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1403-Einstein v7n3p376-82 PDF
1403-Einstein v7n3p376-82 PDF
ABSTRACT INTRODUCTION
Until recently, the ophthalmologic examination of newborns in maternity Leukocoria may be a common sign in various ocular
hospitals was not a priority; even today, few hospitals perform this conditions – such as cataract, retinoblastoma, and
examination adequately. Consequences may be disastrous, because retinal and vitreous diseases – and may be characterized
by the time eye alterations are found, the child may have developed
by a whitish pupillary reflex (leukos: white, kore: pupil)
permanent loss of visual acuity. The ophthalmologic examination in
nurseries, carried out by neonatologists, permits an early diagnosis and
that differs from the normal red ocular reflex.
referral for effective therapy and adequate development of vision. This The red ocular reflex appears when a light beam
study underlines the importance of the red reflex test in newborns and is focused on the eye through the pupil; the light is
presents the main causes of leukocoria (cataract, retinoblastoma, and partly absorbed and partly reflected by the retina back
retinal and vitreous diseases) to alert pediatricians and neonatologists through the pupil, appearing as a reddish-orange reflex
about this condition. Special emphasis is given to retinoblastoma, a characterizing the normal color of the retina and the
condition affecting 1/14,000 to 1/20,000 live newborns; genetic, clinical, choroid.
diagnostic, and therapeutic aspects are presented. Early diagnosis of An early diagnosis is possible with the red reflex test,
retinoblastoma is essential for reducing morbidity and mortality.
which reduces the morbidity and possibly the mortality
Keywords: Reflex, pupillary/etiology; Eye diseases/complications; of various ocular conditions.
Eye manifestations; Diagnostic techniques, ophthalmological
MD; Ocular Oncology Sector of the Department of Ophthalmology at Universidade Federal de São Paulo – UNIFESP, São Paulo (SP), Brazil.
2
Corresponding author: Mirna Yae Yassuda Tamura – Rua Pedro de Toledo 1800 – Vila Clementino – CEP 04039-901 – São Paulo (SP), Brasil – Tel.: (11) 5078-9681 – e-mail: mirnayassuda@hotmail.com
Received on Jan 30, 2009 – Accepted on July 30, 2009
may be anterior, intermediate or posterior, according as retinal detachment and vitreous-retinal traction
to the site. areas.
Uveitis may be associated with leukocoria, as in These conditions generally involve one eye only;
cases of chronic anterior uveitis, which is commonly due bilateral involvement is rare. The mean age for
to juvenile rheumatoid arthritis in pediatric patients. It presenting the disease is 7 to 8 years, ranging from 2 to
may progress to cataract and leukocoria. In cases of 9 years; visceral Larva migrans infection, on the other
posterior uveitis, leukocoria may be associated with hand, occurs at ages 2 to 3 years(5). The diagnosis is
vitreitis (progressing to vitreous opacity), choroiditis based on clinical findings and specific laboratory tests
or retinitis. Infections such as toxocariasis, syphilis, (ELISA).
candidiasis, toxoplasmosis, rubella, CMV, and herpex Medical therapy consists of topical or systemic
simplex (TORCH) should be excluded in these cases(4). corticosteroids, depending on the degree of intraocular
inflammation. Single use of antihelminthic therapy,
such as thiabendazol, is questionable, since larval death
Ocular toxocariasis increases inflammation that may result in ocular damage.
Toxocariasis is caused by a parasite (Toxocara canis) It should therefore be used together with corticosteroids.
endemic in dogs; it is also the cause o visceral Larva Surgery is reserved for retinal detachment cases(6).
migrans infection.
Human infection takes place after a person
consumes earth contaminated with parasite eggs or food PHPV
contaminated with dog feces. In the human intestine, the PHPV is a generally unilateral congenital, non-hereditary
egg gives rise to the nematode larva, which penetrates ocular malformation that is usually not associated with
the wall of the intestine. There is systemic infestation of other congenital defects, except for cataract formation.
various organs – liver, lungs, brain and eyes – through It results from persistent fetal vascularization – the
the bloodstream and lymphatic system. fetal hyaloids system – that usually disappears by the 8th
In the eye, nematodes induce focal choroidal month of pregnancy.
inflammation and granuloma formation; if they reach In most cases, the fibrovascular membrane fed by
the vitreous cavity, nematodes may cause intense vitreitis the persistent hyaloid artery adheres to the posterior
associated with choroiditis that results in endophtalmitis capsule of the crystalline. In more severe cases,
(Figure 4). fibrovascular invasion of the crystalline may ensue,
leading to cataract, a shallow anterior chamber,
and closed angle glaucoma. Central or peripheral
retinal detachment may also be present. The most
feared complications are closed angle glaucoma
and intraocular hemorrhage, which may originate
from bleeding in the fibrovascular membrane in the
retrocrystalline space(7).
PHPV may be associated with microphthalmia. The
affected eye is generally smaller than the contralateral
eye; in some cases, this difference is only visible on
ocular ultrasound. Documenting and diagnosing
microphthalmia is important to exclude retinoblastoma,
which may occasionally be associated with PHPV.
Early therapy includes cataract surgery and removal
of the fibrovascular membrane. The prognosis for
vision depends on how much the posterior segment is
involved(8).
Figure 4. Endophtalmitis caused by ocular toxocariasis
Genetics
Retinoblastoma was one of the first malignancies to be
associated with genetic alterations. The retinoblastoma
gene (gene RB1) is located on the long arm of
chromosome 13 on region 14 (13q14). This is a tumor
suppressant gene that codes a protein (p RB) responsible
for controlling the cell cycle between phases G1 and S
to inhibit cell proliferation.
Tumor growth requires two mutated retinal cell Figure 6. Leukocoria due to retinoblastoma
RB alleles. These mutations are two isolated events(13).
The first mutation (or first event) may be somatic (non-
inherited) or germinal (inherited), which affects the
presentation of the disease. The second mutation is
always somatic.
Mutation of both alleles in non-inherited tumors
occurs in a single retinal cell, forming a single tumor
in one eye (unifocal and unilateral disease). This
form comprises about 60% of all cases, and generally
arises in the second year of life. The first mutation
in the inherited form of the disease occurs in a germ
cell; the mutate allele, thus, is present in all body cells,
including retinal cells. Mutation of the second allele
(second event) may take place in some of these retinal
cells and give rise to multiple tumors located in one or Figure 7. Campaign for early diagnosis of retinoblastoma, carried ou by the
both eyes of children (multifocal unilateral or bilateral Associação para Crianças e Adolescentes com Tumor Cerebral (TUCCA)
disease). This form is generally diagnosed in the first
year of life, and comprises about 40% of retinoblastoma
cases. The latter patients, having a mutated allele in all
Diagnosis
body cells, have a higher chance of developing other Early diagnosis of retinoblastoma is essential to reduce
malignancies during life, particularly if they are exposed disease morbidity and mortality. Initial lesions are
to radiation(14). more easily treated and result in a higher cure rate and
conservation of the eye and vision. Continued education
Clinical presentation of pediatricians and general ophthalmologists – and red
The most frequent clinical presentation of retinoblastoma reflex testing with dilated pupils – at maternity hospitals
is leukocoria (from 60 to 80% of cases), also known as and in routine pediatric examinations during the first
“cat’s eye reflex”(15). Leukocoria may be unilateral or three months of life are important measures for early
bilateral, according to each type of retinoblastoma in detection of retinoblastoma and other ocular diseases
children (Figures 6 and 7). in children.
Other common presentations are strabismus, red Fundus of the eye examinations should be
eyes, enlarged ocular globe due to increased intraocular done since birth in patients with a family history of
pressure, and loss of vision. Less common forms are retinoblastoma.
aseptic orbit cellulitis due to tumor necrosis, altered Most patients are referred to special care when
color of the iris (heterochromia), intraocular bleeding symptomatic. In these cases, a detailed clinical history
(vitreous or hyphema hemorrhage), and pseudo- and fundus of the eye examinations are initial and
uveitis. Retinoblastoma may be diagnosed in a routine fundamental steps for diagnosis.
examination, especially in cases with a family history of Image tests may help the diagnosis; ultrasound
the disease. provides information about the size of the lesions and
Advanced disease, where tumors invade the orbit or may find calcification within the tumor – a typical sign of
the optic nerve, may present with ocular proptosis and retinoblastoma. Magnetic resonance imaging provides
restricted eye motility. information about extraocular involvement and
invasion of the optic nerve; it also helps differentiate the child’s life and, secondarily, to conserve the eye and
retinoblastoma from other ocular conditions, such as vision.
Coats’ disease. Computed tomography is the best exam for There are different options available for each
detecting calcium within a tumor; nevertheless, it should individual case. Local and systemic factors should be
be used parsimoniously, because exposure to radiation taken into account when choosing the treatment, such
may increase the risk of a second neoplasm, particularly as the intraocular tumor size and site, extraocular
in patients with germinal retinoblastoma(16). involvement, laterality, the prognosis for vision, the
Invasive procedures, such as fine needle biopsies, patient’s clinical status, disease spread, and others.
should not be done in suspected retinoblastoma Current therapies of choice for intraocular
cases, since such procedures increase the possibility of disease are chemotherapy through different routes
extraocular tumor spread, worsening the prognosis. (endovenous, subconjunctival and intra-arterial), local
cryotherapy and lasertherapy, radiotherapy (teletherapy
Classification of the intraocular disease and brachytherapy), and enucleation (surgical removal
Use of chemotherapy in place of external beam of the eye)(18).
radiotherapy as the treatment of choice for intraocular Chemoreduction has changed the approach to
retinoblastoma has led to a new classification for retinoblastoma; it has become the first choice in most
this disease. International efforts in 2001 generated cases(19-21). Chemoreduction may use an endovenous
the International Classification for Intraocular approach with various drug protocols in six monthly
Retinoblastoma, which comprises five groups based
cycles. After the tumor is reduced, treatment may be
on the natural history of the disease(17). Groups A to
completed with local therapy, such as cryotherapy, laser
E reflect disease progression and the prognosis after
thermotherapy, and brachytherapy.
chemotherapy (Charts 1 and 2).
External beam radiotherapy is less and less used;
it is recommended in cases where tumor cells have
Chart 1. International Classification for Intraocular Retinoblastoma spread to the vitreous cavity and/or the subretinal
Group A Tumors confined to the retina, located in at least 3.0 mm from the space that could not be controlled previously by
fovea and 1.5 mm from the optic disk. Lesions smaller than 3.0 mm in chemotherapy(22). Complications include ocular
height or basal diameter. Absence of vitreous or subretinal seeding. alterations such as cataract, radiation retinopathy,
Group B Tumors larger than those in group A, in any site. Absence of vitreous facial hypoplasia due to bone atrophy, and an
or subretinal seeding. Presence of subretinal fluid up to 5.0 mm from
the base of the lesion.
increased risk of a second neoplasm in patients with
germinal retinoblastomas.
Group C Tumors with focal vitreous or subretinal seeding. Up to one quadrant
of subretinal fluid. Enucleation is the first treatment in patients with
advanced intraocular tumors with anatomical and
Group D Eyes with diffuse vitreous or subretinal seeding and/or significant
endophytic or exophytic disease. Avascular masses. More than one functional alterations(23). Enucleation as secondary
quadrant of subretinal fluid. treatment may be used when there is no response to
Group E Eyes that have suffered definitive anatomical and functional changes. the initial therapy. The eye should be removed with
They present one or more than the following alterations: irreversible the largest possible segment of the optic nerve, which is
neovascular glaucoma; massive intraocular hemorrhage; aseptic
orbital cellulitis; tumor touching the lens; diffuse retinoblastoma; considered the most important surgical margin.
atrophic eye. High-dose chemotherapy and external beam
radiotherapy are the options in extraocular disease(24).
Exenteration is becoming less used in these cases.
Chart 2. Prognosis of retinoblastoma
Group A Very low risk
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