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Ocular and Oculocutaneous Albinism

Title: Ocular and Oculocutaneous Albinism

Authors: Jenna Jensen; M. Margarita Parra, MD

Photographer: JMEC photographers

Date: 9/8/2021

Keywords/Main Subjects: Albinism; Oculocutaneous albinism; Ocular albinism; Foveal hypoplasia; Hermansky-Pudlak Syndrome; Chediak Higashi Syndrome; Retina; Retinal Pigment Epithelium

Diagnosis: Ocular Albinism, Oculocutaneous Albinism

Brief Description: Albinism is a group of heterogeneous disorders with impairment of melanin pigment biosynthesis as a common pathophysiological pathway. Different mutations lead to the variable phenotypes including nonsyndromic types, such as oculocutaneous albinism and  ocular albinism, and syndromc albinism. Ocular signs include nystagmus, uveal and retinal pigment epithelium  hypopigmentation, foveal hypoplasia and abnormal retinostriate projections. The diagnosis can be made clinically in some cases, but genetic testing is very important to determine the type and if there is an associated systemic condition. Visual evoked potentials  can also be performed. In addition, early refractive correction is important.

Comparison of RPE pigmentation and fovea between eyes with albinism and a normal eye

Comparison of RPE pigmentation and fovea between eyes with albinism and a normal eye

The degree of fundus hypopigmentation allows varying ease of visualizing underlying choroidal vessels. A normal fundus (bottom right) shows a well-formed fovea (Hartnett ME. Pediatric retina. 3rd edition. Philadelphia: Lippincott Williams & Wilkins. 2021. Section IV. Genetics and developmental disorders in pediatric retina. Pages 280- 295. With permission).

Grades of iris transillumination in eyes with albinism

Grades of iris transillumination in eyes with albinism

Note the highly iris transillumination (top left) and minimal (bottom right).

Prevalence and Gender: Collectively, the group of disorders affects approximately 1/17,000 people worldwide.  The most common type of albinism world-wide and Africa is oculocutaneous albinism type 2. Oculocutaneous albinism type 1  is common in America and Asia, and oculocutaneous albinism type 3  is found in South Africa. Hermansky-Pudlak syndrome  is relatively common in Puerto Rico and in an isolated village in the Swiss Alps. However, all forms of albinism can be found throughout the world.

Albinism presents in both males and females. Males affected with ocular albinism typically express only the ocular features of albinism.

Genetics: Most forms of albinism present with autosomal recessive inheritance, except ocular albinism  and Chediak-Higashi syndrome, which have X-linked recessive patterns.

Albinism is characterized by a genetic defect in melanin production, transport, trafficking, or maintenance. Phenotypic patterns are dependent on the level of the defect in the enzymatic pathway of melanin production.

The most common types of albinism and their genetic mutations summarized below.

Symptoms and signs: These include highly variable cutaneous and hair hypopigmentation, visual acuity ranging from 20/20 to 20/600,  nystagmus that starts in early infancy, and strabismus. Uveal and retinal pigment epithelium  hypopigmentation leads to iris translucency and visualization of choroidal vessels in the macula (macular transparency) and periphery.

Structural changes also include excessive decussation of retinostriate nerve projections. Abnormal crossing can be detected by visual evoked potentials. Foveal hypoplasia is present and noted as an absence or flattening of the normal foveal pit. This finding can be appreciated by optical coherence tomography.

Environmental Factors and other Considerations: No environmental factors are known to be involved in the pathophysiology of albinism. However, living near the equator, high altitude or without protection from the sun can contribute to skin cancer. Therefore, appropriate protection is recommended.

Pathophysiology: In normal embryonic development, melanin accumulates in the retinal pigment epithelium. Decreased levels of melanin results in misrouted optic nerve fibers, retinal hypopigmentation, and decreased visual acuity due to foveal hypoplasia.

Diagnosis: Albinism can be clinically apparent, but genetic testing is necessary to determine the type of albinism. It is important to determine conditions such as Hermansky Pudlak Syndrome, which is associated with bleeding diathesis, and predisposition to granulomatous colitis, interstitial lung disease and immunodeficiency.  Chediak Higashi syndrome is associated with bacterial infections and a bleeding disorder. Over time, peripheral neuropathy can develop.

Differential Diagnosis: Rarer hypopigmentation disorders, such as Cross syndrome, should be considered depending on the age at presentation and other symptoms. Some ophthalmic disorders can be suspected in patients without cutaneous hypopigmentation, such as achromatopsia, isolated foveal hypoplasia, incomplete congenital stationary night blindness, Stickler syndrome, prematurity, as examples.

Treatment: There is currently no definitive treatment regimen; however ongoing ophthalmology care is needed. Vision rehabilitation including early refractive correction as patients have high refractive errors. Also, photochromic lenses are useful to alleviate photosensitivity and ultraviolet protection is important required. Consultation with dermatology and genetic counseling is recommended.

References: Hartnett ME. Pediatric retina. 3er edition. Philadelphia: Lippincott Williams & Wilkins. 2021. Section IV. Genetics and developmental disorders in pediatric retina.  Pages 280- 295.

Faculty Approval by: M.E. Hartnett, MD

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