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CASE REPORT
Year : 2010  |  Volume : 17  |  Issue : 4  |  Page : 379-381 Table of Contents     

Progressive posterior lenticonus in a patient with alport syndrome


1 Division of Anterior Segment, King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia
2 Department of Ophthalmology, Bin Rushd Specialized Center, Riyadh, Kingdom of Saudi Arabia
3 Department of Ophthalmology, Bahrain Defense Force Hospital, Kingdom of Bahrain

Date of Web Publication13-Oct-2010

Correspondence Address:
Ammar M Al-Mahmood
Division of Anterior Segment & Uveitis, King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia, P. O. Box 7191, Riyadh 11462
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-9233.71591

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   Abstract 

We report a rare case of Alport syndrome with progressive posterior lenticonus. A 24-year-old male presented to our tertiary eye care center with history of poor vision. At initial presentation, the patient had bilateral anterior lenticonus, posterior subcapsular cataract, and renal failure. The patient was diagnosed with Alport syndrome based on a positive family history of the disease and clinical findings. Further examination revealed progressive posterior lenticonus that was not present initially. The presence of such finding is important because it influences the surgical approach to avoid complications during cataract surgery.

Keywords: Alport Syndrome, Anterior Lenticonus, Posterior Lenticonus, X-linked Disease


How to cite this article:
Al-Mahmood AM, Al-Swailem SA, Al-Khalaf A, Al-Binali GY. Progressive posterior lenticonus in a patient with alport syndrome. Middle East Afr J Ophthalmol 2010;17:379-81

How to cite this URL:
Al-Mahmood AM, Al-Swailem SA, Al-Khalaf A, Al-Binali GY. Progressive posterior lenticonus in a patient with alport syndrome. Middle East Afr J Ophthalmol [serial online] 2010 [cited 2017 Mar 26];17:379-81. Available from: http://www.meajo.org/text.asp?2010/17/4/379/71591


   Introduction Top


Alport syndrome is a rare clinical entity characterized by the familial occurrence of hemorrhagic nephritis and sensorineural deafness (Alport 1927). Alport syndrome has a prevalence of 1/5000, with 85% of affected individuals having the X-linked form, where the affected males develop renal failure and usually have high-tone sensorineural deafness by the age of 20. The typical ocular signs are dot-and-fleck retinopathy, which occurs in 85% of the affected adult males, anterior lenticonus, which occurs in about 25%, and rare posterior polymorphous corneal dystrophy. [1] Anterior lenticonus is considered a characteristic sign of Alport syndrome. [2] Posterior lenticonus has been described as a rare manifestation in Alport syndrome [2],[3],[4] and a review of the literature revealed a relative paucity of reports. We present here a case of Alport syndrome with anterior lenticonus and progressive posterior lenticonus.


   Case Report Top


A 24-year-old male presented to our tertiary eye care hospital complaining of cloudy vision bilaterally since childhood, with the right eye affected more than the left. The patient had long-standing episodes of hematuria and was on renal dialysis for chronic renal failure at the time of initial presentation. In addition, the patient had reported difficulty in hearing.

Ocular examination revealed best corrected visual acuity of 20/80 +1 in the right eye and 20/60 +1 in the left eye. The patient's manifest refraction was −2.50 −0.25 × 80 in the right eye and −2.50 −2.50 × 95 in the left eye. Intraocular pressure was normal bilaterally. Slit lamp examination of the right eye was within normal limits except for advanced anterior lenticonus, and fleck retinopathy was present on fundus examination [Figure 1]. The left eye, on examination, was within normal limits with the exception of anterior lenticonus, posterior subcapsular cataract, and fleck retinopathy. Direct ophthalmoscopy revealed an oil droplet reflex bilaterally [Figure 2]. The diagnosis of Alport syndrome was made and the patient was advised to seek additional care from a nephrologist and an ear, nose, and throat specialist. Eighteen months later, the patient developed progressive posterior lenticonus bilaterally [Figure 3]. Progression of the cataract in the left eye was also noted. The manifest refraction changed to −4.00 −1.00 × 85 and −8.00 −0.75 ×125 in the right and left eyes, respectively. One year after his initial presentation, the patient underwent renal transplant for his chronic renal failure. The patient was kept on regular follow-up visits as the decision for cataract surgery was delayed as the patient's vision was not significantly affected.
Figure 1: Anterior lenticonus in the right eye in a patient with Alport syndrome

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Figure 2: Oil droplet sign with retro-illumination in a patient with Alport syndrome

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Figure 3: Posterior lenticonus in the right eye in a patient with Alport syndrome

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   Discussion Top


Some authors have considered anterior lenticonus as a manifestation of Alport syndrome, whereas posterior lenticonus is not associated with systemic disease. [5] Others have suggested that posterior lenticonus is a rare manifestation of Alport syndrome. [2],[3],[4] The prevalence of posterior lenticonus is estimated at 1-4 in 100,000 children. [6]

The ocular and clinical features of Alport syndrome are identical in both the X-linked and autosomal recessive forms. Retinopathy and cataracts are the only ocular abnormalities described in the rare autosomal dominant form of Alport syndrome. [1] Previous literature has reported variability in the incidence of ocular manifestations of Alport syndrome. Colville et al. [1] reported dot-and-fleck retinopathy in 85% of affected adult males, anterior lenticonus in approximately 25%, and with posterior polymorphous corneal dystrophy being rare. Chugh et al. [7] reported the prevalence of anterior lenticonus in 37.8% of the subjects, retinal flecks in 22.2%, cataract in 20%, and keratoconus in 6.7% of subjects. Teekhasaenee et al. [8] reported ocular manifestations in 82.3% of subjects with Alport syndrome. Posterior polymorphous dystrophy was the most common manifestation, occurring in 64.7% of subjects. Jacobs et al. [9] reported that ocular changes are uncommon and subtle in young patients with Alport syndrome, and that the signs increase in frequency and severity with age. In our case, both anterior lenticonus and cataract were present. The presence of posterior lenticonus late in the natural history of the syndrome may reflect the progressive nature of this manifestation.

The X-linked mutations have been mapped to defects in the α-5-chain of the type IV collagen gene, compromising the COL4A5, COL4A3, and COL4A4 genes. All mutations lead to abnormalities in the basement membrane of the glomerulus, cochlea, retina, lens capsule, and cornea, which eventually contribute to the typical phenotype of Alport syndrome. [1] Recently, the presence of a complex (core plus secondary) binding site for TCF8 in the promoter of Alport syndrome gene COL4A3, which encodes collagen type IV alpha 3 is thought to cause posterior polymorphous dystrophy. [10]

As Alport syndrome represents a mutation coding for collagen type IV, the lens capsule is considerably thinner. Junk et al. [11] conducted an electron microscopy study of a fragile capsulorhexis specimen and found typical thinned basal lamina with basement membrane disruptions. Similar findings were reported by Citirik et al., [12] Kato et al., [13] and Takei et al. [14] Choi et al. [15] reported the presence of numerous vascular dehiscences localized at the inner part of the lens capsule, large numbers of capsular dehiscences containing fibrillar materials, and vacuoles in addition to decreased thickness of the anterior lens capsules (4-13 μm).

The presence of cataract, either as a component of the disease or as a side effect of oral steroids following renal transplant, together with a fragile capsule makes cataract surgery more challenging. Phacoemulsification has been reported as a safe procedure in such cases. Zare et al. [16] reported good results with phacoemulsification and implantation of a single-piece acrylic hydrophobic intraocular lens (IOL) in 11 eyes of 6 patients with Alport syndrome. Seymenoπlu et al . [17] and Aslanzadeh et al. [18] reported the safety of phacoemulsification with IOL implantation in 8 and 4 eyes, respectively. Anterior capsular rupture either spontaneously [19],[20] or following trauma [21] have been reported. In order to perform a continuous curvilinear capsularhexis (CCC) and avoid inadvertent spontaneous capsular rupture, several maneuvers have been reported. Van Setten et al. [22] reported performing cortical lens matter aspiration prior to performing CCC. Zare et al. [16] and Jaspreet et al. [3] reported performing a CCC starting at the midperiphery rather than a conventional CCC, which is initiated at the center of the capsule. A pars plana approach for cataract surgery in the posterior lenticonus has also been reported in a single case with good outcome. [23]

In conclusion, Alport syndrome affects multiple systems, including the eye. The ocular manifestations are important to recognize in order to determine the proper medical and surgical therapy. Posterior lenticonus, which was once considered as an isolated manifestation is being reported more frequently in association with Alport syndrome, suggesting that posterior lenticonus is part of the disease.

 
   References Top

1.Colville DJ, Savige J. Alport syndrome: A review of the ocular manifestations. Ophthalmic Genet 1997;18:161-73.  Back to cited text no. 1  [PUBMED]    
2.Vedantham V, Rajagopal J, Ratnagiri PK. Bilateral simultaneous anterior and posterior lenticonus in Alport's syndrome. Indian J Ophthalmol 2005;53:212-3.  Back to cited text no. 2  [PUBMED]  Medknow Journal  
3.Jaspreet S, Jagit S, Arun K. Phacoemulsification and intraocular lens implantation in an Alport's syndrome patient with bilateral anterior and posterior lenticonus. J Cataract Refract Surg 2003;29:1834-6.  Back to cited text no. 3      
4.Bhatnagar R, Kumar A, Pakrasi S. Alport's syndrome: Ocular manifestations and unusual features. Acta Ophthalmol (Copenh) 1990;68:347-9.  Back to cited text no. 4  [PUBMED]    
5.Jacobs K, Meire FM. Lenticonus. Bull Soc Belge Ophthalmol 2000;277:65-70.  Back to cited text no. 5      
6.Cheng KP, Hiles DA, Biglan AW, Pettapiece MC. Management of posterior lenticonus. J Pediatr Ophthalmol Strabismus 1991;28:143-9; discussion 150.  Back to cited text no. 6  [PUBMED]    
7.Chugh KS, Sakhuja V, Agarwal A, Jha V, Joshi K, Datta BN, et al. Hereditary nephritis (Alport's syndrome): Clinical profile and inheritance in 28 kindreds. Nephrol Dial Transplant 1993;8:690-5.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Teekhasaenee C, Nimmanit S, Wutthiphan S, Vareesangthip K, Laohapand T, Malasitr P, et al. Posterior polymorphous dystrophy and Alport syndrome. Ophthalmology 1991;98:1207-15.  Back to cited text no. 8  [PUBMED]    
9.Jacobs M, Jeffrey B, Kriss A, Taylor D, Sa G, Barratt TM. Ophthalmologic assessment of young patients with Alport syndrome. Ophthalmology 1992;99:1039-44.  Back to cited text no. 9  [PUBMED]    
10.Krafchak CM, Pawar H, Moroi SE, Sugar A, Lichter PR, Mackey DA, et al. Mutations in TCF8 cause posterior polymorphous corneal dystrophy and ectopic expression of COL4A3 by corneal endothelial cells. Am J Hum Genet 2005;77:694-708.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]  
11.Junk AK, Stefani FH, Ludwig K. Bilateral anterior lenticonus: Scheimpflug imaging system documentation and ultrastructural confirmation of Alport syndrome in the lens capsule. Arch Ophthalmol 2000;118:895-7.  Back to cited text no. 11  [PUBMED]    
12.Citirik M, Batman C, Men G, Tuncel M, Zilelioglu O. Electron microscopic examination of the anterior lens capsule in a case of Alport's syndrome. Clin Exp Optom 2007;90:367-70.   Back to cited text no. 12  [PUBMED]  [FULLTEXT]  
13.Kato T, Watanabe Y, Nakayasu K, Kanai A, Yajima Y. The ultrastructure of the Lens capsule abnormalities in Alport's syndrome. Jpn J Opthalmol 1998;42:401-5.  Back to cited text no. 13      
14.Takei K, Furuya A, Hommura S, Yamaguchi N. Ultrastructural fragility and type IV collagen abnormality of the anterior lens capsules in a patient with Alport syndrome. Jpn J Ophthalmol 2001;45:103-4.  Back to cited text no. 14  [PUBMED]    
15.Choi J, Na K, Bae S, Roh G. Anterior lens capsule abnormalities in Alport syndrome. Korean J Ophthalmol 2005;19:84-9.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]  
16.Zare MA, Rajabi MT, Nili-Ahmadabadi M, Oskouee SJ, Moghimi S. Phacoemulsification and intraocular lens implantation in Alport syndrome with anterior lenticonus. J Cataract Refract Surg 2007;33:1127-30.  Back to cited text no. 16      
17.Seymeno?lu G, Baser EF. Ocular manifestations and surgical results in patients with Alport syndrome. J Cataract Refract Surg 2009;35:1302-6.  Back to cited text no. 17      
18.Aslanzadeh GA, Gharabaghi D, Naderi N. Clear lens phacoemulsification in the anterior lenticonus due to Alport syndrome: Two case reports. J Med Case Reports 2008;2:178.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]  
19.Wilson ME Jr, Trivedi RH, Biber JM, Golub R. Anterior capsule rupture and subsequent cataract formation in Alport syndrome. J AAPOS 2006;10:182-3.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]  
20.Pelit A, Oto S, Yilmaz G, Akova YA. Spontaneous rupture of the anterior lens capsule combined with macular hole in a child with Alport's syndrome. J Pediatr Ophthalmol Strabismus 2004;41:59-61.  Back to cited text no. 20  [PUBMED]    
21.Olitsky SE, Waz WR, Wilson ME. Rupture of the anterior lens capsule in Alport syndrome. J AAPOS 1999;3:381-2.  Back to cited text no. 21  [PUBMED]  [FULLTEXT]  
22.van Setten G. Anterior lenticonus: Histological evaluation and approach for cataract surgery. J Cataract Refract Surg 2001;27:1071-5.  Back to cited text no. 22  [PUBMED]  [FULLTEXT]  
23.Simons BD, Flynn HW Jr. A pars plana approach for cataract surgery in posterior lenticonus. Am J Ophthalmol 1997;124:695-6.  Back to cited text no. 23  [PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]


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