Ocular and orbital manifestations of the inherited bone marrow failure syndromes: Fanconi anemia and dyskeratosis congenita

Abstract

Purpose: The inherited bone marrow failure syndromes (IBMFS) are a heterogeneous group of genetic disorders that share the inability of the bone marrow to produce an adequate number of blood cells. The 4 most frequent syndromes are Fanconi anemia (FA), dyskeratosis congenita (DC), Diamond-Blackfan anemia (DBA), and Shwachman-Diamond syndrome (SDS). All 4 syndromes have been associated with various physical abnormalities. As part of a genotype/phenotype/cancer susceptibility study, we determined the prevalence of ophthalmic manifestations in these 4 syndromes.

Design: Cross-sectional study of a patient cohort.

Participants: Seventy-five patients with an IBMFS and 121 of their first-degree relatives were seen in the National Eye Institute, National Institutes of Health, from 2001 to 2007. The patient group included 22 with FA, 28 with DC, 19 with DBA, and 6 with SDS.

Methods: Every participant underwent a complete ophthalmic evaluation and digital facial photography with an adhesive paper ruler on the patient's forehead for an internal measure of scale. Interpupillary distance (IPD), inner canthal distance (ICD), outer canthal distance (OCD), palpebral fissure length (PFL), and corneal diameter (CD) were measured. Thirteen of the 22 patients with FA underwent axial length (AL) measurements by A-scan ultrasonography.

Main outcome measures: Type and prevalence of ophthalmic manifestations.

Results: Ninety-five percent of patients with FA had at least 1 abnormal parameter, and 25% of patients had at least 4 abnormal parameters. Eighty-two percent of patients had small palpebral fissures, 69% of patients had simple microphthalmia, 64% of patients had small OCD, 55% of patients had microcornea, 28% of patients had ptosis, and 6% of patients had epicanthal folds. In patients with DC, abnormalities of the lacrimal drainage system (29%) were the most prevalent findings, followed by retinal abnormalities (pigmentary changes, retinal neovascularization, retinal detachment, exudative retinopathy) in 21%, cicatricial entropion with trichiasis and blepharitis in 7% each, and sparse eyelashes and congenital cataract in 3.5% each. No significant ophthalmic abnormalities were seen in patients with DBA or SDS.

Conclusions: Syndrome-specific ocular findings are associated with FA and DC and may antedate diagnosis of the specific syndrome. Early recognition of these abnormalities is important for optimal management.

Figure 1

Comparison of Z-scores for ophthalmic parameters among patients and their relatives: A) Interpupillary distance (IPD); B) Inner canthal distance (ICD); C) Outer canthal distance (OCD); and D) Palpebral fissure length (PFL); E) Corneal diameter (CD)*. Each box represents 25^th - 75^th percentile. The whiskers are between 5^th - 95^th percentiles; outliers are individual observations beyond the whiskers; horizontal line through each box is the median. Any observation at or below the solid black line (≤-2 Z-score) is an abnormally low value. *CD is in millimeters; normal is at or above 11 millimeters. PT, patient. REL, relative. Relatives are unaffected siblings and parents.

Figure 2

Frequency of small eye parameters in patients and relatives: A) Fanconi anemia (FA); B) Dyskeratosis congenita (DC); C) Diamond-Blackfan anemia (DBA); D) Shwachman-Diamond syndrome (SDS). Black dots, Interpupillary distance (IPD). Diagonal lines, Inner canthal distance (ICD). Vertical lines, Outer canthal distance (OCD). Interrupted vertical lines, Palpebral fissure length (PFL). Small blocks, Corneal diameter (CD).

Figure 3

Ophthalmic manifestations in Dyskeratosis congenita (DC): A) External photograph of the right eye of a 21 year-old patient with cicatricial entropion and trichiasis; B) Funduscopic photograph, and C) Fluorescein angiography of the periphery of the retina of a 12 year-old patient with areas of perivascular sheathing (B, white stars) and non-perfusion (C, white arrows).