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Dr. Natasha Healey PhD BSc (Hons) MCOptom
31st May 2014
Dr Julie McClelland, Dr Kathryn Saunders, Prof Jonathan Jackson, Ms Eibhlin McLoone
The Northern Ireland Nystagmus & Albinism Study
The NINA StudyThe NINA Study
ContentsAlbinism
- Background and subtypes
- Ocular Features
- Visual Symptoms
Northern Ireland Nystagmus & Albinism (NINA) Study
- Background
- Results
Background
Albinism term used to describe a group of disorders with absent or reduced melanin production
Results in hypopigmentation of the hair, skin and eyes
Prevalence: 1 in 20,000 worldwide 1 in 10,000 **N. Ireland
** NEW Results
AlbinismAlbinism2 broad categories exist:
Albinism Subtype
Category Sub-category
OCA
OCA1OCA1A
OCA1B
OCA2
OCA3
OCA4
OA OA1 Several others
OCA1AOCA Type
Cause Pigment Birth appearance
Adult appearance
OCA1A tyrosinase negative OCA
Mutation of tyrosinase gene
Nil •Snow white hair
•white pale skin
•pale blue/violet irides
No change
Skin does not tan
OCA1BOCA Type
Cause Pigment Birth appearance
Adult appearance
OCA1B Reduced function- tyrosinase enzyme is minimally active
Varies (normal to minimal)
Same as OCA1A
•Hair and iridies can darken with age
•Eyelashes darker than eyebrows/hair
•Skin may tan / develop freckles
OCA2OCA Type
Cause Pigment Birth appearance
Adult appearance
OCA2 •Normal tyrosinase activity
•defective trans-membrane protein
Varies •Hair / eyes pigmented at birth
•Hair colour at birth can range (light blonde-brown)
•Similar to OCA1B but in pigment is less pronounced
•Pigment can remain unchanged
OCA 3 Common in African & Papua
New Guinean populations. Brick reddish skin, hair and iris.
OCA 4 Mainly found in Japanese / Korean populations Physical appearance often indistinguishable from
OCA1B or OCA2.
Secondary OCA Blood clotting or immune disorders, more frequent in
Puerto Rico, Holland & Switzerland.
Fovea
Eye muscle
The Eye
Characteristic Ocular Features• Iris transillumination*
Fovea
Eye muscle
The Eye
Characteristic Ocular Features• Iris transillumination*
• Foveal hypoplasia* **NEW FINDINGS
Fovea
Eye muscle
The Eye
‘typical’ fovea Foveal Hypoplasia‘absent fovea’
Characteristic Ocular Features• Iris transillumination*
• Foveal hypoplasia*
• Fundal hypopigmentation*
Typical fundus colour fundus hypopigmention
Characteristic Ocular Features• Iris transillumination*
• Foveal hypoplasia*
• Fundal hypopigmentation*
• Macular transparency
• Optic nerve hypoplasia
• Anomalous retinal vessel presence in the foveal avascular area
Typical fundus colour fundus hypopigmention
Characteristic Ocular Features• Iris transillumination*
• Foveal hypoplasia*
• Fundal hypopigmentation*
• Macular transparency
• Optic nerve hypoplasia
• Anomalous retinal vessel presence in the foveal avascular area
• Abnormal misrouting of retinal ganglion cell axons at the optic
chiasm (VEP asymmetry)
‘Typical’ Visual Pathway: 60% fibres cross, 40% remain uncrossed
Typical Visual Pathway: 60% fibres cross, 40% remain uncrossed
Albinism: Higher percentage of fibres cross (95%), 5% uncrossed
• Reduced visual acuity
Characteristic Visual Symptoms
• Reduced visual acuity
• High refractive errors
Characteristic Visual Symptoms
No Refractive Error •Eye that does not need glasses
No Refractive Error •Eye that does not need glass•Light / image rays focused perfectly on fovea / retina
Long Sighted Eye•Hypermetropia•Light/image focused behind retina
Long Sighted Eye•Hypermetropia•Eye needs PLUS lenses to focus light/image on retina
Short Sighted Eye•Myopia•Light / image is focused in front of the retina
Short Sighted Eye•Myopia•Eye needs MINUS lenses to focus light/image on retina
Short Sighted Eye•Myopia•Eye needs MINUS lenses to focus light/image on retina
• Reduced visual acuity
• High refractive errors
• Reduced contrast sensitivity
Characteristic Visual Symptoms
• Reduced visual acuity
• High refractive errors
• Reduced contrast sensitivity
• Nystagmus
Characteristic Visual Symptoms
• Reduced visual acuity
• High refractive errors
• Reduced contrast sensitivity
• Nystagmus
• Photophobia
Characteristic Visual Symptoms
• Reduced visual acuity
• High refractive errors
• Reduced contrast sensitivity
• Nystagmus
• Photophobia
• Reduced or absent stereoacuity
Characteristic Visual Symptoms
• Reduced visual acuity
• High refractive errors
• Reduced contrast sensitivity
• Nystagmus
• Photophobia
• Reduced or absent stereoacuity
• Amblyopia
Characteristic Visual Symptoms
• Reduced visual acuity
• High refractive errors
• Reduced contrast sensitivity
• Nystagmus
• Photophobia
• Reduced or absent stereoacuity
• Amblyopia
• Strabismus
Characteristic Visual Symptoms
The Northern Ireland Nystagmus & Albinism (NINA) Study
The NINA StudyAutumn 2008- Spring 2012
Location:
Royal Group of Hospitals
Altnagelvin Area Hospital
Recruited:
105 participants (age range 4.5 months-47 years)
Albinism n=73
ICN n=32 (control group)
Retrospective analysis (n=147 medical files, 1986-2010)
Control GroupIdiopathic congenital nystagmus (ICN)
Nystagmus may also occur in isolation
Onset prior to 6 months of age
Normal ocular and neurological anatomy
MethodRefractive Error: strict cycloplegic protocols
MethodRefractive Error: strict cycloplegic protocols
Visual acuity: age appropriate tests
MethodRefractive Error: strict cycloplegic protocols
Visual acuity: age appropriate tests
Nystagmus assessment : video recorded/graded
MethodRefractive Error: strict cycloplegic protocols
Visual acuity: age appropriate tests
Nystagmus assessment : video recorded/graded
Corneal curvature: Nidek Hand-held keratometer
Fovea
Eye muscle
MethodRefractive Error: strict cycloplegic protocols
Visual acuity: age appropriate tests
Nystagmus assessment : video recorded/graded
Corneal curvature: Nidek Hand-held keratometer
Axial Length: IOL Master (NC) Biometer
Fovea
Eye muscle
MethodRefractive Error: strict cycloplegic protocols
Visual acuity: age appropriate tests
Nystagmus assessment : video recorded/graded
Corneal curvature: Nidek Hand-held keratometerIOL Master (NC) Biometer
Axial Length:
Contrast Sensitivity & Straylight: -Pelli Robson Chart - Straylight meter
MethodRefractive Error: strict cycloplegic protocols
Visual acuity: age appropriate tests
Nystagmus assessment : video recorded/graded
Corneal curvature: Nidek Hand-held keratometer
Axial Length: IOL Master (NC) Biometer
Contrast Sensitivity: Pelli Robson Chart
Foveal imaging: SD-OCT
Fovea
Eye muscle
Prevalence of Albinism
In N. Ireland
•Worldwide prevalence 1 in 20,000•N. Ireland prevalence 1 in 10,000
•New NINA Study Results albinism prevalence in N. Ireland
1 in 4,500 – 6,000
•published March 2014, British Journal of Ophthalmology
1 in 4,500 – 6,000
NINA Study has highlighted:• Public health issue- with higher numbers than services are planned for
•Numbers need taken into consideration when planning future service- eye appointments, funding for benefits, classroom assistants etc
•NINA suggest this underestimation of albinism prevalence is not an isolated case, suspecting worldwide figures to be erronous
The Significance of Foveal Hypoplasia
Fovea
Eye muscle
Normal Retinal Development
•Fovea begins @ 25 weeks gestation
•Continues to develop until 15-45 months of age
•During this time the foveal cells change shape and mature
typical fovea Foveal hypoplasia: OCA/OA
Foveal Morphology ResultsSpectrum of foveal hypoplasia occurred
Examples of Foveal Hypoplasia
Foveal Morphology ResultsSpectrum of foveal hypoplasia occurred
Grade of foveal hypoplasia was statistically significantly related to Visual Acuity (Agreement with Thomas et al., (2011)
Poorest VA (mean VA 6/36) was associated with the severest foveal hypoplasia
NEW NINA Findings:Highest refractive error (highest hypermetropia) was
associated with the severest foveal hypoplasia
Foveal Morphology ResultsSpectrum of foveal hypoplasia occurred
Grade of foveal hypoplasia was statistically significantly related to Visual Acuity (Agreement with Thomas et al., (2011)
Poorest VA (mean VA 6/36) was associated with the severest foveal hypoplasia
NEW NINA Findings:Highest refractive error was associated with the severest
foveal hypoplasia - published April 2013, Investigative Ophthalmology & Visual Science
Refractive Error
Previous studies of refractive error in albinism Author Location Subject
numbersAge range (years)
Most prevalent type of refractive error
Wildsoet et al 200027 Boston 25 3-51 Long sighted
Edmunds 194932 New York 16 7-45 Long sighted
Mvogo et al 199933 Cameroon 42 Not available Short sighted with astigmatism
Loshin and Browning 1983 34
Not available 8 Not available Long sighted
Nathan et al 198535 Australia 35 1-16 Long sighted
Perez-Carpinell et al 198231
Spain 9 7-39 Short sighted
Sampath and Bedell 200236
USA 19 10-35 Long sighted
Kasmann et al 199637 Germany 68 0.5-78 Link between short sight and OCA1
Refractive Error
Long sightedEye length typical Large range of refractive errors existedHigh horizontal astigmatism
Why are the high levels of refractive error present?Typically at birth babies have high levels of long
sightedness and astigmatism
Why are the high levels of refractive error present?Typically at birth babies have high levels of long
sightedness and astigmatismTypically these levels decrease over the first 8 years
of life
Why are the high levels of refractive error present?Typically at birth babies have high levels of long
sightedness and astigmatismThese levels decrease over the first 8 years of lifeProcess is called ‘Emmetropisation’
Why are the high levels of refractive error present?Typically at birth babies have high levels of long
sightedness and astigmatismThese levels decrease over the first 8 years of lifeProcess is called ‘Emmetropisation’
New: NINA study has found that the high levels
found at birth do not appear to decrease as much
as we would expect over the first 8 years of life.
Another important feature the NINA Study has found is:
That some element of astigmatism in albinism is
congenital (higher at birth than typical baby eye)
Therefore are not solely a mechanical consequence of nystagmus
Recommend, if have astigmatism to wear glasses as early as possible, don’t wait and to wear full time.
Another important feature the NINA Study has found is:
That some element of astigmatism in albinism is
congenital (higher at birth than typical baby eye)
Therefore are not solely a mechanical consequence of nystagmus
Future ResearchNINA Study Findings currently in process for
publication:
1.Corneal Astigmatism
2.Questioning SSI and SI Categories for Albinism
- worldwide call for further research
3.Advanced Clinical Guidelines for Eye care in Albinism
4.**Need for future research in genetics, and foveal hypoplasia during gestation and infancy
NINA Study SummaryPrevalence of Albinism is greater than expected in NI, and
also possibly worldwide
Need to look at public spending in this area
Role of Foveal Hyoplasia in Visual Acuity and Refractive Error
Longsighted with horizontal astigmatism most common, suggesting glasses from a very early age
Astigmatism generally corneal and some already there before birth
Re-diagnosed some of those participating in the ‘control group’
NINA OutcomesClinical recommendationsProvided answers to worldwide questionsIncreased awareness Increased awareness of support parents requireIncreased awareness of Albinism Fellowship and
Angel Eyes Charities (NI)Highlighted need for future researchFurther publications pending
Last thing to say is a huge.....
Thank YouThank You
AcknowledgementsChildren, adults and parentsMs. E. McLooneMr. C.E. WilloughbyMs. R.BrennanDr. G. MahonDr. D. BurnsThe Low Vision Clinic, RGHDayward, RGHOptometry Clinic, AAHCharities (AE/AF)University of UlsterDepartment of Education & Learning
Note: the author of this presentation does not give permission for its content/images to be copied or reused in any way.