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Bull’s Eye Maculopathy as a Phenotypic Presentation of Stargardt Disease

Home / Retina and Vitreous / Hereditary Retinal and Choroidal Dystrophies

Title: Bull’s Eye Maculopathy as a Phenotypic Presentation of Stargardt Disease

Author: Troy Teeples, MSIV, University of Utah School of Medicine

Photographer: Unknown

Date: 8/14/2017

Image or video:

Image 1: Color fundoscopy shows pigment changes of the macula along with temporal pallor of the optic disc.

Image 2: Fundus Autoflourescence demonstrations central macular hypoautoflourescence with a surrounding hyperautoflourescent ring.

Figure 3: OCT demonstrations a discontinuous ELM layer, IS-OS dropout, and RPE disruption.

Keywords/Main Subjects:

Diagnosis: Stargardt Disease

Description of Image:

Patient Presentation: The patient is a previously healthy 7-year-old boy with no past medical history or family history of ocular disease who originally presented with blurry vision, problems with depth perception and central vision loss. In clinic he was found to have a visual acuity of 20/150 OD, 20/125 OS that was not corrected with refraction along with decreased color vision (Ishihara plates 4/8 OD, 5/8 OS). On fundoscopy he was found to have a Bull’s Eye Maculopathy OU with temporal pallor of the optic disc. No round pisciform flecks were seen on fundoscopy.

Stargardt Disease is the most common inherited macular dystrophy, though it may have many different phenotypic presentations. It is caused by accumulation of lipofuscin in the RPE, resulting from a mutation of the ABCA4 gene. With a faulty ABCA4 gene, the retina is not able to clear a toxic byproduct, bisretinoid-A2E, after the retinoid visual cycle, eventually resulting in RPE atrophy and photoreceptor cell death.

Phenotype Variation: Due to the large size of the ACBA4 gene (6.8kb), there are a significant number of disease-causing variants. In fact, over 500 distinct disease-associated mutations have been discovered that can cause Stargardt disease in addition to other ABCA4 associated diseases such as Cone Dystrophy, AMD, and Retinitis Pigmentosa. This patient presented with a 2 bp deletion resulting in a frameshift mutation on one allele as well as a missense mutation on the other, causing a Bull’s Eye Maculopathy as the phenotypic presentation. While some genotype-phenotype associations have been discovered, many remain yet to be determined. A prospective epidemiological study was performed over 12 months by Cornish and Ho in 2017 in order to determine the incidence of Stargardt Disease in the UK. Phenotypic presentations of the macula were quantified and of the 71 cases used in the study, 4% were found to have no macular abnormalities, 29% were found to have pigment mottling of the macula, 24% had a Bull’s Eye Maculopathy, 37% demonstrated macular atrophy and 36% had round pisciform flecks in the macula.

Imaging: Fundus Autoflouresence revealed a hypoautoflourescent macula with a surrounding hyperautoflourescent ring. An OCT revealed macular thinning, a discontinuous, ‘ratty’ ELM layer, IS-OS dropout, and disruption of the RPE.

References:

  1. http://eyewiki.aao.org/Stargardt_disease/Fundus_flavimaculatus
  2. Kurt Spiteri Cornish, Jason Ho, Susan Downes, Neil W. Scott, James Bainbridge, Noemi Lois. The Epidemiology of Stargardt Disease in the United Kingdom. Ophthalmology Retina,Volume 1, Issue 6, 2017, Pages 508-513., ISSN 2468-6530, https://doi.org/10.1016/j.oret.2017.03.001 (http://www.sciencedirect.com/science/article/pii/S2468653017300593)

Faculty Approval by: Griffin Jardine, MD

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Disclosure (Financial or other): None


Conjunctival Melanoma

HomeOphthalmic Pathology Conjunctiva

Title: Conjunctival Melanoma

Author: Xavier Mortensen, MS4

Photographer: Slit Lamp Photo: Glen Jenkins, CRA, OCTC. Ultrasound Image: Roger Harrie, MD

Date: 6/28/18 (images taken 6/20/18)

Image or video:

Image 1: Slit lamp of left eye showing a 9×9 mm large, vascular, pigmented mass which is non-adherent to the sclera in temporal conjunctiva. Biopsy was consistent with a conjunctival malignant melanoma arising from a preexisting primary acquired melanosis (PAM) with atypia.

Image 2: An immersion scan using a high-frequency 40 MHz probe. The lesion measured 2.7 mm in thickness by 10.3 mm in basal dimension. It appears to only involve the outer 25% of the sclera and with no intraocular extension. The ciliary body also appeared normal without evidence of melanoma.

Keywords/Main Subjects: melanoma, neoplasm, ocular, conjunctiva, sclera, ultrasound, b-scan

Secondary CORE Category: External Disease and Cornea / Neoplasms of the Conjunctiva and Cornea

Diagnosis: Conjunctival Melanoma

Description of Images: see above

Clinical Findings:

Conjunctival melanomas typically present as a nodular brown mass that are often well vascularized. In fact, due to the substantial vascular supply the tumors are more susceptible to bleeding. They occur most commonly on the bulbar conjunctiva or limbus, but may also be found on palpebral conjunctiva. Histologically, isolated or confluent nests of atypical melanocytes are often seen composed of large abnormal cells with high nuclear-cytoplasmic ratio, mitotic figures, and prominent nucleoli. Conjunctival malignant melanomas display invasion into subepithelial layers.

Etiology:

They are more common in patients of European descent and rare in black and Asian populations. Prognosis is poor with an overall mortality rate of 25-45%[3]. Conjunctival melanomas can arise from PAM (70%), nevi (20%), or de novo (10%)[3,4]. Intraocular and orbital extension can occur. It is important to check for an underlying ciliary body melanoma, which can imitate a conjunctival melanoma.

Management:

Treatment is time-sensitive and includes excisional biopsy with cryotherapy and/or alcohol corneal epitheliectomy. Depending on how invasive the malignancy is, exenteration may be required. Ultrasound biomicroscopy (UBM) should be done to rule out extrascleral extension of a ciliary body melanoma of a conjunctival melanoma. The recurrence rate is greater than 50% in treated patients[4], so patients should be followed-up closely by their ophthalmologist.

References:

  1. Bagheri, Nika, et al. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 7th Edition. Philidelphia: Wolters Klewer, 2017.
  2. Herwig, Martina C. Conjunctival Melanocytic Tumors. 7 November 2017. American Academy of Ophthalmology. 29 June 2018. <http://eyewiki.aao.org/Conjunctival_Melanocytic_Tumors>.
  3. Kaiser, Peter K, Neil J Friedman and Roberto Pineda. The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology. 4th Edition. Elsevier Inc., 2014.
  4. Skuta, Gregory L, Louis B Cantor and George A Cioffi. “Basic and Clinical Sciences Course.” Section 8: External Disease and Cornea. 2013-2014. American Academy of Ophthalmology, 2013. 227-228.

Faculty Approval by: Roger Harrie, MD; Griffin Jardine, MD

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Disclosure (Financial or other): None


Horner’s Syndrome in a 17 Year Old

Home / Neuro-Ophthalmology / Systemic Conditions with Neuro-Ophthalmic Signs

Title: Horner’s Syndrome in a 17 year old

Author: Emily Ross, 4th Year Medical Student at Indiana University-Purdue University Indianapolis

Date: 9/21/2017

Keywords/Main Subjects: Horner’s syndrome, anisocoria, ptosis

CORE Category:

Neuro-Ophthalmology > Pupillary Abnormalities > Anisocoria

Diagnosis: Horner’s Syndrome

Description of Case:

The patient is a 17-year-old girl who presented with ptosis on the right and anisocoria that began four months prior to presentation at clinic. She denies any cough, chest pain, neck pain, eye pain, neck manipulation, trauma, or preceding illnesses. She has no other significant findings on exam and no significant medical history. She does not use any eye drops. Differential diagnosis: Horner’s Syndrome, physiologic anisocoria, Adie tonic pupil, or topical/systemic medications. The patient was found to have Horner’s Syndrome.

Horner’s Syndrome:

Horner’s syndrome can result from a lesion anywhere along the three neuron oculosympathetic pathway.  It can produce three main deficits: ipsilateral ptosis (eyelid drooping) because of loss of innervation to Muller’s muscle, ipsilateral miosis (pupillary constriction) because of unopposed parasympathetic drive to the pupil, and ipsilateral anhydrosis (lack of sweating) on the face that may be best appreciated by the patient as contralateral hemifacial redness during exertion. This hemifacial redness is called the harlequin sign.

When evaluating a patient with anisocoria, first check that both pupils react appropriately to light, then determine if the difference in pupil size is greater in dim light or bright light. Horner’s Syndrome will have a greater difference seen between the two pupils in dim light. Dilation lag will also be present in Horner’s Syndrome and can help differentiate it from physiologic anisocoria. When the normal pupil dilates, there is both a parasympathetic signal allowing relaxation of the sphincter and a sympathetic signal contracting the pupillary dilator muscle. In Horner’s syndrome, the sympathetic signal is absent so the pupil only dilates by parasympathetic sphincter relaxation which is not as brisk resulting in a slower dilation response to dim light.

Figure 1: Dilation lag: After five seconds in dim light, the left (unaffected) pupil has dilated to 7mm, while the right (affected) pupil is only dilated to 5mm. After 15 seconds, the left pupil is dilated to 7.5mm and the right is dilated to almost 7mm.

Confirming the diagnosis of Horner’s Syndrome can be accomplished pharmacologically using either cocaine or aproclonidine eye drops. Cocaine is a norepinephrine reuptake inhibitor. When instilled in a patient with Horner’s Syndrome, the unaffected pupil will dilate significantly while the affected pupil will have a minimal or no response. The sympathetic innervation to the affected pupil is absent so the cocaine will have no (or very little) norepinephrine present in the synapse to prevent reuptake of resulting in little or no dilation of the pupil. Additionally, after a positive cocaine test, one can apply topical phenylephrine to the miotic pupil which directly stimulates sympathetic receptors resulting in dilation of the affected pupil. Aproclonidine is a strong alpha-2 adrenergic agonist and a weak alpha-1 adrenergic agonist. In the unaffected pupil, the alpha-2 stimulation results in pupillary constriction but in the affected pupil, the alpha-1 receptors become hypersensitive about one week after the sympathetic denervation and will cause pupillary dilation reversing the anisocoria as well as improvement of the ptosis.

Figure 2: Cocaine eye drop test: Upon presenting to clinic, the patient shows anisocoria with a smaller left pupil and ptosis on the left. Thirty minutes after application of 4% cocaine eye drops in room light, the right pupil has dilated significantly while the left pupil remains unaffected confirming the diagnosis of Horner’s Syndrome.

Localizing the lesion to either a first order or second order neuron lesion (preganglionic) versus a third order neuron (postganglionic) lesion can be accomplished pharmacologically by using hydroxyamphetamine eye drops though these drops are not routinely available even at large institutions. If the postganglionic neuron is functioning, the hydroxyamphetamine will cause release of norepinephrine from the neuron resulting in pupil dilation and narrowing the differential to a lesion in either the central or preganglionic neurons. If there is no dilation, then the lesion has been localized to the postganglionic neuron. If a cocaine test is performed, one must wait at least 24 hours before performing the hydroxyamphetamine test as the cocaine can interfere with this localizing test. Additionally, history and exam findings may also assist the clinician in localizing the lesion.

Understanding the anatomy of the oculosympathetic pathway is crucial. First order or central neurons run from the hypothalamus through the brainstem and spinal cord to the level of C8/T1. Second order or preganglionic neurons exit the brainstem and ascend to the superior cervical ganglion located near the carotid artery bifurcation. On this route, second order neurons pass near the subclavian artery and lung apex. Third order or postganglionic neurons begin at the superior cervical ganglion and run with the internal carotid artery.

Imaging of the head, neck, and chest may be required to establish an underlying cause for the Horner’s syndrome with either MRI, CT, angiography, or ultrasound.  Wallenberg Syndrome, carotid artery dissections, Pancoast or apical lung tumors, basal skull tumors, dislocation of cervical vertebrae, aortic dissection or aneurysm, and iatrogenic causes are a few potential etiologies of a Horner’s Syndrome to investigate.

References:

  1. Ophthalmology AA of. 2017-2018 Basic and Clinical Science Course Neuro-Ophthalmology. S.I.: American Academy of Ophthalmology; 2017.
  2. Kanagalingan S, Miller NR. Horner syndrome: clinical perspectives. Eye and Brain. April 2015; (10)7:35-46. doi: 10.2147/EB.S63633.
  3. Davagnanam I, Fraser CL, Miszkiel K, Daniel CS, Plant GT. Adult Horner’s syndrome: a combined clinical, pharmacological, and imaging algorithm. Eye. March 2013; 27(3):291-8. doi: 10.1038/eye.2012.281.
  4. Kedar S, Biousse V, Newman N. Horner Syndrome. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on September 23, 2017.)

Identifier: Moran_CORE_24942

Copyright statement: Copyright 2018. Please see terms of use page for more information.


Two Cases of Wolfram Syndrome

Home / Neuro-Ophthalmology / Grand Rounds Presentations and Cases

Title: Two Cases of Wolfram Syndrome

Author: Nathan G. Lambert, BS; Kathleen B. Digre, MD

Keywords: Wolfram Syndrome; WFS1; Wolframin; Diabetes insipidus; Diabetes mellitus; Optic atrophy; Sensorineural deafness;

Secondary CORE Location: Neuro-Ophthalmology / Systemic Conditions with Neuro-ophthalmic Signs

Diagnosis: Wolfram Syndrome

Intro

Wolfram Syndrome, or DIDMOAD, is a rare genetic syndrome consisting of diabetes insipidus, diabetes mellitus, optic atrophy and deafness. It was first reported in 1938 by Wolfram and Wagener who reported a family of 8 siblings, 4 of whom had juvenile diabetes mellitus and optic atrophy.1 We report two cases of siblings who exhibited typical findings of Wolfram Syndrome and describe their disease course and progression.

Case 1

A 10-year-old boy with a family history of Wolfram Syndrome presented to Moran neuro-ophthalmology clinic after referral for possible hereditary optic atrophy. The patient had a 5-year preceding history of diabetes mellitus and high frequency hearing loss. During elementary school he experienced increased urinary frequency and was eventually diagnosed with diabetes insipidus and treated with DDAVP. His older brother had also recently tested positive for Wolfram Syndrome. His vision was 20/30 OD and 20/20 OS with mild correction. Color vision was 5/6 OD and 6/6 OS, with full stereo 9/9. No APD was noted at the time.

At age 12 later he was noted to have some slight temporal pallor. His color vision was 6/7 with stereoscopic vision of 8/9. At age 14, his genetic testing returned positive for a mutation in the Wolfram gene (WFS1), located at map position 4p16.1. He had also experienced some decrease in hearing. He continued to require insulin therapy for his diabetes mellitus.

Between the age of 16 to 18, he was noted to have some peripapillary atrophy on funduscopic examination, and Humphrey visual field (HVF) testing showed an enlarged blind spot with mean deviation of -4.65 (OD) and -5.07 (OS) (Figure 1). His pupils were noted to be slightly sluggish to light reaction with a slight near dissociation. His color vision had decreased to 7/9 but his stereoscopic vision remained full.

At his most recent appointment, at age 22, his vision continued to be stable, but hearing loss in right ear appeared to be worse than previously. His stereoscopic and color vision were also decreased at 4/9 (stereo) and 1/10 (OD) and 2/10 (OS) (color). OCT revealed thinning of the retinal nerve fiber layer (RNFL) He still showed no APD at this time, however his pupils continued to react sluggishly to light. At this point he had started to report swallowing difficulties.

Case 2

This the older brother of patient in Case 1 was sdiagnosed with diabetes mellitus at age 7. He was later diagnosed with diabetes insipidus and treated with DDAVP. At age 10 he failed the school eye exam and presented to neuro-ophthalmology clinic where he was found to have decreased color vision and a VA (CC) of 20/200 (OD) and <20/400 (OS). He scored 0/7 for color vision and 6/9 for stereoscopic vision. His pupils were very poorly reactive but showed no afferent pupillary defect (APD). Funduscopic exam showed a pale nerve and OCT showed extensive retinal nerve fiber layer loss. His visual fields showed an enlarged blind spot bilaterally. Later that year an MRI showed atrophy and thinning of the brainstem with cerebellar hemispheric atrophy.

Throughout this process he was found to have depression, anxiety, and obsessive-compulsive disorder (OCD) and had previously been diagnosed with Asperger’s Syndrome. Genetic results at age 14 showed two mutations within exon 8 of the WFS1 gene and he was officially diagnosed with Wolfram Syndrome.

His condition continued to decline over the next 8 years. By age 22 he was placed on a CPAP for obstructive sleep apnea (OSA). By age 23 he exhibited swallowing difficulties and presented to the emergency department on multiple occasions for dysphagia and frequent choking episodes. He had also started to develop an uncoordinated, wide-based gait. At age 25 he experienced another episode of aspiration whereby he eventually died of pneumonia and respiratory failure.

Discussion

Wolfram Syndrome is neurodegenerative condition due to a loss of function mutation in the WFS1 gene, which codes for the protein wolframin1. This rare genetic disease is thought to occur in 1:770,0002, with an average life expectancy of 40 years3. Although genetic testing is necessary for definitive diagnosis, Wolfram Syndrome should be suspected in any patients with an inherited association of juvenile-onset (before age 16) insulin-dependent diabetes mellitus and progressive bilateral optic atrophy4.

Genetics

The WFS1 gene codes for the protein wolframin, and endoglycosidase H-sensitive membrane glycoprotein that localizes primarily to the endoplasmic reticulum (ER)5. This protein is thought to function as an ER calcium channel or regulator of calcium channel activity, and as such is important in cell-to-cell communication, muscle contraction, and protein processing6. Fonseca et al. found that WFS1 was upregulated during glucose-induced insulin secretion. They also noted that knockdown of WFS1 resulted in an ER stress signal, leading to beta-cell dysfunction and cell death, and subsequent diabetes7. Deletion or loss-of-function mutations in WFS1 result in ER dysfunction, leading to apoptosis of that associated cell.

Diabetes Insipidus

Seventy percent of patients with Wolfram Syndrome go on to develop central diabetes insipidus1, due to loss of vasopressin producing neurons. Proper functioning of the WFS1 gene is important for maintenance of neuron’s responsible for vasopressin synthesis and processing. Gabreels et al. found that patients with Wolfram Syndrome had vasopressin neuron loss in the supraoptic nucleus as well as defects in vasopressin precursor proteins8.

Diabetes Mellitus

Impaired glucose control is usually one of the first signs of Wolfram Syndrome. Diabetes mellitus is often diagnosed by age 61, Wolframin is highly expressed in the pancreatic beta-cells and may assist in folding mechanisms of insulin precursor proteins7. WFS1 deficient mice have destruction of beta-cells resulting in impaired glucose tolerance and diabetes mellitus9. Patients with Wolfram Syndrome often remain insulin dependent throughout the course of their life.

Optic Atrophy

Optic atrophy, noticed as loss of color and peripheral vision, is usually the second symptom behind diabetes mellitus, often occurring by age 111. Optic atrophy occurs in almost all patients10, and most patients eventually go blind1. Wolframin is localized to retinal ganglion cells, inner nuclear layer photoreceptors and glial cells of the retina11. The complete cellular mechanism resulting in optic atrophy is unclear, but is thought to be from issues in proper ER function leading to protein deficits, axonal transport deficiencies, and subsequent optic atrophy1.

Deafness

The mechanistic etiology of sensorineuronal hearing loss seen from WFS1 mutations has also not been fully elucidated. Some studies suggest that proper wolframin function is necessary for maintenance of cochlear hair cells12. It has also been suggested that calcium dysregulation that occurs secondary to WFS1 mutations is implicated in resultant deafness12. It is likely that both mechanisms are at work, however further study is needed to clarify this process.

Mental Illness

Neurologic and psychological complications are also common in patients with Wolfram Syndrome. Takeda et al found that WFS1 mRNA and protein were highly expressed in the amygdala, hippocampus, and other areas of the limbic system13. Patients with Wolframin Syndrome are often affected with severe mental and emotional illness such as anxiety, depression, psychosis, and aggression14. WFS1 gene is also expressed in the raphe nucleus and nucleus ceruleus, making it logical that mutations leading to imbalanced levels of serotonin and norepinephrine could lead to impulsive suicide and psychiatric disease15. One study looking at MRI findings in Wolfram Syndrome patients found associated generalized brain atrophy, especially in the cerebellum, medulla, and pons16. Interestingly, one of the most common causes of death in these patients is central respiratory failure secondary to severe brainstem atrophy17,18.

Other Manifestations

A variety of other pathologic associations have been seen occur commonly in patients with Wolfram Syndrome. By their early 20’s, many patients with WS experience incontinence1 secondary to neurogenic bladder and other urinary tract or bladder abnormalities19. Many patients develop cerebellar ataxia resulting in gait and balance issues10. Other issues include peripheral neuropathy, loss of gag reflex, myoclonus, mental retardation, seizures, and dementia1.

Conclusion

The two patient cases presented exhibit a variety of common findings of Wolfram Syndrome including, diabetes insipidus, diabetes mellitus, progressive optic atrophy, sensorineural deafness, swallowing difficulties, mental illness (anxiety, depression), bladder incontinence, cerebellar ataxia, and death secondary to aspiration and central respiratory failure. Any patient with a personal and family history of juvenile onset diabetes mellitus and bilateral progressive optic atrophy should be suspected and evaluated for Wolframin Syndrome.

Bibliography

  1. Rigoli, L., Lombardo, F. & Di Bella, C. Wolfram syndrome and WFS1 gene. Clin Genet 79, 103-117 (2011).
  2. Ganie, M.A. & Bhat, D. Current developments in Wolfram syndrome. J Pediatr Endocrinol Metab 22, 3-10 (2009).
  3. Kinsley, B.T., Swift, M., Dumont, R.H. & Swift, R.G. Morbidity and mortality in the Wolfram syndrome. Diabetes Care 18, 1566-1570 (1995).
  4. Khanim, F., Kirk, J., Latif, F. & Barrett, T.G. WFS1/wolframin mutations, Wolfram syndrome, and associated diseases. Hum Mutat 17, 357-367 (2001).
  5. Garcia, J.B., Venturino, M.C., Devesa, G. & Basabe, J.C. Insulin secretion induced by alloantigens. Mechanisms of action. Acta Diabetol Lat 26, 283-289 (1989).
  6. Osman, A.A., et al. Wolframin expression induces novel ion channel activity in endoplasmic reticulum membranes and increases intracellular calcium. J Biol Chem 278, 52755-52762 (2003).
  7. Fonseca, S.G., et al. WFS1 is a novel component of the unfolded protein response and maintains homeostasis of the endoplasmic reticulum in pancreatic beta-cells. J Biol Chem 280, 39609-39615 (2005).
  8. Gabreels, B.A., et al. The vasopressin precursor is not processed in the hypothalamus of Wolfram syndrome patients with diabetes insipidus: evidence for the involvement of PC2 and 7B2. J Clin Endocrinol Metab 83, 4026-4033 (1998).
  9. Ishihara, H., et al. Disruption of the WFS1 gene in mice causes progressive beta-cell loss and impaired stimulus-secretion coupling in insulin secretion. Hum Mol Genet 13, 1159-1170 (2004).
  10. Tranebjaerg, L., Barrett, T. & Rendtorff, N.D. WFS1-Related Disorders. (1993).
  11. Yamamoto, H., et al. Wolfram syndrome 1 (WFS1) protein expression in retinal ganglion cells and optic nerve glia of the cynomolgus monkey. Exp Eye Res 83, 1303-1306 (2006).
  12. Cryns, K., et al. Mutational spectrum of the WFS1 gene in Wolfram syndrome, nonsyndromic hearing impairment, diabetes mellitus, and psychiatric disease. Hum Mutat 22, 275-287 (2003).
  13. Takeda, K., et al. WFS1 (Wolfram syndrome 1) gene product: predominant subcellular localization to endoplasmic reticulum in cultured cells and neuronal expression in rat brain. Hum Mol Genet 10, 477-484 (2001).
  14. Swift, M. & Swift, R.G. Wolframin mutations and hospitalization for psychiatric illness. Mol Psychiatry 10, 799-803 (2005).
  15. Sequeira, A., et al. Wolfram syndrome and suicide: Evidence for a role of WFS1 in suicidal and impulsive behavior. Am J Med Genet B Neuropsychiatr Genet 119B, 108-113 (2003).
  16. Hardy, C., et al. Clinical and molecular genetic analysis of 19 Wolfram syndrome kindreds demonstrating a wide spectrum of mutations in WFS1. Am J Hum Genet 65, 1279-1290 (1999).
  17. Sam, W., Qin, H., Crawford, B., Yue, D. & Yu, S. Homozygosity for a 4-bp deletion in a patient with Wolfram syndrome suggesting possible phenotype and genotype correlation. Clin Genet 59, 136-138 (2001).
  18. Barrett, T.G., Bundey, S.E. & Macleod, A.F. Neurodegeneration and diabetes: UK nationwide study of Wolfram (DIDMOAD) syndrome. Lancet 346, 1458-1463 (1995).
  19. Cremers, C.W., Wijdeveld, P.G. & Pinckers, A.J. Juvenile diabetes mellitus, optic atrophy, hearing loss, diabetes insipidus, atonia of the urinary tract and bladder, and other abnormalities (Wolfram syndrome). A review of 88 cases from the literature with personal observations on 3 new patients. Acta Paediatr Scand Suppl, 1-16 (1977).

Legend

Humphrey visual field (HVF) showing progression of enlarging blind spot.

Humphrey visual field (HVF) showing progression of enlarging blind spot.

Identifier: Moran_CORE_24609


39-year-old Male with New-Onset Right Vision Loss

Home / Retina and Vitreous / Focal and Diffuse Choroidal and Retinal Inflammation

Title: 39-year-old male with new-onset right vision loss
Author: Nina Boal, BA
Photographer: James Gilman, CRA, FOPS
Date: September 2017
Images:

Figure 1: Dilated fundus examination of the right eye on presentation

Figure 2: MRI of orbits with IV contrast, post-contrast T1 5 mm ring enhancing foci in the right thalamus.

Figure 3: Dilated fundus examination of the right eye after 1.5 months of treatment

 

Keywords/Main Subjects: Toxoplasma gondii; Toxoplasma retinitis; HIV; AIDS
Secondary CORE CategoryIntraocular Inflammation and Uveitis / Ocular Involvement in AIDS (HIV)
Diagnosis: Toxoplasma Retinitis
Discussion of Images:

The fundus photos and MRI are from a 39-year-old male who presented with right sided vision loss over the course of two days. A complete review of systems was positive only for ten-pound weight loss in three months, fatigue, nausea, and bloody stools. The patient immigrated from Guatemala 25 years ago. He endorsed no significant past medical history.

The patient was treated empirically with intravitreous clindamycin and foscarnet, intravenous acyclovir, oral trimethoprim/sulfamethoxazole and admitted for work up of endogenous endophthalmitis. Further testing revealed:

The patient was diagnosed with toxoplasma retinitis and AIDS. Other medications started after this admission were emtiracitabine/tenofovir alafenamide and raltegravir. Valgancyclovir and azithromycin were started for CMV and MAC prophylaxis.

Follow-up appointment 1.5 months after treatment began showed improved vision to 20/40 in the right eye. Dilated fundus exam of the right eye showed improved subretinal fluid and hemorrhages with slightly larger area of retinal whitening along the inferior arcade (Figure 3).

Discussion:

Ocular toxoplasmosis, caused by the protozoan parasite Toxoplasma gondii, is considered to be the most common identifiable cause of infectious posterior uveitis in many parts of the world including northern Europe, North America, and South America. The immune system plays a critical role in susceptibility to infection with toxoplasmosis, and patients are at a particularly high risk when their CD4+ T-cell count is below 200 cells/mm3.

Active ocular toxoplasmosis can appear as focal white fluffy retinal lesions with indistinct borders. Overlying vitreous inflammation is commonly seen, with more severe overlying vitreous inflammation representing more advanced active disease, and classically described as a “headlight in a fog.” Older ocular toxoplasmosis lesions are typically seen as areas of well-circumscribed retinal necrosis, and as the lesion heals, its borders become more defined and hyperpigmented. Ocular toxoplasmosis in an immunocompromised patient typically demonstrates a more fulminant course with multifocal disease in one eye, bilateral eye disease, or extensive areas of necrotizing retinitis that can progress to panophthalmitis and orbital cellulitis. Between 30 and 50 percent of patients with HIV who have ocular toxoplasmosis will have central nervous system involvement.

In healthy patients with peripheral retinal lesions, infection with T. gondii is self-limited and may not require treatment, however treatment is required for patients who are immunocompromised, pregnant, or have vision threatening lesions. There have been three prospective, randomized, placebo-controlled clinical trials using systemic antibiotics to treat ocular toxoplasmosis. However, two of these studies were conducted almost 40 years ago and they are all considered to be methodologically poor. In the three studies, there was a lack of evidence that antibiotics (short or long term) would prevent vision loss. The “classical triple therapy” remains the combination of oral pyrimethamine, sulfadiazine, and corticosteroids. Trimethoprim/sulfamethoxazole is required for neurotoxoplasmosis, as in this case, and intravitreous clindamycin in combination with dexamethasone was shown to be efficacious in 16 out of 16 patients in a recent study (Zamora YF et al., 2015). Caution may be warranted in the use of steroids for immunocompromised patients.

Format: Images

References:

  1. Cunningham ET Jr, Margolis TP. Ocular manifestations of HIV infection. N Engl J Med 1998; 339: 236–44.
  2. Holland GN. Ocular toxoplasmosis: a global reassessment. Part I: epidemiology and course of disease. Am J Ophthalmol 2003; 136:973-88.
  3. Holland GN. Ocular toxoplasmosis: a global reassessment. Part II: disease manifestations and management. Am J Ophthalmol 2004; 137:1-17.
  4. Maenz M, Schluter D, Liesenfeld O, Schares G, Gross U, Pleyer U. Ocular toxoplasmosis past, present and new aspects of an old disease. Progress in Retinal and Eye Research 2014; 38: 77-106.
  5. Moshfeghi DM, Dodds EM, Couto CA et al. Diagnostic approaches to severe, atypical toxoplasmosis mimicking acute retinal necrosis. Ophthalmology 2004; 111: 716–25.
  6. Talabani H, Mergey T, Yera H, Delair E, Brezin AP, Langsley G, Dupouy-Camet J. Factors of occurrence of ocular toxoplasmosis. Parasite 2010; 17: 177-182.
  7. Zamora YF, Arantes T, Reiz FA, Garcia CR, Saraceno JJ, Belfort JR, Muccioli C. Local treatment of toxoplasmic retinochoroiditis with intravitreal clindamycin and dexamethasone. Arg Bras Oftalmol 2015; 78 (4): 216-9.

Faculty Approval by: Griffin Jardine, MD

Copyright: Nina Boal, © For further information regarding the rights to this collection, please visit: URL to copyright information page on Moran CORE

Disclosure (Financial or other): None

Identifier: Moran_CORE_24588


Terson Syndrome

Home / Retina and Vitreous / Other Retinal Vascular Diseases

Title: Terson Syndrome
Author (s): Dan Nguyen, MS4
Photographer: Unknown
Date: 8/16/17
Keywords/Main Subjects: Terson Syndrome, boat hemorrhage
Diagnosis: Terson Syndrome
Description of Case: Terson Syndrome is intraocular hemorrhage (IOH) in the presence of intracranial hemorrhage or elevated intracranial pressure (ICP). IOH can include vitreous, sub-hyaloid, pre-retinal, intraretinal, and subretinal bleeding. Vitreous hemorrhage is the most frequent subtype of ocular hemorrhage in Terson syndrome. It may present with visual loss and can cause permanent blindness if severe. It is most commonly associated with subarachnoid hemorrhage (SAH) secondary to an anterior circulation aneurysmal rupture. It can be seen in up to 46% of SAH patients, and its presence is associated with a higher mortality in SAH. The sudden spike in ICP with aneurysmal rupture is thought to underlie the cause of IOH. This increased pressure is transmitted along the optic nerve sheath and causes sudden intraocular venous HTN and rupture of thin capillary walls. The diagnosis is made with a fundoscopic exam, and ophthalmological exams should be routinely performed in patients diagnosed with SAH. Related complications of Terson Syndrome include macular holes, epiretinal membrane formation, proliferative vitreoretinopathy, retinal folds, retinal detachments, and optic neuropathy.

Some recommendations in literature suggest 3-6 months of observation after the acute event followed by vitrectomy if there is no improvement in visual acuity. But other studies suggest that earlier intervention before 3 months is optimal, especially in younger patients.

The fundus photos are from patient TS, a 35 year old female who was seen at Moran emergently for papilledema. Previously, she was found to have a Chiari malformation and had a suboccipital craniectomy at the end of May. On 7/29 she woke up on the floor, unable to move for 25 minutes, and had bilateral vision loss and was only able to see colors and shapes. At Moran she was noted to have stage III papilledema and peripapillary hemorrhages and was sent to the University ED. She had an LP with an opening pressure of 35 cm and was admitted to Neurosurgery with a shunt placed on 7/31. She was seen in the Neuro-Ophthalmology clinic on 8/16 with continued vision impairment, particularly in her right eye. On exam, her VA was 20/200 OD and 20/25 OS with correction. She had a tilt afferent pupillary defect OD. Slit lamp showed vitreous RBCs bilaterally, OD > OS. Fundoscopic exam (see pictures below) showed large pre-retinal/subhyaloid hemorrhages OU, more central OD vs OS. Visual fields showed mild central scotoma OD. The etiology of her ICP elevation is uncertain. She was treated with a pars plana vitrectomy (PPV) with membrane peeling (MP) in her right eye. Following surgery her VA improved to 20/30 post-op day 1.

Images or video:

Fundoscopic photograph demonstrating boat shaped retinal heme in the right eye of patient TS due to Terson Syndrome. In this specific case, the heme is a result of pre-retinal hemorrhage, posterior to the internal limiting membrane and anterior to the nerve fiber layer. Sub-hyaloid hemorrhage, a result of heme between the posterior vitreous base and the internal limiting membrane, presents similarly as a boat shaped retinal heme. The only way to reliably differentiate between sub-hyaloid and pre-retinal heme is during surgery.

Fundoscopic photograph demonstrating boat shaped heme in OS of patient TS from either sub-hyaloid or pre-retinal hemorrhage. Here, the macula is less affected vs OD, and this is seen clinically with her VA, 20/200 OD and 20/25 OS.

 Summary of the Case: TS is a 35 YO F who presents with decreased vision secondary to pre-retinal hemorrhage due to transient elevated ICP resulting in intra-ocular hemorrhage. Intra-ocular hemorrhage subsequent to intracranial hemorrhages or elevated IOP is known as Terson Syndrome. The patient was treated with PPV with MP and her vision OD improved from 20/200 pre-surgery to 20/30 post-surgery.

Format: image
References:

  1. Hassan, A. Giuseppe, L. Eelco, FM et al. Terson’s Syndrome. Neurocrit Care. 2011 May;15:554-558.
  2. Fang, K. Knox, DL. The Ocular Pathology of Terson’s Syndrome. American Academy of Ophthalmology. 2010;117:1423-1429.
  3. Garweg, JG. Koerner, F. Outcome Indicators for Vitrectomy in Terson Syndrome. Acta Ophthalmologica. 2009;87:222-226.

Faculty Approval by: Paul Berstein, MD

Copyright statement: Copyright Dan Nguyen, ©2015. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/
Identifier: Moran_CORE_24577


Fundus Photography and Fluorescein Angiography of Branch Retinal Artery Occlusion

Home / Retina and Vitreous / Other Retinal Vascular Disease

Title: Fundus Photography and Fluorescein Angiography of Branch Retinal Artery Occlusion
Author: Johnny Lippincott
Photographer: Unknown
Date: 8/28/2017
Images:

Keywords/Main Subjects: Branch Retinal Artery Occlusion, BRAO, Retinal Vascular Disease
CORE Category:
Disorders of the Retina and Vitreous: Other Retinal Vascular Diseases, 8: Arterial Occlusive Disease

RETINA AND VITREOUS

Diagnosis: Branch Retinal Artery Occlusion
Description of Image: Branch Retinal Artery Occlusion (BRAO) is the obstruction of adequate bloodflow to a retinal artery distal to the central retinal artery. Hypoperfusion of downstream tissue leads to retinal ischemia, cell damage, and vision loss. More than two-thirds of BRAOs are caused by emboli composed of either cholesterol, platelet-fibrin, or calcific plaques.1 Cholesterol emboli are known as Hollenhurst plaques. Emboli tend to occlude vessels at points of bifurcation. BRAOs are almost always found in the temporal, not nasal, arteries.2

Patients typically present with monocular sudden, painless vision loss in a sectoral or altitudinal distribution. Severity of vision loss (in field and acuity) varies significantly and depends on the area affected and degree of ischemia. 80% of affected eyes recover visual acuity of 20/40 or better.3 Given this rate of recovery, invasive therapy is usually avoided in cases without significant foveal involvement. Ocular massage or paracentesis can dislodge an embolus (albeit rarely), and employing laser therapy to disrupt an embolus may improve visual outcomes but is associated with vitreous hemorrhages.2, 4

This fundus photograph demonstrates characteristic findings in BRAO, including a sectoral area of opaque (“cloudy”), whitened, edematous retina. Retinal veins form the boundaries of this ischemic area, which here includes part of the superior fovea. A cotton-wool spot has developed (arrow). Though not seen in this photograph, an embolus is visible on fundus photography in a majority of cases. Fluoroscein angiography displays a hyperfluorescent spot (arrow) that may represent the culprit embolus that has migrated beyond the point of occlusion. The area of ischemia is hypofluorescent.

References:

  1. Hayreh SS, Zimmerman MB. Fundus changes in branch retinal arteriolar occlusion. Retina. 2015 Oct 1;35(10):2060-6.
  2. Yanoff M, Duker JS. Retinal arterial obstruction. Ophthalmology 4th edition. Elsevier Saunders. 2014;129.
  3. Brown GC, Magargal LE, Shields JA, Goldberg RE, Walsh PN. Retinal arterial obstruction in children and young adults. Ophthalmology. 1981 Jan 1;88(1):18-25.
  4. Man V, Hecht I, Talitman M, Hilely A, Midlij M, Burgansky-Eliash Z, Achiron A. Treatment of retinal artery occlusion using transluminal Nd: YAG laser: a systematic review and meta-analysis. Graefe’s Archive for Clinical and Experimental Ophthalmology. 2017:1-9.


Faculty Approval by: Griffin Jardine, MD

Copyright statement: Copyright Johnny Lippincott, ©2016. For further information regarding the rights to this collection, please visit: https://morancore.utah.edu/terms-of-use/

Disclosure (Financial or other): The author has no financial or business interests that may be affected by this site or its contents.

Identifier: Moran_CORE_24567


Fundus Photography, Fluorescein Angiography, and Indocyanine Green Angiography of Tuberculous Choroiditis

Home / Intraocular Inflammation and Uveitis Infectious Uveitis

Author (s): Kristen Russell
Photographer: N/A
Date: 11/1/2016
Image or video:

Keywords/Main Subjects: Tuberculous Choroiditis
Diagnosis: Tuberculous Choroiditis
Description of Image:

Here we are showing the fundus photo, FA, and ICG from a 51 year old female. She was referred to uveitis clinic because her BCVA was 20/60 OS and she had a history of recurrent vitreous cell, floaters, and photophobia. Previously, she had several PPD’s (purified protein derivative) that were positive, however, her chest x-ray had remained negative. On exam, her right eye was normal, but her left eye had mutton fat keratic precipitates, posterior synechiae, 1-2+ cell in the anterior chamber, vitreous haze, loss of the foveal reflex and inferior punched out chorioretinal lesions. Her left fundus photo showed mild haze and intraretinal heme. On FA, there were numerous nasal lesions that demonstrated early hypofluorescence and late hyperfluorescence. The ICG had multiple hypo-fluorescent lesions which matched the FA. Her laboratory work-up revealed a positive QuantiFERON-TB Gold. She was started on ethambutol, isoniazid, pyrazinamide, and rifampin and within one month, BCVA returned to 20/30 OS.

Mycobacterium Tuberculosis can cause a variety of ocular manifestations ranging from retinitis to scleritis. However, the most common is focal or multifocal choroiditis. Patients often present with no history of active TB and only half have a positive chest x-ray (1). Instead, patients may report photopsias, floaters, or scotomas. On slit lamp exam, there will be signs of uveitis, such as mutton fat keratic precipitates, cell and flare, posterior synechiae, and vitreous cells. Fundus exam may reveal areas of atrophy or active choroidal lesions. On fluorescein angiography (FA), the active site will typically show early hypo-fluorescence but late hyperfluorescence—versus indocyanine green angiography (ICG), where the lesions remain hypo-fluorescent throughout the course of the study. The differential diagnosis for these symptoms and imaging studies includes syphilis, sarcoidosis, birdshot retinochoroidopathy, and Vogt-Koyanagi-Harada syndrome. A common work-up, therefore, might include a QuantiFERON-TB Gold, RPR, FTA-ABS, chest x-ray, ACE, HLA-A29, hearing screening, and lumbar puncture. If a patient is diagnosed with ocular tuberculosis, the treatment is anti-TB medication, sometimes in conjunction with systemic corticosteroids.

References:

  1. Bennett, J. E., Dolin, R., Blaser, M. J., Mandell, G. L., & Douglas, R. G. (2015). Infectious Causes of Uveitis. In Mandell, Douglas, and Bennetts Principles and practice of infectious diseases. (pp 1423-1431). Elsevier Inc.
  2. American Academy of Ophthalmology. (n.d.). White Dot Syndromes: Multifocal Choroiditis and Panuveitis. Retrieved from https://www.aao.org/focalpointssnippetdetail.aspx
  3. Gupta, A., Bansal, R., & Gupta, V. (2014). Tuberculosis, Leprosy, and Brucellosis. In Ophthalmology (pp. 716-719). Elsevier Inc.

Faculty Approval by: Griffin Jardine, MD

Copyright statement: Copyright Author Name, ©2017. For further information regarding the rights to this collection, please visit: URL to copyright information page on Moran CORE

Identifier: Moran_CORE_

Disclosure (Financial or other): None


Anterior Basement Membrane Dystrophy (ABMD)

Home External Disease and Cornea / Corneal Dystrophies and Ectasias

Title: Anterior Basement Membrane Dystrophy (ABMD)
Authors: Paul D Chamberlain, BS, Brian Zaugg, MD
Photographer: Becky Weeks, CRA
Date: 8/14/2017
Image or video:

Slit lamp photograph of the characteristic map lines seen in ABMD.

Topography of an eye with ABMD showing irregular astigmatism with superior flattening of the central cornea.

Topography of the same eye 6 weeks following superficial keratectomy with diamond burr polishing.

 

Keywords/Main Subjects: Anterior basement membrane dystrophy; Corneal dystrophy; recurrent erosions;
Diagnosis: Anterior Basement Membrane Dystrophy (ABMD) (also: Epithelial basement membrane dystrophy(EBMD), map-dot-fingerprint dystrophy, Cogan’s microcystic epithelial dystrophy).

Description of Image:
The first corneal topography shown here (image 2a) is from a patient who initially presented for evaluation of worsening vision in the right eye (20/60 with correction) and was found to have visually significant cataracts. As part of his pre-operative evaluation this corneal topography was taken, showing a very irregular cornea. During his follow-up visit he reported that since the initial evaluation he had experienced right eye pain upon wakening in the morning, consistent with a recurrent erosion. The scheduled cataract surgery was changed to superficial keratectomy with diamond burr polishing following which his vision corrected to 20/20 in the right eye, with a subsequent  correction of the abnormal topography (image 2b) . Thus, in patients presenting with visual loss who are found to have both ABMD and cataracts, the ABMD should be treated first.

Anterior basement membrane dystrophy (ABMD) is a disease affecting the basement membrane of the corneal epithelial cells and is the most common corneal dystrophy. It is commonly bilateral though can be asymmetric. Patients may present with significant visual impairment due to ABMD, or it may be an incidental finding upon corneal examination. ABMD may also present as recurrent epithelial erosions. In this case the patient may complain of intermittent, severe eye pain, usually upon awakening in the morning and opening their eyes.

Diagnosis of ABMD is made from physical examination of the cornea (see image 1). The characteristic findings include either thick, irregular lines that may resemble a coastline (maps); small, punctate gray-white opacities with distinct edges (dots or microcysts); or thin hair-like lines arranged in parallel (fingerprints). These represent changes in the corneal epithelial basement membrane. Corneal topography may demonstrate irregularities in the cornea (see image 2a).

Mild cases without recurrent erosions may be treated with lubricating ointment and hypertonic saline drops/ointment. Recurrent erosions may require bandage contact lenses and antibiotic ointment. If these fail to provide benefit for the patient, or if the ABMD is causing significant visual impairment either superficial keratectomy with diamond burr polishing or photorefractive keratectomy might be required to relieve symptoms. Both treatments have been found to be highly successful, especially in the treatment of recurrent erosions.

References:

  1. Laibson PR. Recurrent corneal erosions and epithelial basement membrane dystrophy. Eye and Contact Lens: Science and Clinical Practice. 2010; 36(5):315-7.
  2. Wong VW, Chi SC, Lam DS. Diamond burr polishing for recurrent corneal erosions: results from a prospective randomized controlled trial. Cornea. 2009; 28(2):152-156.
  3. Sridhar MS, Rapuano CJ, Cosar CB, Cohen EJ, Laibson PR. Phototherapeutic keratectomy versus diamond burr polishing of Bowman’s membrane in the treatment of recurrent corneal erosions associated with anterior basement membrane dystrophy. Ophthalmology. 2002; 109(4):674-679.

Faculty Approval by: Brian Zaugg, MD; Griffin Jardine, MD
Copyright statement: Moran Eye Center, ©2017. For further information regarding the rights to this collection, please visit: URL to copyright information page on Moran CORE.
Identifier: Moran_CORE_24507
Disclosure (Financial or other): None


Fundus Photography of Traumatic Choroid Rupture with Angioid Streaks

Home / Retina and Vitreous Retinal Degenerations Associated with Systemic Disease

Title: Fundus Photography of Traumatic Choroid Rupture with Angioid Streaks
Author: Alaina Hamilton, B.S.
Photographer: James Gilman, CRA, FOPS
Date: June 2004 (image 1) and October 2013 (image 2)
Image or video:

June 2004

October 2013

Keywords/Main Subjects: Angioid Streaks; Traumatic Choroid Rupture;

Secondary CORE Category:

Retina and Vitreous / Other Retinal Vascular Diseases

Retina and Vitreous Posterior Segment Manifestations of Trauma 

Diagnosis: Traumatic Choroid Rupture with Angioid Streaks
Description of Image:

The fundus photos shown are from a middle-age man with pseudoxanthoma elasticum and angioid streaks that presented to the clinic a month after he was struck as a pedestrian by a motor vehicle. The first image shows his right eye before the accident and the second image was taken a month after the accident. The image taken before the accident demonstrates peau d’orange (arrow), which is the pebbly orange appearance to the retina and a classic finding seen with angioid streaks. On exam after the accident, he was found to have traumatic choroid rupture and extensive subretinal hemorrhage in both eyes, the left worse than the right. His vision after the accident was found to be 20/70 in the right eye and count fingers in the left (prior to the accident he had 20/20 vision in both eyes). A couple of months after this visit, he returned to clinic where his vision had improved to 20/25 in the right eye and 20/40. However, he was found to have developed a choroidal neovascular membrane in the left eye so he was treated with intravitreal anti-VEGF at that time. His vision in his left eye improved to 20/25 with the treatment and he is still currently stable with the monthly anti-VEGF injections.

Angioid streaks are bilateral, irregular tapering lines that lie deep to the retina and radiate from the peripapillary region within the posterior pole. Later ingrowth of fibrovascular tissue from the choroid into the sub-retinal pigment epithelial space can partially or totally obscure the streaks margins. The streaks represent breaks in a weakened Bruch’s membrane. These breaks can occur spontaneously or may be the result of even mild trauma. Other complications that can arise include choroidal neovascularization and subretinal hemorrhage. Approximately 50% of patients with angioid streaks have an associated systemic disease, pseudoxanthoma elasticum being the most common. Other commonly associated diseases can be remembered with the mnemonic PEPSI: Pseudoxanthoma elasticum, Ehler-Danlos syndrome, Paget’s disease of bone, Sickle cell disease, and Idiopathic, although there are many other less common associations. Diagnosis is usually made by clinical examination alone but can be confirmed with fluorescein angiography. Fluorescein angiography is particularly useful in evaluating choroidal neovascularization, as this would warrant treatment. Intravitreal anti-VEGF therapy can be used to stabilize vision if CNV has occurred, but often requires repeated injections due to recurrence.

References:

Mathew R, Sivaprasad S, Augsburger JJ, Corrêa ZM. Retina. Vaughan & Asbury’s General Ophthalmology, 19e New York, NY: McGraw-Hill
Georgalas I, Papaconstantinou D, Koutsandrea C, et al. Angioid streaks, clinical course, complications, and current therapeutic management. Therapeutics and Clinical Risk Management. 2009;5:81-89.

Faculty Approval by: P.S. Bernstein, MD, PhD
Copyright statement: Copyright Author Name, ©2016. For further information regarding the rights to this collection, please visit: URL to copyright information page on Moran CORE
Identifier: Moran_CORE_24493
Disclosure (Financial or other): None