INTRAVITREAL AFLIBERCEPT IN THE TREATMENT OF POLYPOIDAL CHOROIDAL VASCULOPATHY ASSOCIATED WITH MORNING GLORY SYNDROME

PURPOSE

To describe an unusual case of polypoidal choroidal vasculopathy secondary to morning glory syndrome successfully treated with three aflibercept intravitreal injections.

METHODS

Case report.

RESULTS

A 68-year-old white man presented with a 2-month history of diminished vision of his left eye. Fundus examination showed a morning glory syndrome disk anomaly with some perimacular subretinal hemorrhages and lipid depositions. Fundus autofluorescence, fluorescein and green indocyanine angiography, spectral domain optical coherence tomography, and optical coherence tomography angiography were performed and confirmed the presence of a juxtapapillary polypoidal choroidal vasculopathy with intraretinal and subretinal fluid. Patient underwent 3 monthly intravitreal injections of aflibercept and at 4-month follow-up visit, multimodal imaging findings did not show any kind of neovascular lesion activity.

CONCLUSION

Polypoidal choroidal vasculopathy can occur in morning glory syndrome and it can be successfully treated with anti-vascular endothelial growth factor intravitreal injections of aflibercept.

SWEPT SOURCE OPTICAL COHERENCE TOMOGRAPHY VALIDATES LAMINA CRIBROSA ANOMALY IN OPTIC DISK PIT

PURPOSE

Swept Source Optical Coherence Tomography validates lamina cribrosa anomaly in optic disk pit.

METHOD

Observational case report.

RESULTS

A 25-year-old African American male presented with decreased vision in right eye of 4 days duration. Best corrected visual acuity (BCVA) for distance in right eye was 20/200 and in left eye was 20/20. Dilated fundus examination of right eye showed serous macular detachment of entire posterior pole along with an optic pit on temporal margin of optic disk. En-face image of the optic disk on Swept source OCT (SS-OCT) confirmed defect in the lamina cribrosa in the right eye.

CONCLUSION

Congenital optic disk pit a birth defect in lamina cribrosa is a rare, visually impairing disorder. Spectral domain optical coherence tomography (SD-OCT) scan showed neurosensory detachment, however, lamina cribrosa defects are not delineated with it. SS-OCT a recent advance in scanning technology allows superior resolution of optic disk and confirms the anomaly of lamina cribrosa.

CONGENITAL CONTRACTILE PERIPAPILLARY STAPHYLOMA WITH RHEGMATOGENOUS RETINAL DETACHMENT

PURPOSE

To describe the occurrence of a congenital contractile peripapillary staphyloma in association with a rhegmatogenous retinal detachment.

METHODS

The clinical course of a 17-year-old patient with a contractile peripapillary staphyloma and undergoing pars plana vitrectomy for repair of an associated retinal detachment was studied.

RESULTS

The left eye showed a peripapillary staphyloma which during the ophthalmoscopical examination revealed contractile movements after the presentation of a light stimulus to either eye. The contraction of the peripapillary staphyloma was not correlated with a Valsalva maneuver, neck venous compression, forced lid closure, or respiratory movements. Because of a retinal detachment involving the inferior, nasal, and temporal retina, best-corrected visual acuity was 20/100. During pars plana vitrectomy under systemic anesthesia, the contractions of the peripapillary staphyloma subsided in the early phase of surgery, and reoccurred at approximately 80 minutes after the start of general anesthesia, when the posterior pole was touched with an aspiration syringe.

CONCLUSION

The etiology of the movements of the congenital peripapillary staphyloma in our patient may include a misbalance between intraocular pressure and orbital cerebrospinal fluid pressure or contractions of extraocular muscles. The observations may give information about the physiology and pathophysiology of the optic nerve head.

Recurrent De Novo Mutations Disturbing the GTP/GDP Binding Pocket of RAB11B Cause Intellectual Disability and a Distinctive Brain Phenotype

The Rab GTPase family comprises ∼70 GTP-binding proteins, functioning in vesicle formation, transport and fusion. They are activated by a conformational change induced by GTP-binding, allowing interactions with downstream effectors. Here, we report five individuals with two recurrent de novo missense mutations in RAB11B; c.64G>A; p.Val22Met in three individuals and c.202G>A; p.Ala68Thr in two individuals. An overlapping neurodevelopmental phenotype, including severe intellectual disability with absent speech, epilepsy, and hypotonia was observed in all affected individuals. Additionally, visual problems, musculoskeletal abnormalities, and microcephaly were present in the majority of cases. Re-evaluation of brain MRI images of four individuals showed a shared distinct brain phenotype, consisting of abnormal white matter (severely decreased volume and abnormal signal), thin corpus callosum, cerebellar vermis hypoplasia, optic nerve hypoplasia and mild ventriculomegaly. To compare the effects of both variants with known inactive GDP- and active GTP-bound RAB11B mutants, we modeled the variants on the three-dimensional protein structure and performed subcellular localization studies. We predicted that both variants alter the GTP/GDP binding pocket and show that they both have localization patterns similar to inactive RAB11B. Evaluation of their influence on the affinity of RAB11B to a series of binary interactors, both effectors and guanine nucleotide exchange factors (GEFs), showed induction of RAB11B binding to the GEF SH3BP5, again similar to inactive RAB11B. In conclusion, we report two recurrent dominant mutations in RAB11B leading to a neurodevelopmental syndrome, likely caused by altered GDP/GTP binding that inactivate the protein and induce GEF binding and protein mislocalization.

Recurrent Macular Detachment Due to Occult Retinal Break in a Patient With Optic Disc Pit

Serous macular detachment occurs in nearly 50% of eyes with optic disc pit. These macular detachments have been historically difficult to treat. The authors report a case of macular retinal detachment due to an occult juxtapapillary retinal break in a patient with optic disc pit refractory to prior treatments. This case demonstrates that a presumed serous detachment associated with an optic disc pit may have a rhegmatogenous etiology. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:432-434.].

Congenital optic nerve anomalies

OBJECTIVE

To update the current knowledge about congenital optic disc anomalies.

METHODS

A comprehensive literature search was performed in the major biomedical databases.

RESULTS

Patients with these anomalies usually have poor vision in infancy. Refractive errors are common, and serous retinal detachment may develop in some of these anomalies. It is critically important to clinically differentiate between these congenital optic disc anomalies, as central nervous system malformations are common in some, whereas others may be associated with systemic anomalies.

CONCLUSIONS

Congenital optic disc anomalies are a heterogeneous group of pathologies with characteristic fundus appearance and systemic associations. We should always try to make a correct diagnosis, in order to ask for specific tests, as well as to provide an adequate follow-up.

Six3 regulates optic nerve development via multiple mechanisms

Malformations of the optic nerve lead to reduced vision or even blindness. During optic nerve development, retinal ganglion cell (RGC) axons navigate across the retina, exit the eye to the optic stalk (OS), and cross the diencephalon midline at the optic chiasm en route to their brain targets. Many signalling molecules have been implicated in guiding various steps of optic nerve pathfinding, however much less is known about transcription factors regulating this process. Here we show that in zebrafish, reduced function of transcription factor Six3 results in optic nerve hypoplasia and a wide repertoire of RGC axon pathfinding errors. These abnormalities are caused by multiple mechanisms, including abnormal eye and OS patterning and morphogenesis, abnormal expression of signalling molecules both in RGCs and in their environment and anatomical deficiency in the diencephalic preoptic area, where the optic chiasm normally forms. Our findings reveal new roles for Six3 in eye development and are consistent with known phenotypes of reduced SIX3 function in humans. Hence, the new zebrafish model for Six3 loss of function furthers our understanding of the mechanisms governing optic nerve development and Six3-mediated eye and forebrain malformations.

High-Resolution Imaging of the Optic Nerve and Retina in Optic Nerve Hypoplasia

PURPOSE

To investigate the optic nerve and macular morphology in patients with optic nerve hypoplasia (ONH) using spectral-domain optical coherence tomography (SD OCT).

DESIGN

Prospective, cross-sectional, observational study.

SUBJECTS

A total of 16 participants with ONH (10 female and 6 male; mean age, 17.2 years; 6 bilateral involvement) and 32 gender-, age-, ethnicity-, and refraction-matched healthy controls.

METHODS

High-resolution SD OCT (Copernicus [Optopol Technology S.A., Zawiercie, Poland], 3 μm resolution) and handheld SD OCT (Bioptigen Inc [Research Triangle Park, NC], 2.6 μm resolution) devices were used to acquire horizontal scans through the center of the optic disc and macula.

MAIN OUTCOME MEASURES

Horizontal optic disc/cup and rim diameters, cup depth, peripapillary retinal nerve fiber layer (RNFL), and thickness of individual retinal layers in participants with ONH and in controls.

RESULTS

Patients with ONH had significantly smaller discs (P < 0.03 and P < 0.001 compared with unaffected eye and healthy controls, respectively), horizontal cup diameter (P < 0.02 for both), and cup depth (P < 0.02 and P < 0.01, respectively). In the macula, significantly thinner RNFL (nasally), ganglion cell layer (GCL) (nasally and temporally), inner plexiform layer (IPL) (nasally), outer nuclear layer (ONL) (nasally), and inner segment (centrally and temporally) were found in patients with ONH compared with the control group (P < 0.05 for all comparisons). Continuation of significantly thicker GCL, IPL, and outer plexiform layer in the central retinal area (i.e., foveal hypoplasia) was found in more than 80% of patients with ONH. Clinically unaffected fellow eyes of patients with ONH showed mild features of underdevelopment. Visual acuity and presence of septo-optic dysplasia were associated with changes in GCL and IPL. Sensitivity and specificity for the detection of ONH based on disc and retinal optical coherence tomography (OCT) parameters were >80%.

CONCLUSIONS

Our study provides evidence of retinal changes in ONH. In addition to thinning of retina layers mainly involving the RNFL and GCL, signs reminiscent of foveal hypoplasia were observed in patients with ONH. Optic nerve and foveal parameters measured using OCT showed high sensitivity and specificity for detecting ONH, demonstrating their useful for clinical diagnosis.

Unilateral Morning Glory Disc Anomaly With Ipsilateral Limbal Dermoids

The authors present the case of a child with multiple limbal dermoids and morning glory disc anomaly in the right eye. These anomalies are rarely associated and this is the first report of co-occurrence in the same eye in a patient without additional systemic anomalies.

[Congenital optic disc anomalies--own observations]

The aim of this article is to present a clinical picture of congenital optic nerve anomalies, which occur quite frequently in the general population, may cause low vision and visual field defects. These abnormalities can coexist with central nervous system defects or the other ocular abnormalities. Some of them may be misdiagnosed as papilloedema during the episode of intracranial fluid pressure elevation or glaucomatous neuropathy. Diagnosing the congenital nerve optic disc defects coexisting with multiorgans anomalies requires multidisciplinary medical care especially in babies. developmental optic disc anomalies, congenital eye abnormalities, differential diagnosis.

The identification and measurement of autistic features in children with septo-optic dysplasia, optic nerve hypoplasia and isolated hypopituitarism

This study aimed to highlight the occurrence of autism spectrum disorders (ASDs) in children with septo-optic dysplasia (SOD) and optic nerve hypoplasia (ONH). A cross-sectional study was designed, including 28 children with SOD and 14 children with ONH. Clinician diagnosis of ASD was reported in 14 children. The Social Communication Questionnaire (SCQ) reported that 23 children met the cut-off point for ASD, and 9 children met the cut-off point for autism. Greater levels of intellectual disability and visual loss were reported in children with ASD in comparison to those without ASD, but, of the two, intellectual disability was a better predictor for ASD. The SCQ lost its sensitivity and specificity in children who had greater visual loss which highlights a requirement for a measure that is sensitive to visual loss. It is also recommended that children with SOD/ONH would benefit from routine screening for ASDs.

An update on progress and the changing epidemiology of causes of childhood blindness worldwide

PURPOSE

To summarize the available data on pediatric blinding disease worldwide and to present current information on childhood blindness in the United States.

METHODS

A systematic search of world literature published since 1999 was conducted. Data also were solicited from each state school for the blind in the United States.

RESULTS

In developing countries, 7% to 31% of childhood blindness and visual impairment is avoidable, 10% to 58% is treatable, and 3% to 28% is preventable. Corneal opacification is the leading cause of blindness in Africa, but the rate has decreased significantly from 56% in 1999 to 28% in 2012. There is no national registry of the blind in the United States, and most schools for the blind do not maintain data regarding the cause of blindness in their students. From those schools that do have such information, the top three causes are cortical visual impairment, optic nerve hypoplasia, and retinopathy of prematurity, which have not changed in past 10 years.

CONCLUSIONS

There are marked regional differences in the causes of blindness in children, apparently based on socioeconomic factors that limit prevention and treatment schemes. In the United States, the 3 leading causes of childhood blindness appear to be cortical visual impairment, optic nerve hypoplasia, and retinopathy of prematurity; a national registry of the blind would allow accumulation of more complete and reliable data for accurate determination of the prevalence of each.

Spontaneous resolution of retinal detachment in morning glory disk anomaly

Morning glory disk anomaly is generally a unilateral, sporadic congenital abnormality of the optic disk. These eyes are at risk of developing retinal detachment requiring surgical repair. The etiology of retinal detachment is incompletely understood in this condition and some reports have attributed it to a retinal break. We report an unusual case of morning glory disk anomaly with total nonrhegmatogenous exudative retinal detachment that displayed remarkable subsequent spontaneous resolution.

SUNCT and optic nerve hypoplasia

SUNCT has been reported in association with abnormalities of the brainstem and pituitary region. We present a patient with a history of left optic nerve hypoplasia, mild hypothalamic-pituitary dysfunction, and SUNCT starting in adolescence. SUNCT with an early age of onset may be associated with congenital abnormality of the hypothalamic-pituitary axis.

Optic nerve hypoplasia and hypopituitarism

Optic nerve hypoplasia (ONH) has a wide clinical spectrum. When it is associated with absence of the septum pellucidum, it has been termed septo-optic dysplasia. Over the past 50 years, much has been learned about ONH and its association with pituitary endocrinopathies. Causative factors have been sought that may disrupt development of the optic nerve and the hypothalamic-pituitary axis simultaneously. The endocrinological aspects of ONH require lifelong monitoring and replacement of pituitary hormones when necessary. Children with ONH are also at greater risk for structural abnormalities of the brain, and abnormalities in certain structures are positively correlated with increased risk for pituitary deficiencies. However, it has also been shown that children with ONH and "normal" head imaging can still manifest endocrinopathies. Subsequently, a long-term multidisciplinary approach, involving pediatric specialists in ophthalmology, endocrinology, neurology, and behavioral therapy, is critical to optimize growth and development of all children with ONH.

Morphologie des Chiasma opticum bei Albinismus

Albinism is associated with a misrouting of fibers at the optic chiasm where the majority of fibers cross to the contralateral side. The cause of this abnormal decussation pattern reflects a disturbance of cell cycle regulation in the development of the retina which is in part controlled by melanin. Growing axons from retinal ganglion cells therefore arrive later than usual at the optic chiasm and are misrouted contralaterally. This atypical decussation leads to morphological changes of the optic chiasm including a reduced chiasm width with larger angles between optic nerves and tracts which can be shown by magnetic resonance imaging.

VEP asymmetry with ophthalmological and MRI findings in two achiasmatic children

Achiasmia is a rarely diagnosed visual pathway maldevelopment where all or the majority of nasal retinal fibres fail to decussate at the optic chiasm. It has been identified by neuroimaging and also by visual evoked potential (VEP) asymmetry. VEP asymmetry has not been defined consistently in previous studies. The aim was to study VEP asymmetry to flash stimulation in two children with maldevelopment of the optic chiasm in comparison to control children. Both children had congenital nystagmus, optic nerve hypoplasia with a bilateral small double ring, bitemporal visual field defect and normal colour vision. In child 1 visual acuity in both eyes was 0.1, in child 2 it was 0.2. MRI showed reduced chiasmal size in child 1, while in child 2 it was combined with other midline abnormalities. VEP to monocular flash stimulation showed in both children distinctive occipital distribution, which was not observed in control children. The N2 wave was distributed asymmetrically over the ipsilateral hemisphere to the stimulated eye, while the P2 wave was distributed over both hemispheres. The P2 wave was however better defined over the ipsilateral hemisphere. Flash VEP occipital distribution remained similar in child 1, who was followed from 10 months to 9 years. These cases of achiasmia demonstrate a distinctive VEP asymmetry in the distribution of the flash VEP N2 wave, as well as the expected structural defect determined by neuroimaging.

Different presentations of intraretinal fluid collections in optic disc pits: OCT study of 3 cases

The congenital optic disc pit is a rare anomaly that can lead to major visual impairment associated with subretinal fluid accumulation. The authors describe the optical coherence tomography study of three cases of untreated congenital optic disc pits with different levels of visual impairment and its different presentations of intraretinal fluid collections.

Clinical Feature Analysis of Congenital Optic Nerve Abnormalities

PURPOSE

We investigated the clinical characteristics and associated ocular and systemic anomalies in young children with congenital optic nerve abnormalities, and evaluated the therapeutic results of treatment for strabismus and amblyopia.

METHODS

A retrospective study was conducted using the medical records of patients who were diagnosed with congenital optic nerve abnormalities in our hospital between 1995 and 2004.

RESULTS

This study involved 72 eyes of 51 young children (M : F = 25 : 26); 21 of these patients (41.2%) had bilateral abnormalities. The types and percentages of each abnormality were as follows: optic nerve hypoplasia, 47%; optic disc coloboma, 31.4%; morning glory syndrome, 11.8%; and myelinated nerve fiber, 9.8%. The first clinical manifestations noticed by parents were strabismus and decreased visual acuity. Occlusion therapy was carried out in 16 patients, and the visual acuities of two patients were improved by more than two lines of the Early Treatment Diabetic Retinopathy Study visual acuity chart. Accompanying strabismus was found in 70.6% of the patients; 14 patients underwent strabismic surgery, and 10 of these patients (41.2%) maintained a stable angle.

CONCLUSIONS

The most common congenital optic nerve abnormality was optic nerve hypoplasia, and the associated systemic abnormalities found were optic nerve hypoplasia and disc coloboma. Patients with congenital optic nerve abnormalities usually have a generally poor visual prognosis, but we emphasize the importance of treatment for associated strabismus and amblyopia.

Retinal nerve fiber analysis and tomography of the optic disc in eyes with tilted disc syndrome

BACKGROUND AND OBJECTIVE

To investigate retinal nerve fiber layer thickness and optic disc parameters in eyes with tilted disc syndrome.

PATIENTS AND METHODS

Thirty-eight eyes with tilted disc syndrome (20 myopic control eyes, and 20 emmetropic control eyes) were examined. After a routine ophthalmologic examination of all eyes, scanning laser polarimetry (for retinal nerve fiber layer thickness) and scanning laser tomography (for optic disc parameters) were performed. Scanning laser polarimetry and scanning laser tomography parameters were compared in the different groups.

RESULTS

On scanning laser polarimetry evaluation, statistically significant differences were found in the superior integral, nasal integral, and superior nasal quadrants of eyes with tilted disc syndrome compared with control groups (P = .01, P = .04, P = .00, P = .00, P = .00, and P = .00, respectively). On scanning laser tomography evaluation, statistically significant differences were found in average diameter, total contour area, effective area, average depth, volume above, neuroretinal rim area, and cup-disc ratio in eyes with tilted disc syndrome compared with control groups (P = .00, P = .00, P = .00, P = .04, P = .02, P = .00, and P = .01, respectively).

CONCLUSION

Parameters acquired through imaging with scanning laser polarimetry and scanning laser tomography in eyes with tilted disc syndrome are different from those of normal eyes.

Cognitive and behavioural characteristics in blind children with bilateral optic nerve hypoplasia

AIM

To describe cognitive and behavioural characteristics in a group of blind children with bilateral optic nerve hypoplasia (ONH).

METHODS

Data from records, parents, teachers, and repeated developmental assessments of 13 blind children with ONH born in 1988-1998 were analysed. All children had neuroimaging and/or hormonal evidence of midline malformations. They were all blind and able to communicate with speech.

RESULTS

Severe mood swings and temper tantrums were common, especially during the first years of life. Later in life, sluggish tempo, low frustration tolerance and a narrow range of interests were common. Autism had been diagnosed in 6/13 children, autistic-like condition (ALC) was found in another three. The behaviour of the remaining four children was not within the autism spectrum. Eight children had cognitive capacities within the normal or near-normal range; five had mental retardation. Autism/ALC was found in all cognitive subgroups. All children exhibited fluent speech and, of these, 12 had started to talk at the expected age, but had clear deficiencies in communicative ability.

CONCLUSION

These children had a common pattern of behavioural characteristics including autism spectrum disorders independent of intellectual capacities.

Optical coherence tomography study of tilted optic disk associated with macular detachment

PURPOSE

To describe the macular findings by optical coherence tomography in both eyes of a patient with tilted optic disk and visual decrease.

METHODS

A 35-year-old woman with bilateral tilted optic disk and serous macular detachment was examined by slit-lamp biomicroscopy, fluorescein angiography, indocyanine green angiography and optical coherence tomography (OCT).

RESULTS

Fluorescein angiography demonstrated staining of the temporal rim of the staphyloma adjacent to the optic disk and hyperfluorescence of the diffuse pigmentary changes in the papillomacular area. Leakage points and serous macular detachment were not observed. The existing neurosensory detachment at the fovea became evident only by OCT.

CONCLUSIONS

The existence of subretinal fluid, which became evident only by OCT, supports the view that OCT could further contribute to the study of the asymptomatic pigmentary lesions of the macula that are present in 11% of eyes with tilted optic disk. The reason for the localized macular detachment remains unclear. Dysfunction of the retinal pigment epithelium (RPE) or leakage of the optic disk staphyloma rim could possibly explain the cause of fluid accumulation in the macula.

Intraocular surgery for optic nerve disorders

This article discusses two current indications for intraocular surgery for optic nerve conditions. The first topic is macular detachment in association with congenital optic disc pit, and includes a review of the theories of pathogenesis and management options including our own experience of treatment with vitrectomy and gas tamponade. In addition, the histopathological findings of a new case of optic disc pit with serous macular detachment are presented, adding to the rare examples previously reported. The second subject is a radial optic neurotomy, a recently advocated treatment for central retinal vein occlusion, which, despite its controversial nature, is gaining in popularity.

Congenital disorders of the optic nerve: excavations and hypoplasia

The principal congenital abnormalities of the optic disc that can significantly impair visual function are excavation of the optic disc and optic nerve hypoplasia. The excavated optic disc abnormalities comprise optic disc coloboma, morning glory syndrome, and peripapillary staphyloma. Optic nerve hypoplasia manifests as a small optic nerve, which may or may not be accompanied by a peripapillary ring (the double ring sign). In addition, the optic disc cupping, which occurs as a sequel to some cases of periventricular leucomalacia, can arguably be classified as a type of optic nerve hypoplasia. All of these conditions can be unilateral or bilateral and can impair visual function mildly or severely. It is essential that children with poor vision due to any of these conditions are managed by treating refractive errors, giving occlusion therapy in selected cases, and optimising the conditions at home and at school in an attempt to ensure that impaired vision does not impede development or education.

[An association between moya-moya disease and morning glory anomaly]

INTRODUCTION

The morning glory disc anomaly is a not very frequent congenital alteration of the optic papilla associated with a retinal vascular dysgenesia. Several cases of association have been described between this disc anomaly and the presence of Moyamoya vessels. We report the case of a boy with this association.

CASE REPORT

A 5 year-old boy was evaluated for several episodes of disconnection, some of them preceded by intense headaches and associated to incoherent language, and in other occasions with hypotonia and unmotivated laugh of variable duration. The physical and neurological exploration was normal, except for the optic disc papilla of the right eye that was very big and dug, compatible with Morning glory disc anomaly. No alterations were found at cranial CT and EEG. In the magnetic resonance imaging were visualized multiple small round low intensity areas in the basal ganglia, because of the high number of collateral vessels. The angioRM showed stenosis of the supraclinoid portions of both internal carotids as well as the proximal segments of the anterior cerebral artery and the left middle cerebral artery with abnormal network of collateral vessels at the base of the brain like a puff of smoke . This is a typical imaging for Moyamoya disease.

CONCLUSIONS

In all patient with Morning glory disc anomaly, mainly if they presents neurological clinical features, the realization of angioRM studies will be evaluated, to discard the existence of Moyamoya disease.

Posterior ocular malformations in children: somatic, neuroradiological and cognitive aspects

AIM

To investigate associated neurological, endocrinological and cognitive dysfunctions in children with visual impairment caused by optic nerve hypoplasia or optic nerve/fundus coloboma and/or microphthalmus.

METHODS

Forty children born between 1990 and 1998 were assessed by neurological examination, re-evaluation of neuroradiological investigations, review of medical records and examination of cognitive levels.

RESULTS

Neurological dysfunctions (epilepsy and/or motor impairment) were found in 13/28 children with optic nerve hypoplasia and in 3/12 children with coloboma/microphthalmus. The optic pathways were thin in 22/24, an abnormal posterior pituitary gland and/or thin infundibulum was found in 16/22 and absence of septum pellucidum in 14/27 children with optic nerve hypoplasia. Other types of cerebral abnormalities occurred in 9/26 children. Among children with coloboma/microphthalmus, the optic pathways were thin in 4/8 children but none had pituitary or cerebral midline abnormalities. Sixteen children with optic nerve hypoplasia were receiving hormone substitution but none of the children with coloboma/microphthalmus. Thirteen of the 16 children with optic nerve hypoplasia and with an abnormal pituitary region had endocrinological deficiencies. Mental retardation was found in 9/24 of the children with optic nerve hypoplasia and in 5/10 of the children with coloboma/microphthalmus.

CONCLUSION

Endocrinological. neurological and neuroradiological defects seem more common in children with optic nerve hypoplasia than in children with coloboma. A pituitary region that appears abnormal in magnetic resonance imaging seems to predict endocrinological deficits in children with optic nerve hypoplasia.

[Formation of congenital anomalies of the optic disc. Part I. Embryological and genetic aspects of the optic disc and nerve development]

Embryogenesis of the eye was presented and definite time of arising congenital anomalies of the optic disc, which characterized abnormal diameter disc, was determined on its background. As well genes, which control development of the optic disc were detailed.

[Formation of congenital anomalies of the optic disc. Part II. Congenital anomalies of the optic disc with inappropriate disc size]

Embryological conditions, each of fifth congenital anomalies of the optic disc from the group of anomalies of inappropriate optic diameter was described. Few available epidemiological data were given. The influence of medications, drugs, intoxications, as well as premature birth on genesis of congenital anomalies was taken into consideration. Malformation of central nervous system was introduced together with clinical syndromes related to congenital anomalies of the optic disc indicating the genetic condition.

Optic nerve entrance coloboma associated with situs inversus

A rare case of optic nerve entrance coloboma associated with situs inversus is reported.

Cyst formation in optic disc pit maculopathy

PURPOSE

To evaluate the presence and the evolution of cyst formation in optic disc pit maculopathy.

METHODS

In this prospective study, 18 cases with optic disc pit maculopathy were studied. Five of them showed cyst formation in the fovea at the initial examination. The fundus findings were documented with slit-lamp biomicroscopy, indirect ophthalmoscopy, and stereoscopic photography of the posterior pole. All 5 patients were treated with a macular scleral buckle procedure.

RESULTS

The presence of cysts in the elevated macula depends on the grade of the disease. Cyst formation can develop not only in the later stage of the disease but also quite early. In all 5 patients cyst formation gradually decreased and finally disappeared after the surgical procedure.

CONCLUSIONS

Cyst formation is an entity which accompanies the macular detachment associated with optic disc pit. The development of the cysts has been noticed after the establishment of the schisis-like separation and before or in conjunction with the formation of a lamellar macular hole which usually accompanies the optic disc pit maculopathy.

A patient with de Morsier and Duane syndromes

de Morsier syndrome, or septo-optic dysplasia, is a developmental malformation complex characterized by optic nerve hypoplasia, dysgenesis of the septum pellucidum, and hypothalamic-pituitary dysfunction. (1,2) In Duane retraction syndrome, there is absence of the sixth nerve nucleus with congenital retraction of the globe and narrowing of the lid fissure in adduction, frequent abduction deficiency, and variable limitation to adduction of the affected eye. (3) The purpose of this report is to present a patient with the uncommon and previously unreported concurrence of both of these congenital malformation complexes, presumably because of a common disturbance of neuronal development.

The macular buckling technique in the treatment of optic disk pit maculopathy

In 1988 we introduced the macular buckling procedure for the treatment of optic disk pit maculopathy and we have been applying it since then. The surgery consists of a scleral sponge fixation of 7.5 x 5.5 mm at the posterior pole of the globe corresponding to the macula along the vertical axis of the 12 to 6 o'clock meridian. No additional treatment of any kind (laser, diathermy, or cryotherapy) is used. The correct positioning of the sponge during the surgery is monitored by B-scan ultrasonography. Within the first week after surgery, indocyanine green angiography (ICG) is used to evaluate the choroidal circulation. During the same period, magnetic resonance imaging (MRI) of the orbit is performed to determine the sponge position in relation to the optic nerve. We analyze the results of 23 eyes with optic disk pit maculopathy that underwent surgery with the macular buckling technique between November 1988 and December 1998. In 20 of them the macula and the surrounding area of the retina became completely flat. No recurrence was noted in the successfully treated patients in the follow-up period, which ranged from 9 months to 10 years. Visual acuity was improved by 1 to 7 Snellen lines in 18 of the 23 patients. An improvement in visual field indices was also recorded. The sponge positioning between the temporal part of the optic disk and the macula acts mechanically and seems to provide a barrier that prevents the flow of the fluid from the pit toward the macula.

Imaging of the pediatric orbit

This article addresses the embryology of the eye, the imaging of common congenital malformations involving the globe, and imaging features of common retro-ocular masses. Clinical entities resulting in alterations in the size and contour, and those producing leukokoria, also are discussed.

Tilted disc syndrome

BACKGROUND

Tilted disc syndrome (TDS) has a varied morphological appearance which can be difficult to differentiate from acquired optic nerve pathology. In addition, there are visual deficits and potential complications associated with this syndrome. Failure to recognize features of the TDS frequently leads to unnecessary medical evaluation or improper examination for possible associated ocular complications.

METHODS

The literature is reviewed to examine the embryonic developmental defects that create TDS. Characteristic ophthalmoscopic features of the disc, visual field deficits, electrofunctional abnormalities, retinal pigment epithelial and choroidal hypoplasia, refractive error, and choroidal neovascular development are examined from a clinical standpoint.

RESULTS

The literature clearly identifies visual deficits and ocular complications, which must be understood in the context of TDS.

CONCLUSIONS

TDS is a congenital anomaly that has visual deficits and an appearance that can mimic serious neurological disease. Also, there are potential vision-threatening complications that are typically not associated with a congenital anomaly.

[Anomalies of optic nerve excavation: the clinical manifestations and differential diagnosis]

Clinical features, electrophysiological characteristics, neuroradiological symptoms and associations with systemic malformations have been studied in 76 children with abnormalities of the optic nerve excavation: the morning glory syndrome, optic nerve coloboma, and congenital peripapillary staphyloma. Based on the results, the criteria are determined for the differential diagnosis of these optic nerve abnormalities and the hypothesis on their different embryogenesis is confirmed.

Congenital intraorbital optic nerve cyst. Case report

Congenital cystic lesions of the optic nerve are exceedingly rare; only one case is reported in the world literature. The authors describe a case of congenital simple glial cyst in the intraorbital portion of the optic nerve with a brief review of the literature and comment on its histogenesis. A 45-day-old male infant was admitted to the hospital because of progressive proptosis and hypotropia in the left eye, which had been present since birth. Magnetic resonance imaging of the left orbit revealed an ovoid, well-demarcated, homogeneous cystic mass in the intraconal retrobulbar area. The mass compressed the left eyeball with downward and lateral displacement. The wall of the cystic mass was very thin, and a needle puncture of the cyst released clear, colorless, watery fluid. The cystic wall was lined by loose astroglial nerve fibers with some scattered glial cells.

Fluorescein and indocyanine green angiographic findings in congenital optic disk pit associated with macular detachment

PURPOSE

To investigate the pattern of congenital optic disk pits associated with maculopathy using indocyanine green angiography (ICG) and fluorescein angiography (FA).

METHODS

Seventeen consecutive patients with unilateral congenital optic disk pit complicated by maculopathy were prospectively enrolled in the study. Complete ophthalmologic examination, color stereophotography, red-free photography, FA, and ICG angiography were performed on all patients during their first examination in our department.

RESULTS

Absolute hypofluorescence of the optic disk pit was noted in all eyes on ICG angiography. On the contrary, all eyes showed early hypofluorescence and late staining of the optic pit on FA. All 17 eyes presented a delineated late hyperfluorescence corresponding to the area of macular elevation on both ICG angiography and FA. The intensity of the hyperfluorescence was milder in cases with long-standing maculopathy.

CONCLUSION

Imaging of congenital optic disk pits associated or not with macular elevation using ICG angiography has not been reported in the literature. The increased hyperfluorescence in the late phases of the macular elevation in the studied eyes could be attributed to leakage of indocyanine or fluorescein dye into the schisis cavity and the subretinal fluid.

Congenital optic nerve anomalies

Congenital optic nerve anomalies are not as rare as was once thought. Visual prognosis depends on the type of anomaly present. Both central nervous system and systemic abnormalities have been associated with congenital optic nerve anomalies. Therefore, correct diagnosis has important visual and systemic implications. Congenital optic nerve anomalies are distinguished by the optic disc and peripapillary retinal appearance. In general, these anomalies can be grouped by abnormalities of optic disc size or conformation and by the presence of tissue not usually present at the disc.

Macular serous retinal detachment caused by subretinal leakage in tilted disc syndrome

OBJECTIVE

To describe a previously unreported complication of tilted disc syndrome: serous retinal detachment, caused by subretinal leakage, that mimics chronic idiopathic central serous chorioretinopathy (ICSC).

DESIGN

Retrospective cohort study.

PARTICIPANTS

Five patients (five eyes) participated.

MAIN OUTCOME MEASURES

Fluorescein angiographic features were measured.

RESULTS

All patients presented with visual loss and metamorphopsia. Fundus examination showed features typical of tilted disc syndrome, including obliquely directed long axis of the disc, situs inversus, retinal pigment epithelium conus, hypopigmentation and staphylomatous ectasia inferonasal to the optic disc, as well as a serous retinal detachment. Fluorescein angiography showed a site of leakage or multiple focal areas of staining and atrophy of the retinal pigment epithelium that correlated to the linear pigmentary changes observed at the junction with the inferior staphyloma. The fluorescein angiographic pattern was very similar to that of chronic ICSC. Spontaneous healing occurred in one case, and successful photocoagulation of the site of leakage was applied in two cases; two eyes could not be photocoagulated because of diffuse leakage in the macular region.

CONCLUSIONS

To the authors' knowledge, macular serous retinal detachment due to subretinal leakage has not been reported as a complication of tilted disc syndrome. The authors hypothesize that choriocapillary and pigment epithelial disturbances at the junction of the inferior staphyloma permit the subretinal leakage, but the pathogenesis of this complication remains unclear. A study of larger series of such patients is needed to identify the most appropriate management of these cases, which first need to be differentiated from a chronic form of ICSC.