

Lifting the White Walker's curse-Management of Coats' disease

Background

Coats' disease, described by George Coats in the early 1900s, is an idiopathic unilateral retinal vascular abnormality with exudation occurring in young males. It is characterized by retinal telangiectasia with intraretinal or subretinal exudation. Coats' disease is mostly diagnosed in the first to the second decade of life, with a common presentation of leukocoria. Younger patients have a more severe presentation and are associated with poor visual prognosis. Management of Coats' disease varies from observation, cryotherapy with anti-VEGFs (Vascular Endothelial Growth Factor), and surgery to enucleation. The mode of treatment depends on the age of presentation, the severity of the disease, and the stage of the disease. Through this video, we describe the clinical features, pathology, and surgical management of a 2-year-old child with grade 3B of Coats' disease.

Purpose

To demonstrate successful surgical management of grade 3B of Coats' disease in a 2-year-old boy.

Synopsis

Coats' disease mostly presents with a diagnostic dilemma due to its varied presentation. Early detection and treatment are the keys to salvaging the eye as well as the vision, hence, avoiding dreadful complications such as neovascular glaucoma or phthisis bulbi. We demonstrate successful surgical management of a child who presented with grade 3B of Coats' disease.

Highlights

Through this video, we aim to describe the clinical features, pathology, and surgical management of a 2-year-old child with grade 3B of Coats' disease. Combination of external drainage with vitrectomy, challenges faced, and the importance of visual rehabilitation postoperatively.

Video Link

https://youtu.be/0obpVTOkKKs.

Epidemiological aspect of retinoblastoma in the world: a review of recent advance studies

AIM

To collect and present updated evidence about epidemiological aspects of retinoblastoma (Rb) in the world.

METHODS

A comprehensive search without the time and language restrictions was conducted in international databases, including MEDLINE, Scopus, Web of Science, and PubMed. The search keywords were "retinoblastoma" OR "retinal Neuroblastoma" OR "retinal glioma" OR "retinoblastoma eye cancer" OR "retinal glioblastoma".

RESULTS

The worldwide incidence of Rb is 1 in 16 000-28 000 live births, but was higher in developing compared to developed countries. Several attempts for improving early detection and treatment had increased the Rb survival rate from 5% to 90% in developed countries over the past decade, but its survival was lower in developing countries (about 40% in low-income countries) and the majority of mortalities occurred in developing countries. The etiology of Rb could be viewed as genetics in the heritable form and environmental and lifestyle factors in the sporadic form. Some environmental risk factors such as in vitro fertilization; insect sprays; father's occupational exposure to oil mists in metal working, and poor living conditions might play a role in the occurrence of the disease. Although ethnicity might affect Rb incidence, sex has no documented effect and the best treatment approaches were now ophthalmic artery chemosurgery and intravitreal chemotherapy.

CONCLUSION

Determining the role of genetics and environmental factors helps to accurately predict the prognosis and identify the mechanism of the disease, which can reduce the risk of tumor development.

The Prevalence of Cataract in Children

Cataract is the leading cause of childhood blindness in developing countries. Early detection and treatment of childhood cataracts can reduce the burden of blindness in the nation. Often the etiology of pediatric cataract is idiopathic; however, genetics play a role in the development of congenital cataract. According to epidemiologists, one-fourth of cases of congenital cataracts are hereditary. Gene responsible for the development of cataract is identified using gene mapping, which helps to prevent future blindness in the family. Cataracts can also present with systemic disease, microphthalmia, microcornea, and aniridia. The presentation of cataracts varies in individuals, some are symptomatic while others are asymptomatic. Parents after noticing strabismus and leukocoria bring their children to an ophthalmologist. Early diagnosis can restore visual function in cases of congenital cataract. In young babies, the type of cataract is determined using slit-lamp examination and examination under anesthesia in OR. Most cases of pediatric cataracts are accidental findings during routine checkups. On direct ophthalmoscopy, red reflex is not appreciated in cases of cataracts. Advancing technology changes the ophthalmologist's approach to pediatric cataract surgery, improving postoperative refractory function. In children, minor incision surgery was preferred to heal early. An appropriate choice of intraocular lens (IOL) should be made for implantation in a child's eye to avoid postimplanted complications. Inflammation and amblyopia affect the outcome of treatment. Complications of cataract surgery include posterior capsule opacification, glaucoma, inflammation, and uveitis.

Retinoblastoma: A review of clinical profile at a regional cancer center in Northwest India

Background

Retinoblastoma is the most common primary intraocular malignancy of childhood. The present study was undertaken to overcome the scarcity of data regarding the epidemiology, demographic and clinical profile, and nature of the first health-care professional consulted.

Materials and Methods

A retrospective analysis of medical records was performed for all cases of retinoblastoma who presented to the department of ophthalmology and oncology between 2010 and 2017. A total of 54 cases were reviewed.

Results

Unilateral disease was seen in 85.2% while 14.8% presented with bilateral disease with a median age of 3 years and 2 years, respectively, at diagnosis. The male: female ratio was 2:1. The most common presenting symptom was leukocoria which was noticed in 42 patients (77.7%), followed by red eye (33.3%) and proptosis (20.3%). The most common stage of presentation was Stage I (44.4%), followed by Stage IV (20.4%), Stage III (9.3%), and Stage II (5.6%). The median time to diagnosis was 8.7 months (range, 0.5-98.7 months), and the median time to treatment was 37.4 days (range, 0-645 days). Majority of the patients were referred by local ophthalmologists (48%), followed by general practitioners (20%), nurses (19%), and quacks (13%). Enucleation was the most preferred treatment modality (48.1%), followed by chemotherapy (33.3%), radiotherapy (13%), photocoagulation (3.7%), and exenteration (1.9%). The overall remission rate was 79.6%, while 12.3% had relapse and 7.4% died.

Conclusion

The study showed a dire need for timely detection and treatment of retinoblastoma which is possible with improved awareness and better accessibility to health-care facilities. It also revealed a decrease in histopathological risk factors with chemoreduction.

Anatomo-Clinical Aspects of Retinoblastoma: A Series of 144 Cases

Retinoblastoma (RB) is the most common intraocular primary malignancy for infants and young children. The tumor is bilateral in 40% of cases and unilateral in 60% of cases. The hereditary form is due to a germinal mutation in the RB1 tumor suppressor gene. In developed countries, patients treated for RB have excellent survival, but unfortunately in developing countries delays in diagnosis and lack of human and financial resources are responsible for deaths. We conducted a retrospective study of 144 cases of RB in order to evaluate the clinico-pathological aspect of RB for the national reference center of RB in Morocco. Our study highlighted the indispensable collaboration between the clinician and the pathologist. Besides the diagnostic confirmation, the anatomopathological study gives us information on histopronostic risk factors to guide the treatment.

Late Diagnosis of Congenital Toxoplasmosis with Macrocephaly in Dizygotic Twins after Incidental Detection of Leukocoria: A Case Report

Untreated congenital toxoplasmosis remains an important cause of neurologic and ocular disease worldwide. However, congenitally infected infants may not have signs and symptoms their physicians recognize, leading to delayed diagnosis and missed opportunities for treatment. We describe a pair of twins diagnosed with congenital toxoplasmosis at 11 months of age following incidental detection of leukocoria in one twin.

Clinical Presentation of Retinoblastoma in Ethiopia: A Case of Jimma University Medical Center Pediatric Oncology Unit, Southwest Ethiopia

BACKGROUND

Retinoblastoma (RB) is one of the most curable childhood cancers if early detected and treated. Late presentation complicates the management of RB results in dismal treatment outcome. Objective: The aim of this study is to report the clinical presentation pattern of retinoblastoma patients seen at Jimma University Medical center (JUMC).

METHODS

The study was a retrospective review of retinoblastoma cases managed at JUMC between August 2016 and July 2020.

RESULTS

Among pediatric oncology cases registered retinoblastoma, accounting 8.5 % (36/423) of all childhood cancer patients in the study period, 29 (90.6%) of them had unilateral retinoblastoma and 3(9.4%) of them had bilateral retinoblastoma. The average age at presentation for bilateral and unilateral retinoblastoma patients was 17 (range 3-30) months and 37.5 months (range 8-84) respectively. The first symptom observed by the family was leukocoria in 21 (65.6%) of the patients but 24(75%) of the patients presented with advanced stage (proptosis and fungating orbital mass) of the disease. The longest and the shortest lag time of presentation from the first symptom was 17 months and 2 weeks respectively with the mean lag time of 1.4 months in bilateral and 6 months in unilateral cases. Clinically, the majority of the eyes 24/35(68.6%) were extraocular tumors involving orbital tissues at presentation.

CONCLUSION

Most of retinoblastoma patients presented at advanced stage of the disease and presented very late after the family observed the disease. Early detection strategies must be designed by the government and responsible stakeholders in mitigating the effects of late presentation.

Ocular Findings Associated With Myelinated Retinal Nerve Fibers

The case involves a five-year-old female patient with a myelinated retinal nerve fiber (MRNF) layer of the right optic disc. Although this is a rare, benign, and often asymptomatic condition, it is sometimes associated with ocular findings which require early detection and treatment. In this case, the patient presented with strabismus, high myopia, and amblyopia. She was found to have myelinated retinal fiber layer lesions of the superotemporal and inferotemporal retina of her right eye. This case report aims to demonstrate the importance of performing a thorough evaluation of MRNF in the pediatric patient as well as to increase awareness of this entity to avoid misdiagnosis.

Bilateral Persistent Hyperplastic Primary Vitreous: A Case Report and Review of the Literature

Bilateral persistent hyperplastic primary vitreous (PHPV) is a rare ocular disorder. Its clinical manifestations include bilateral corneal haziness, microphthalmia, and cataract. It is the second most common cause of leukocoria after retinoblastoma. Most cases of PHPV are unilateral. The typical imaging features of PHPV comprise bilateral echogenic masses and a fibrous cord extending from the posterior surface of the lens to the optic disc. In this report, we present a case of bilateral PHPV in an infant who presented with bilateral corneal haziness and watery discharge. A detailed ocular examination and knowledge about its features on imaging can lead to a timely and accurate diagnosis of the condition.

Unilateral Leukocoria in an Infant

A nine-day-old male infant presents with his mother to the pediatric clinic with a concern of a white spot in his right eye. There was no history of antenatal or perinatal complications and the mother's serology was negative. Physical examination was remarkable only for leukocoria in the right eye. He was evaluated to have a Mittendorf dot. This is a benign clinical finding. Pupillary reflex check is an important part of a physical examination which can recognise pathological conditions such as cataract, retinoblastoma, metabolic errors with ocular manifestations and lead to early treatment before the child loses vision.

Improving parents' knowledge of early signs of paediatric eye disease: A double-blind randomized controlled trial

IMPORTANCE

Educating parents to recognize signs of eye disease and consult a healthcare professional is critical to timely diagnosis, intervention and outcomes.

BACKGROUND

We evaluate the effectiveness of an eye-health information pamphlet on parents' level of concern and help-seeking intention should they hypothetically observe leukocoria or strabismus in their child.

DESIGN

Double-blind, randomized controlled trial conducted at a metropolitan antenatal outpatient clinic.

PARTICIPANTS

In total, 518 pregnant women were enrolled in the study.

METHODS

After completing a study-specific, pre-test survey describing hypothetical clinical scenarios at baseline, participants were randomly assigned to receive a pamphlet on either paediatric eye health (intervention) or infant play (control). The post-test survey was sent by email 2 weeks after baseline.

MAIN OUTCOME MEASURES

A change in the parents' level of concern if they observed leukocoria or strabismus and a change in their help-seeking intention if they hypothetically observed leukocoria or strabismus in their child.

RESULTS

Of the 518 women, 382 (73.7%) completed the post-test survey. At follow-up, women who received the intervention were more likely to report a higher level of concern if they observed leukocoria (OR 1.711 [CI: 1.176-2.497] P = .005]) and were less likely to delay help-seeking (OR 0.560 [CI 0.382-0.817] P = .003). No change in the level of concern for strabismus was identified between the groups; however, at follow-up, women who received the intervention were less likely to delay help-seeking (OR 0.318 [CI 0.125-0.806] P = .016).

CONCLUSION AND RELEVANCE

Providing parents with relevant, evidence-based information can significantly improve their knowledge and positively influence help-seeking intentions if leukocoria or strabismus are observed.

Detection of anomalies in the red reflex test requires adequate training

CLINICAL RELEVANCE

Midwives should receive appropriate training to enable them to reliably detect an abnormality in the red reflex, so as to detect potentially sight- (and possibly life-) threatening visual anomalies in newborns.

BACKGROUND

Midwives who had completed the relevant Newborn and Infant Physical Examination (NIPE) training in the UK, were tested to determine whether they could reliably detect an abnormality in the red reflex of a model eye. Their results were compared to a group of undergraduate optometry students in their final year, who had considerably more experience with ophthalmoscopy.

METHODS

Two groups of adult participants, 27 post-graduate midwives and 10 undergraduate optometry students with different levels of experience in ophthalmoscopy were recruited. Participants were required to perform the red reflex test repeatedly on a set of 10 model eyes with interchangeable simulated retinas, that produced both normal and abnormal 'red' reflexes, under controlled conditions.

RESULTS

A total of 1,810 observations were recorded across both groups of participants. Both the sensitivity and the specificity for distinguishing between normal and abnormal reflexes were higher for the optometry students (sensitivity 77.5 per cent and specificity 96.7 per cent) than the midwives (sensitivity 53.9 per cent and specificity 75.4 per cent). The positive predictive values were 21.7 per cent and 67.4 per cent for the midwives and optometry students, respectively. The negative predictive values were 92.8 per cent for the midwives and 98.0 per cent for the optometry students.

CONCLUSION

Despite completion of required training on the red reflex test, optometry students outperformed midwives in the detection of anomalous red reflex test simulations from a model eye. This result is likely due to differences in training in ophthalmoscopy between the two groups of participants. Additional training in the conduct of the red reflex test for midwives is therefore recommended.

Different Types of Clinical Presentations and Stages of Retinoblastoma Among Children

Introduction

Retinoblastoma (Rb) is the most common intraocular malignant tumor of childhood. The different modes of Rb presentation comprise proptosis, anterior chamber inflammatory signs, spontaneous hyphema, secondary glaucoma, and strabismus. The primary aim of this study was to investigate the different clinical presentations and stages of Rb that may help in early detection and timely diagnosis to prevent the advancement of the disease and increase rates of survival in children. 

Materials and methods

This was a descriptive cross-sectional study conducted between December 2019 and May 2020 over a period of six months at a tertiary care hospital in Karachi, Pakistan. The sample size included 68 eyes of children with lesions of Rb at the time of presentation to the hospital. Brightness scans (B-scans), computed tomography (CT) scans, and magnetic resonance imaging (MRI) were performed. The International Intraocular Retinoblastoma Classification (IIRC) was used to stage each eye. In case of enucleation (if necessary) of the eye, the biopsy was performed to evaluate the histological features of cancer. All statistical analysis was performed using Statistical Package for Social Sciences version 17.0 (IBM Corp., Armonk, New York).

Results

The mean age of the children was 3.21 ± 1.75 years. Leukocoria was the most common clinical presentation observed in more than half (n = 35, 51.47%) of the sample population followed by proptosis reported in nearly two-fifths (n = 25, 36.76%), strabismus and phthisis bulbi observed in equal proportions (n = 3, 4.41%), and hypopyon documented in a minor proportion (n = 2, 2.94%) of patients. Regarding stages of the Rb disease, the most common stages were observed to be stage C and stage E. 

Conclusions

This study concludes that the early detection of Rb is possible through a better understanding of presenting features of the disease. It can prevent the progression of the disease to the advanced stages and decrease morbidity and mortality. The early detection of Rb can be made possible through the examination of red reflex on the regular check-ups of children as leukocoria is the most common clinical presentation.

The Outcome of Manual Small Incision Cataract Surgery and Anterior Vitrectomy for Persistent Fetal Vasculature in an 18-Year-Old Woman: A One-Year Follow-Up

The surgical management of persistent fetal vasculature (PFV) is challenging and the visual outcome can be compromised by coexisting ocular pathologies and amblyopia. It can be considered for relief of retinal traction and improved cosmetic appeal when a squint or a posterior capsular cataract is present. In the case presented in this report, the intermittent exotropia improved from 45 to 30 degrees in one year, which suggests an improvement in binocular single vision. There was also a resolution of the leukocoria and retinal traction. The patient underwent the following examinations: visual activity, slit-lamp biomicroscopy, intraocular pressure (Goldmann), fundus photography (OCT TOPCON, 3D OCT-1 Maestro, Topcon, Tokyo, Japan), B-scan Doppler ultrasonography (Mindray DC-N3, Mindray, Shenzhen, China), Keratometry (Topcon KR 800, Topcon, Tokyo, Japan), and axial length (Sonomed 300AP+A Scan/Pachymeter, Sonomed Escalon, Lake Success, NY). Intraocular lens (IOL) power was calculated with the Sanders-Retzlaff-Kraff (SRK) II formula. During surgery, a rigid polymethyl methacrylate (PMMA) IOL was inserted into the sulcus after excision of the lesion and anterior vitrectomy. The first day's postoperative evaluation included visual acuity, corneal transparency, depth of anterior chamber, pupil size, shape, pupillary reaction to light, and position of the IOL. Intraocular pressure was normal within the follow-up period. Fundus photography and B-scan examinations were performed at one month and one year.

Abnormal Red Reflex: Etiologies in a Pediatric Ophthalmology Population

Children who present with an abnormal red reflex (ARR) are often referred to ophthalmology due to concern for retinoblastoma. However, an ARR can indicate a wide variety of pathologies, all of which have the potential to develop amblyopia and irreversible vision loss. In this retrospective cohort study, we demonstrate that children who presented with an ARR had a mean age of 22.0 ± 32.5 months and were more frequently referred by their pediatricians (74.5%). The majority of these patients (61.8%) had a normal examination on further evaluation, followed by refractive error (20.4%). Amblyopia was diagnosed in 83.9% of patients with refractive error, with a mean age of 50.3 ± 49.2 months. Because many ARR-associated pathologies require time-sensitive treatment to prevent vision loss, proper screening is critical for diagnosis. Pediatricians play a key role in screening, so education on more common ARR pathologies can better facilitate referrals and improve outcomes.

Coats' disease: characteristics, management, outcome, and scleral external drainage with anterior chamber maintainer for stage 3b disease

To report on the characteristics and outcome of management of Coats' disease, and to describe a novel surgical technique for management of stage 3B with total retinal detachment (RD) by scleral external drainage with anterior chamber (AC-maintainer) placement before the drainage without pars plana vitrectomy.A retrospective study of 26 eyes from 25 Coats' patients. Outcome measures included: demographics, presentation, laterality, stage, treatment, and outcome.The median age at diagnosis was 3.5 years. Twenty patients (80%) were males, and all except 1 girl had unilateral disease. The presenting complaint was impaired vision in 13 (50%) eyes, leukocoria in 6 (23%) eyes, and strabismus in 7 (27%) eyes. Based on the Shields classification; 3(12%) eyes were stage 1, 9 (35%) eyes were stage 2, 10 (38%) eyes were stage 3, 2 (8%) eyes were stag e4, and 2 (8%) eyes were stage 5. Primary management included cryotherapy (54%), laser photocoagulation (27%), intravitreal anti-vascular endothelial growth factor (23%), intravitreal steroids (23%), and surgical drainage (12%). The 3 eyes in stage 3B (with total exudative RD) underwent subretinal fluid drainage with AC maintainer, and all had the retina reattached completely for 6 months follow up after the surgery. At mean follow up 21 months, 4 (15%) eyes were enucleated, 19 (73%) eyes had improvement or stabilization in visual acuity.Coats' disease usually presents at advanced stage with poor visual prognosis, individualized management with close follow up are mandatory to save the eye. Subretinal fluid drainage with AC maintainer is a safe and useful technique for repairing total RD in eyes with stage 3B Coats' disease.

Photoleukocoria with smartphone photographs

A 3-year-old boy was referred with suspected leukocoria in the right eye, detected in all smartphone photographs taken by his parents. His medical and family history was unremarkable. The visual acuity was 20/20 in both eyes. Eye examination revealed full motility and normal pupils. The ocular fundi and ultrasonography appeared normal. The child was looking to the left side in his photographs, away from the camera, and illuminating the nasal retina. In this circumstance, the optic nerve head acts as a diffuse reflector, reflecting the light out of the eye through the pupil. In the case of normal clinical findings in a child presenting leukocoria in smartphone photographs (photoleukocoria), the ophthalmologist should suspect the possibility of the described phenomenon avoiding other studies.

Coats' disease - disease of the eye rarely encountered by pathologists

Coats' Disease is an idiopathic condition of the eye affecting young children although it can be seen in adults. Most patients present early in life with unilateral decreased vision, strabismus or leukocoria. The most important differential diagnosis is unilateral retinoblastoma. In this study we report a case of coat's disease in an young girl, and evaluate histopathological and clinical findings.

Crowd-sourced Ontology for Photoleukocoria: Identifying Common Internet Search Terms for a Potentially Important Pediatric Ophthalmic Sign

Purpose

Leukocoria is the most common presenting sign for pediatric eye disease including retinoblastoma and cataract, with worse outcomes if diagnosis is delayed. We investigated whether individuals could identify leukocoria in photographs (photoleukocoria) and examined their subsequent Internet search behavior.

Methods

Using a web-based questionnaire, in this cross-sectional study we invited adults aged over 18 years to view two photographs of a child with photoleukocoria, and then search the Internet to determine a possible diagnosis and action plan. The most commonly used search terms and websites accessed were recorded.

Results

The questionnaire was completed by 1639 individuals. Facebook advertisement was the most effective recruitment strategy. The mean age of all respondents was 38.95 ± 14.59 years (range, 18-83), 94% were female, and 59.3% had children. An abnormality in the images presented was identified by 1613 (98.4%) participants. The most commonly used search terms were: "white," "pupil," "photo," and "eye" reaching a variety of appropriate websites or links to print or social media articles.

Conclusions

Different words or phrases were used to describe the same observation of photoleukocoria leading to a range of websites. Variations in the description of observed signs and search words influenced the sites reached, information obtained, and subsequent help-seeking intentions.

Translational Relevance

Identifying the most commonly used search terms for photoleukocoria is an important step for search engine optimization. Being directed to the most appropriate websites informing of the significance of photoleukocoria and the appropriate actions to take could improve delays in diagnosis of important pediatric eye disease such as retinoblastoma or cataract.

Familial exudative vitreoretinopathy presentation as persistent fetal vasculature

Purpose

To illustrate a presentation of familial exudative vitreoretinopathy (FEVR) that can be mistaken for persistent fetal vasculature (PFV) and the importance of wide angle fluorescein angiography in making this distinction. A patient was referred with a unilateral retrolental membrane and retinal detachment from PFV but was found to have FEVR.

Observations

A 4 month-old full-term infant was referred with the diagnosis of PFV based on findings of a dense retrolental membrane and microphthalmia in the left eye. The patient had a near-complete retinal detachment with some exudation. Wide-field fluorescein angiography of the right eye revealed avascular retina and leakage at the vascular/avascular junction. Genetic testing confirmed a mutation in FZD4, supporting the clinical diagnosis of FEVR. Prompt laser therapy to the avascular area in the right eye was performed and lensectomy/vitrectomy with membrane dissection was performed in the left eye.

Conclusions and importance

FEVR can present with great variability between eyes. In patients presenting with findings suggestive of PFV, careful bilateral examination with wide-field fluorescein angiography is helpful. Early diagnosis and treatment are important to preserve visual acuity, especially in the less affected eye.

Retinoblastoma in Mongolia: Clinical characteristics and survival from 1987 to 2014

Background/Purpose:

This study aims to describe the clinical characteristics and treatment outcome of retinoblastoma in Mongolian children.

Methods:

Data of all children diagnosed with retinoblastoma at the National Center for Maternal and Child Health of Mongolia from 1987 to January 2014 were reviewed retrospectively. The ICRB classification was used. Survival characteristics of the cohort were analyzed.

Results:

Retinoblastoma was diagnosed in 79 eyes of 64 cases during the study period. Median age of diagnosis was 24.5 ± 15.8 months. There were no differences in sex ratio, and 15 cases (23%) were bilateral. Forty-three (67%) patients were from rural areas. The more frequent clinical presentations were leukocoria in 50 (78%) patients, strabismus in 24 (38%) patients, and glaucoma in 21 (33%) patients. Sixty-one (95%) patients were diagnosed with Classification D or worse when presented to us. Due to late diagnosis in the majority of cases, unilateral and bilateral enucleations were performed in 48 (61%) eyes and 24 (30%) eyes, respectively; exenteration was done in three (4%) eyes. Fifty-two (81%) patients received chemotherapy and 13 (8.3%) patients underwent external beam radiation after enucleation. At the time of last follow-up, 52 (81%) patients were alive, five (8%) patients were dead, and seven (11%) patients had lost to follow-up or unknown vital status. The mean follow-up period was 121.5 months (range, 12–360 months). In five cases with immunohistochemistry analysis in the eye specimen, neuron-specific enolase-, Ki-67 protein-, and B-cell lymphoma 2-positive cells were found in all five (100%) cases and Rb protein was detected in three (60%) cases.

Conclusion:

Retinoblastoma in Mongolia is frequently diagnosed at late stages and has a poor outcome. These data show the importance of early pediatric eye examinations and better treatment of retino-blastoma in children younger than 3 years in Mongolia.

Retinoblastoma

Retinoblastoma is the most common primary intraocular malignancy of childhood. It typically presents with leukocoria or strabismus. In later stages of the disease, the child may exhibit proptosis, buphthalmos, or hypopyon. The pathognomonic molecular aberration is a loss of function mutation in the RB1 gene on chromosome 13q. The degree of tumor involvement within the eye is defined by its group. Grouping was historically done with Reese-Ellsworth System. Recent therapeutic advances have led to the development of a new grouping system, the International Classification of Retinoblastoma (ICRB). In cases of extraocular extension and metastatic disease, the degree of tumor involvement outside of the eye is defined by its stage. Retinoblastoma is staged using the International Retinoblastoma Staging System (IRSS). Children with intraocular retinoblastoma have an excellent overall and ocular survival. In order to avoid the morbidity of enucleation and external beam radiation, treatments for isolated intraocular retinoblastoma have progressively moved toward targeted local modalities. Patients with extraocular involvement, such as those with trilateral retinoblastoma, have a poorer prognosis. The majority of these higher stage patients are now able to be cured with combination chemotherapy.

Bilateral persistent fetal vasculature due to a mutation in the Norrie disease protein gene

We report a case of a 7-week-old boy with bilateral leukocoria and asymmetric microphthalmia who was found to have Norrie disease. Symmetrically hyperdense globes with no evidence of calcification were seen on CT scan. The MRI showed bilateral retinal hemorrhages resulting in conical vitreous chambers-narrow at the optic disc and widened toward the lens-characteristic of persistent fetal vasculature. Genetic evaluation revealed a previously undescribed mutation in the Norrie disease protein gene.

Complications of combined retinal and retinal pigment epithelium hamartoma involving the optic disc in a child, treated with Avastin - a review of the literature and case presentation

We present a case of a 9 years old boy, followed up for 4 years, with bilateral combined pigmented epithelial and retinal hamartoma, complicated with recurrent vitreous hemorrhages in one eye and neovascular glaucoma and cataract in the other eye, treated with repeated intravitreal injections of Bevacizumab. A review of the literature suggested that such lesions may be symptomatic because of decreased vision, macular pucker, strabismus and vitreous hemorrhages. This particular compressive, bilateral form of hamartoma of the optic nerve has not previously been reported as a cause for such an ischemic syndrome, complicated with neovascular glaucoma and cataract.

Retinoblastoma: experience of a referral center in the North Region of Portugal

Purpose

To describe the experience of the Ophthalmology Department of Hospital São João (HSJ), a tertiary health care center in North Region, Portugal, in terms of the diagnosis, treatment, and follow-up of retinoblastoma.

Methods

This was a retrospective study of patients diagnosed with retinoblastoma in Hospital São João, between 1978 and 2012.

Results

Fifty patients with retinoblastoma were evaluated in our institution between 1978 and 2012. Four patients were excluded due to loss of follow-up. Among the 46 retinoblastoma cases, 33 (71.7%) were unilateral and 13 (28.3%) bilateral, with a mean age at diagnosis of 22.19 months and 6.92 months, respectively (P<0.001). Leukocoria was the most common presenting sign (36.9%), followed by strabismus (19.6%), a combination of leukocoria and strabismus (8.7%), and buphthalmia (2.2%). Between 1978 and 1992, nine retinoblastoma cases were referred to our hospital, all of them unilateral, and, in each case, enucleation was performed, with or without salvage therapy. Between 1993 and 2012, 18 eyes with retinoblastoma were successfully managed with conservative treatment.

Conclusion

Demographic results were generally coincident with previous reports. It is crucial to screen leukocoria in pediatric practice, even in asymptomatic children. The outcome of retinoblastoma treatment in our hospital is similar to other series in developed countries.

Retinoblastoma: concerning its initiation and treatment

Retinoblastoma (RB) is the most common intraocular cancer of infancy and childhood. This cancer is initiated by mutation on RB1, the tumor suppressor gene that is responsible for the regulation of both cell cycle and gnome stability in retinal cells. Patients with a constitutional mutation on RB1 can be inherited. RB occurs approximately 1 in every 15 000-20 000 live births. The worldwide mortality for this cancer is about 5%-11%. However, this rate rises to about 40%-70% in developing countries due to a delay in diagnosis. A wide variety of options are available for the treatment, but often a combination of therapies is adopted to optimize individualized care.

Proposal of a novel classification of leukocorias

Background

To report a case series of nine patients presenting with leukocoria without lens opacification or retrolental abnormalities and to propose a novel classification for leukocoria.

Methods

An institutional and retrospective study including a case series of patients assisted in the Congenital Cataract Section of Federal University of São Paulo, Brazil, during the period between 2005 and 2010 with prelenticular leukocoria and clear lens.

Results

Nine patients younger than 4 years old presented with the diagnosis of unilateral prelenticular opacities without cataract formation. Echography in all patients revealed no posterior segment or lens abnormalities in the affected eye. Among the patients, three had idiopathic prelenticular membrane, two presented with juvenile xanthogranuloma with secondary pupillary membrane, one had persistent fetal pupillary membrane, one had prelenticular membrane due to congenital toxoplasmosis, one presented with pupillary membrane due to hyphema caused by iris hemangioma, and one had anterior segment persistent fetal vasculature.

Conclusions

This case series of patients presented unilateral prelenticular leukocoria without lens opacification or posterior segment abnormalities. Several etiologies were associated with this condition. The correct diagnosis is important in order to avoid clear lens extraction. A new classification of leukocoria is proposed herein including: prelenticular leukocoria, lenticular leukocoria, retrolenticular leukocoria, and mixed presentation leukocoria.

Presentation of retinoblastoma at a paediatric eye clinic in ghana

BACKGROUND

Retinobalstoma, the commonest childhood malignant intraocular tumour, is usually diagnosed early with over 90% survival rate in developed countries. In developing countries, the diagnosis is late resulting in less than 50% survival.

OBJECTIVE

To determine retinoblastoma stages at presentation and patients' outcomes.

DESIGN

Retrospective case series.

METHODS

The clinical and histopathological records of children with retinoblastoma seen from May 2004 to December 2005 were studied. Data was analysed for mode of presentation, laterality, clinical staging using Reese-Ellsworth (R-E) classification, histopathological high risk features (HHRF) for metastasis, and patient outcome.

SETTING

Ophthalmology Unit, Korle-Bu Teaching Hospital, Ghana.

RESULTS

Twenty-three patients presented with retinoblastoma over the period. Males were 12(52.2%). The age range from 1 to 84 months, mean 36.3(±22.15) and median (36 months). Nineteen (82.6%) had unilateral and 4(17.4%) bilateral disease. The common clinical presentations were leukocoria in 20(87.0%), proptosis 8(34.8%), strabismus 5(21.7%) and red eye 5(21.7%). The clinical features were commensurate with R-E stage V in 20(87.0%) patients, 2(8.7%) with orbital recurrence and 1(4.3%) with post-enucleation anophthalmos. HHRFs were present in 9(75%) enucleated eyes with invasion of optic nerve as the commonest site (7/9). The patients were followed up for 1 day to 19 months. Eight abandoned treatment, 2 were discharged for palliative treatment, 2 out of 5 with metastasis died and 6 had no metastases at their last visit. Common sites for metastasis were the bone marrow, brain and orbit.

CONCLUSION

Majority of the patients presented with advanced disease manifesting as leukocoria, proptosis, RE stages V disease and poor outcome.

Clinical presentation of retinoblastoma in Malaysia: a review of 64 patients

AIM

To analyze the demography, presenting clinical features, spread of the disease of retinoblastoma in patients who were treated in two tertiary hospitals in Malaysia.

METHODS

In this retrospective study, information of gender, age, race, presenting clinical features, findings of CT scan orbits and brain, lumbar puncture and bone marrow aspiration results were collected from the medical records of retinoblastoma patients diagnosed in Hospital of Universiti Sains Malaysia and General Hospital of Kuala Lumpur over a period of ten years. The data were collected in the same type of proforma from both hospitals.

RESULTS

A total of 64 patients were treated in both hospitals together, of whom boys and girls were almost equally affected. The mean age of children at presentation was 24.2 (range 3-84) months, 53 (82.8%) children were under 36 months old. The disease was unilateral in 39 (60.9%) patients. The most common presenting signs were leukocoria in 46 (71.8%), followed by proptosis in 21 (32.8%) patients. Routine screening of the siblings of affected children revealed retinoblastoma in 2 patients. There was intracranial extension in 8 (12.5%) and metastasis in bone marrow in 6 (9.3%) patients.

CONCLUSION

Leukocoria is the most common presentation of retinoblastoma in Malaysia. However, the disease was intraocular in 40 (62.5%) and extraocular (orbital involvement, intracranial and distant metastasis) in 24 (37.5%) patients.

Differential diagnosis of leukocoria and strabismus, first presenting signs of retinoblastoma

Leukocoria in infants is always a danger signal as retinoblastoma, a malignant retinal tumor, is responsible for half of the cases in this age group. More common signs should also be considered suspicious until proved otherwise, such as strabismus, the second most frequent sign of retinoblastoma. Less frequent manifestations are inflammatory conditions resistant to treatment, hypopyon, orbital cellulitis, hyphema or heterochromia. Other causal pathologies, including persistent hyperplastic primary vitreous (PHPV), Coats' disease, ocular toxocariasis or retinopathy of prematurity, may also manifest the same warning signs and require specialized differential diagnosis. Members of the immediate family circle are most likely to notice the first signs, the general practitioner, pediatrician or general ophthalmologist the first to be consulted. On their attitude will depend the final outcome of this vision and life-threatening disease. Early diagnosis is vital.