Spontaneous retinal capillary reperfusion in a systemic illness.
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Biomedical subjects
Publications and source records attributed to K G Noble.
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Three siblings (a sister and two identical-twin brothers) had bilateral choroidal osteomas. The sister was seen at 11 years of age, and the tumor showed significant growth two years later. The twin brothers' tumors were diagnosed at 9 years of age, and their conditions remained stable over two years except for a new, isolated lesion that occurred in one eye of one brother. The siblings' mother had a yellow mottling situated nasal to the disk in each eye that was similar in appearance to that in one eye of one of the twins. She showed no evidence of calcium on ultrasonography. The appearance of osteomas in three siblings suggests a choristoma as the cause of this tumor.
We studied three members of three successive generations of a family with autosomal dominant congenital stationary night blindness and normal fundi. Psychophysical studies on two members showed normal final cone thresholds and mildly increased rod thresholds. Full-field electroretinograms on all three members showed normal photopic b-wave amplitudes and implicit times. Under scotopic conditions, the rod response was absent, and with a bright flash stimulus, there was a normal a-wave with no b-wave. This electronegative dark-adapted electroretinogram resembled the Schubert-Bornschein type seen in congenital stationary blindness, which has been seen only in autosomal and X-linked recessive pedigrees.
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Three patients with peripapillary (pericentral) pigmentary retinal degeneration described in 1978 were examined over a follow-up period of nine to 13 years. There was no extension of the geographic pigmentary abnormalities. The affected areas worsened as evidenced by an increase in pigment abnormalities, focal choroidal atrophy as seen on fluorescein angiography, and a diminution of the electroretinographic responses. One patient had increasing disabling symptoms of nyctalopia and poor peripheral and central vision, whereas the other two patients remained asymptomatic with excellent central vision.
Three male siblings, born of nonconsanguineous parents, manifested the characteristic paravenous bone spicule accumulation typically seen in pigmented paravenous chorioretinal atrophy. The wide range of fundus appearances was apparent. The electroretinogram confirmed a localized dystrophy, and an abnormal electro-oculogram in the least affected brother suggested a more widespread abnormality. The onset of the disorder in all three brothers was early in life (possibly congenital), and there was minimal, if any, progression. The mode of inheritance could not be established. Because some mildly affected individuals will be asymptomatic and have minimal fundus abnormalities, it is important to examine all family members when considering the diagnosis of pigmented paravenous chorioretinal atrophy.
Three members from two successive generations demonstrated a bilateral, symmetric pigmentary maculopathy consisting of a diffuse yellowish sheen of the posterior pole. The visual acuity was variable (20/25 to 10/400) and visual function tests indicated a localized disorder. Historic information suggests the disorder is slowly progressive. On the basis of mode of inheritance, fundus and angiographic appearance, and visual function testing this appears to be a newly described disorder.
A study of 67 patients with a diagnosis of Stargardt's disease (juvenile macular degeneration) or fundus flavimaculatus showed that, apart from the ophthalmoscopic appearance, there is no clear distinction between these two disorders. The disease is an autosomal recessive macular degeneration that is bilateral and symmetrical in appearance, with diminished central vision as the hallmark symptom. The onset of symptoms usually occurred in the first or second decade, but a substantial number of patients were asymptomatic until the fourth or fifth decade. Psychophysical and electrophysiologic tests indicated that this is a localized and not a generalized retinal dystrophy. While the initial vision in the better eye was 6/12 (20/40) or better in one third of the patients, follow-up studies showed progression to levels between 6/30 (20/100) and 6/60 (20/400).
A 36-year-old black man who was taking low doses of systemic corticosteroids for systemic sarcoidosis had a vascular lesion of the left optic disk as the only ocular sign. The lesion regressed over a four-month period with high dosage corticosteroid therapy, but he developed optic atrophy and visual acuity of no light perception.
This report is a retrospective study of 33 patients seen over a 16-year period in whom a diagnosis of Leber's congenital amaurosis was made. The findings of an autosomal recessive heredity in 33%, connatal blindness (visual acuity less than 20/200) in 95%m nystagmus in 75%, and a markedly abnormal electroretinogram in 100% is in agreement with the findings of previously published large series. The difficulty in making the correct diagnosis initially was related to the wide variety of fundus findings and a high association (30%) of central nervous system disease. In the differential diagnosis of connatal blindness, only Leber's congenital amaurosis exhibits an absent or markedly diminished response on electroretinogram. The histopathologic findings in a 6-month-old infant with this disorder are compared with those of previously published reports.
We studied four patients with peripapillary pigmentary retinal degeneration, an asymptomatic disorder that was probably benign and nonprogressive. The ophthalmoscopic appearance showed a segmental, grayish metallic sheen in association with bone spicule pigmentation, which radiated from the disk along the temporal vessel arcades and joined temporal to the macula. The optic disk, retinal vessels, periphery, and macula were normal in all patients. Visual function tests and fluorescein angiography indicated a segmental disease of the retinal pigment epithelium-photoreceptor complex.
A brother and sister born of a consanguinous marriage had bilateral foveal retinoschisis and a generalized rod-cone dysfunction. This was associated with nyctalopia, hyperopia, minimal vitreous opacities in the sister, a paramacular tapetal sheen reflex, normal retinal vessels, an abnormal electroretinogram, and a normal electro-oculogram in the less affected brother. Foveal retinoschisis is not pathognomonic for x-chromosome-linked juvenile retinoschisis. It may be seen as a manifestation of a macular dystrophy or associated with a generalized tapetoretinal dystrophy.
Four members of a family with dominantly inherited macular dystrophy demonstrated the essential features of hereditary hemorrhagic macular dystrophy. They reported decreased visual acuity in the third decade and eventually developed bilateral disease. Fundus evaluations revealed hemorrhagic and exudative maculopathy associated with pigment atrophy, pigment clumping, and eventual glial scar formation. Early stages of the disease manifested a macular subretinal neovascular network. Photocoagulation treatment of subretinal neovascularization was successful in Case 3, unsuccessful in Case 1. Follow-up of these four brothers lasted over a period of two to 12 years. After they reached the cicatricial phase, the size of the lesion and visual symptoms remained stable. Visual function tests in the early and late stages indicated a local or geographic disease. We differentiated this dystrophy from other hereditary causes for subretinal neovascularization. We recommend early obliteration of the subretinal neovascular network with intense photocoagulation because the outcome of untreated hereditary hemorrhagic macular dystrophy is legal blindness.
Two dominantly inherited macular dystrophies demonstrate the difficulty in establishing a diagnosis based on the fundus appearance. In 1 family the propositus presented with unilateral retinal haemorrhage associated with subretinal choroidal neovascularisation which remained unilateral over an 8-year period. In the other family the propositus presented with bilateral central choroidal atrophy. All affected family members had an abnormal electro-oculogram and a normal electroretinogram, suggesting the diagnosis of vitelliform macular dystrophy. Since vitelliform macular dystrophy has a wide range of expressivity, with polymorphous appearances of the fundus, the diagnosis is best made by the presence of a dominant mode of inheritance and an abnormal electro-oculogram.
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Three members of a family with central areolar choroidal dystrophy showed the early and late stages of this disorder. The youngest affected was a 12-year-old girl who exhibited decreased vision, a red-green dyschromatopsia, and mild granularity of the macula with a diffuse foveal reflex. A discrete focal loss of choriocapillaris in the macula was seen on fluorescein angiography. This indicates that choriocapillaris atrophy is an early finding in this disease.