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ARTICLES
Year : 1985  |  Volume : 33  |  Issue : 3  |  Page : 195-197

Homocystinuria with bilateral absolute glaucoma


Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

Correspondence Address:
S Ghose
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029
India
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Source of Support: None, Conflict of Interest: None


PMID: 3879832

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How to cite this article:
Kalra B R, Ghose S, Sood N N. Homocystinuria with bilateral absolute glaucoma. Indian J Ophthalmol 1985;33:195-7

How to cite this URL:
Kalra B R, Ghose S, Sood N N. Homocystinuria with bilateral absolute glaucoma. Indian J Ophthalmol [serial online] 1985 [cited 2019 Oct 16];33:195-7. Available from: http://www.ijo.in/text.asp?1985/33/3/195/30821

Homocystinuria was first detected as a new metabolic disorder in 1962[1],[2]. Since then many cases have been reported in the litera­tures[3],[4],[5],[6],[7],[8],[9],[10],[11],[12]. The association of glaucoma[10],[13],[14],[15] and even buphthalmos[10],[13],[14], is known, but there is no case of homocystinuria with glaucoma documented in Indians. The present case is a report of absolute glaucoma in both eyes with bilateral ectopia lentis in a typical case of homocystinuria.


  Case report Top


An 8-year-old Hindu girl was referred with complaints of sudden loss of vision in both eyes, right eye 4 months ago, followed by left eye one and a half months back. The loss of vision in each eye was preceded by an acute attack of redness and pain in the eyes and severe vomiting. She was hospitalised else­where for treatment of vomiting, the ocular cause not being then suspected.

The patient was a full term normal deli­very, and had cried soon after birth. The developmental milestones were considerably delayed-social smile at 4 months, head hol­ding 5 months, sitting with support 9 months and without support 10 months, standing 18 months, walking 2-1/2 years and intelligible speech at 3-1/2 years. All three brothers and other family members were apparently normal. There was no history of con­ sanguinity.

On general examination, the patient was poorly built with body weight 15.2 Kg., height 107.5 cms., span 112.5 cm, with a height to span ratio of 0.95: 1, and upper segment to lower segment ratio of 0.95 : 1. The pulse, respiration and blood pressure were normal. She had a high arched palate and the uvula was absent. The child was moderately retarded mentally; the exact I. Q. score was difficult to ascertain because of aphasia. Examination of the musculoskeletal system revealed pectus excavatum, and ara­chnodactyly, genu valgum and flat foot [Figure - 1].

The other systemic examinations were unremarkable.

The facies was characteristic of homocys­tinuria [Figure - 2]. Ocular assessment showed absence of perception of light in both eyes. Nystagmoid movements were present. The adnexae were normal. The eyeballs showed bilateral equatorial and circumferential ciliary staphyloma [Figure - 2][Figure - 3]. The right anterior chamber was very shallow, being absent in the central area due to anterior dislocation of the lens [Figure - 2], the anterior surface of which was touching the back of a hazy cornea. In the left eye [Figure - 3] the anterior chamber was deep and there was posterior dislocation of the lens, the latter lying in the inferonasal quadrant of the vitreous. Both lenses showed punctate cataractous changes. The iris had patches of atrophy on both sides. The pupils were round, dilated and fixed. On examina­tion of the funds in the right eye, only a faint glow could be seen, but in the left eye the cup/disc ratio was 0.8 to 1 with pronounced pallor and obvious glaucomatous optic atro­phy. The digital tension was markedly raised in both eyes.

The haemogram, routine urinalysis, and X-rays chest and skull were within normal limits. X-ray long bones revealed osteoporo­sis. The urinary cyanide-nitroprusside and the more specific, silver-nitroprusside tests[11], were strongly positive for homocystine. Electrocardiography and echocardiography revealed no significant heart disease. The patient was kept on oral pyridoxine and appropriate diet. The parents and siblings were examined and found to have no signifi­cant ocular, systemic or biochemical abnor­mality.


  Discussion Top


The present case had systemic and bioche­mical features typically known in homocys­tinuria[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12[. The association of absence of the uvula does not seem to have been reported before. Bilateral punctate cataractous chan­ges have not been described in homocystinu­ria, where lamellar or nuclear cataract is usually seens[6],[16]

She developed the serious ocular compli­cation of absolute glaucoma at a relatively early age which had led to equatorial and ciliary staphyloma in both eyes. The mecha­nism of pupillary block in the production of glaucoma in homocystinuria is documented earlier[13],[14],[15]. This is definitely the cause of glau­coma in the right eye of our patient, where the lens was dislocated anteriorly. In the left eye with posterior lens dislocation into the vitreous, the glaucomatous optic atrophy may be because of vascular insufficiency of the optic nerve due to minor thromboembolic phenomena[11], and partly due to secondary changes following lens dislocation into the vitreous. It is possible that in this eye also the lens had been earlier causing pupillary block glaucoma, and only later was dislocated posteriorly into the vitreous.

Bilateral equatorial and circumferential ciliary staphyloma with absolute glaucoma in association with bomocystinuria, as in this case, does not seem to have been reported before in the Indian population. The glau­coma was detected too late in the course of the disease for any ocular treatment to be beneficial in this case, as she had already lost total vision.


  Summary Top


A case of homocystinuria with typical systemic features and bilateral ectopia lentis in an 8-year-old Indian girl is presented, who lost vision in both eyes due to absolute glau­coma following bilateral dislocation of lenses.

There was equatorial and circumferential ciliary staphyloma in both eyes. Specific biochemical tests confirmed the diagnosis of homocystinuria. The aetiopathogensis of glau­coma in this case is discussed. The importance of early detection of ocular complications in homocystinuria is stressed.

 
  References Top

1.
Carson, N. A. J. and Neill, D. W., 1962, Arch. Dis. Child., 37; 505.  Back to cited text no. 1
    
2.
Gerritsen, T., Vaugh, J. G. and Waisman, H. A., 1962, Biechem. Biophys. Res., 9 : 493.  Back to cited text no. 2
    
3.
Verma, 1. C. and Sinclair, S., 1970, Ind. J. Paediat. 37 . 263.  Back to cited text no. 3
    
4.
Singha, S. S. and Singh, H., 1972, Orient. Arch Ophthalmol., 10: 328.  Back to cited text no. 4
    
5.
Verma, I. C., Sud, N. and Manerikar. S., 1974, Ind. Pediatrics„ 11 : 753.  Back to cited text no. 5
    
6.
Gandhewar. R. N., Tiwaskar, I. H. V. and Deshpande, M. K., 1973, East. Arch. Ophthalmol;, 1 : 228.  Back to cited text no. 6
    
7.
Gupta, S. D., Jain, I. S. and Kumar, J, 1971 Ind. J. Ophthalmol;, 19: 49.  Back to cited text no. 7
    
8.
Schimke, R. N., McKusick, V. A., Huang, T. and Pollack, A. D, 1965, J. Amer. Med. Ass., 193:711.  Back to cited text no. 8
    
9.
Cross, H. E. and Jensen, A. D., 1973. Amer J. Ophthalmol., 75 ; 405.  Back to cited text no. 9
    
10.
Carson, N. A. J., Dent, C. E., Field, C. M. B. and Gaull, G. E., 1965, J. Pediat., 66 ; 565.  Back to cited text no. 10
    
11.
Spaeth, G. L. and Barber, G. W., 1967, Pediatrics, 40 : 586.  Back to cited text no. 11
    
12.
Arnott, E. J. and Greaves, D. P. 1964, Brit, J. Ophthalmol,. 48 : 688  Back to cited text no. 12
    
13.
Gibson, J. B., Carson, N. A. J. and Neill, D. W., 1964, J. Clin. Path; 17 :427.  Back to cited text no. 13
    
14.
Lieberman, T. W., Podos, S. M., Hartstein, J., 1966, Amer J. Ophthalmol., 61 ; 252.  Back to cited text no. 14
    
15.
Johnson, S. S,, 1968, Brit J. Ophthalmol., 52 : 251.  Back to cited text no. 15
    
16.
Gerritsen, T,, and Waisman, H. A., 1964, Pediatrics, 33 : 413.  Back to cited text no. 16
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]



 

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