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PHOTO ESSAY
Year : 2019  |  Volume : 14  |  Issue : 2  |  Page : 229-231

A child with Joubert syndrome: Clinical and imaging features


Eye Research Center, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran

Date of Submission23-Sep-2017
Date of Acceptance11-Mar-2018
Date of Web Publication19-Apr-2019

Correspondence Address:
Amin Zand
Department of Ophthalmology, Eye Research Center, Rassoul Akram Hospital, Sattarkhan-Niayesh St., Tehran 14456
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jovr.jovr_183_17

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How to cite this article:
Abri Aghdam K, Zand A, Sanjari MS. A child with Joubert syndrome: Clinical and imaging features. J Ophthalmic Vis Res 2019;14:229-31

How to cite this URL:
Abri Aghdam K, Zand A, Sanjari MS. A child with Joubert syndrome: Clinical and imaging features. J Ophthalmic Vis Res [serial online] 2019 [cited 2019 Nov 20];14:229-31. Available from: http://www.jovr.org/text.asp?2019/14/2/229/256542




  Presentation Top


Joubert syndrome is a rare autosomal recessive congenital syndrome that was first described by Joubert in 1969.[1] Diagnosis is based upon clinical features such as hypotonia, developmental delay, and progressive ataxia.[2],[3]

The syndrome can have variable ophthalmic features such as ptosis; ocular motor signs, including nystagmus, horizontal strabismus, “wheel-rolling” torsional eye movements, periodic alternating gaze deviation, elevation of the abducting eye on lateral gaze (with bilateral superior rectus and superior oblique muscle over-action), and skew deviation; and also fundus disorders such as optic nerve drusen, cellophane maculopathy, and pigmentary change at the periphery of the retina.[4],[5],[6]

In Joubert syndrome, abnormality of the cerebellum is seen on cross-sectional axial brain MRI. The posterior fossa typically exhibits a bat wing 4th ventricle and hypoplastic cerebellar vermis with hypoplasia of the superior cerebellar peduncle resembling the “molar tooth sign”.[7]

Our patient was a 2-year-old boy who was referred to the neuro-ophthalmology clinic for evaluation by a pediatrician due to abnormal eye movements, especially during the past year. His medical history and general examination indicated that he had hypotonia with slow limb movements and developmental delay. However, he did not show any signs of specific organ involvement associated with hepatic, renal or skeletal disease except for polydactyly. He had no significant family history and his parents were not consanguineous.

Upon ocular examination, the patient had poor fixation and could not follow moving objects. He had bilateral ptosis, high rounded eyebrows, and a broad nasal bridge [Figure 1]. The patient exhibited primary position nystagmus (see-saw pattern) in conjunction with saccadic dysfunction. Anterior segment examinations were normal. Fundus examination showed a dystrophic retinal appearance in conjunction with optic disc coloboma of the right eye [Figure 2]a and optic disc drusen of the left eye with mottled pigmentation at the periphery of the retina in both eyes [Figure 2]b, that was confirmed using fluorescein angiography [Figure 3]a and [Figure 3]b. Brain MRI showed hypoplasia of the cerebellar vermis with straight and thickened superior cerebellar peduncles suggestive of the “molar tooth sign” [Figure 4]a. Brain MRI revealed apposed cerebral hemispheres and absence of the vermis [Figure 4]b.
Figure 1. Bilateral ptosis, high rounded eyebrows, and broad nasal bridge.

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Figure 2. (a) Right eye: Optic nerve coloboma with the absence of physiologic cup and central retinal artery and vein. (b) Left eye: Optic disc drusen mimicking optic disc swelling. Also note peripheral pigmentary changes of the retina are evident.

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Figure 3. (a) Fluorescein angiography of the right eye: The blood vessels transiting the coloboma to reach the normal retina. (b) Fluorescein angiography of the left eye. Staining of the optic disc borders without optic disc leakage.

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Figure 4. (a) Brain MRI, T1-weighted, an axial cut without contrast: Cerebellar vermis hypoplasia, thickening of superior cerebellar peduncles and prominent cisterna magna, referred to as the “molar tooth sign”. (b) Brain MRI, T1-weighted, an axial cut without contrast. Absence of the vermis with apposed cerebellar hemispheres.

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  Discussion Top


Joubert syndrome is characterized by the following criteria: cerebellar vermis hypoplasia, developmental delay, hypotonia, and abnormal eye movements or breathing pattern.[3]

One of the differential diagnoses for Joubert syndrome is COACH syndrome, which entails cerebellar vermis hypoplasia, oligophrenia, congenital ataxia, coloboma, and hepatic fibrocirrhosis.[8] However, our patient did not exhibit these features.

Khan et al in a case series study, reported the ophthalmic features of patients suffering from Joubert syndrome as saccadic dysfunction, compensatory head turns, primary position nystagmus (see-saw pattern), dystrophic retinal appearance, and ptosis.[6]

In our study, the patient was found to have hypotonia and global developmental delay. His ocular features included bilateral ptosis, primary position nystagmus with a see-saw pattern, saccadic dysfunction, optic nerve coloboma (right eye), optic nerve drusen (left eye), and pigmentary change at the periphery of retina in both eyes. Few cases of optic disc drusen have been reported in patients with Joubert syndrome.[9]

In conclusion, primary position nystagmus in children with developmental delay, which indicates subsequent exhaustive fundal examination and neuroimaging.

Declaration of Patient Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients parents have given their consent for his images and other clinical information to be reported in the journal. They understand that the childs name initials name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.



 
  References Top

1.
Joubert M, Eisenring JJ, Robb JP, Andermann F. Familial agenesis of the cerebellar vermis A syndrome of episodic hyperpnea, abnormal eye movements, ataxia, and retardation. Neurology 1969;19:813-825.  Back to cited text no. 1
    
2.
Joubert syndrome U.S.: Department of Health & Human Services; 2016. Available from: https://rarediseases.info.nih.gov/diseases/6802/joubert-syndrome.  Back to cited text no. 2
    
3.
Elhassanien AF, Alghaiaty HA. Joubert syndrome: Clinical and radiological characteristics of nine patients. Ann Indian Acad Neurol 2013;16:239-244.  Back to cited text no. 3
    
4.
Ling J, Mehta V, Reddy A, Hollar M, Donahue S. An abnormal ocular motor manifestation of Joubert syndrome. J AAPOS 2017;21:75-77.  Back to cited text no. 4
    
5.
Papanagnu L, Klaehn LD, Bang GM, Ghadban R, Mohney BG, Brodsky MC. Congenital ocular motor apraxia with wheel-rolling ocular torsion—A neurodiagnostic phenotype of Joubert syndrome. J AAPOS 2014;18:404-407.  Back to cited text no. 5
    
6.
Khan AO, Oystreck DT, Seidahmed MZ, AlDrees A, Elmalik SA, Alorainy IA. Ophthalmic features of Joubert syndrome. Ophthalmology 2008;115:2286-2289.  Back to cited text no. 6
    
7.
Nag C, Ghosh M, Das K, Ghosh TN. Joubert syndrome: The molar tooth sign of the mid-brain. Ann Med Health Sci Res 2013;3:291-4.  Back to cited text no. 7
    
8.
Gentile M, Di Carlo A, Susca F, Gambotto A, Maria L, Caruso ML, et al. COACH syndrome: Report of two brothers with congenital hepatic fibrosis, cerebellar vermis hypoplasia, oligophrenia, ataxia, and mental retardation. Am J Med Genet 1996;64:514-520.  Back to cited text no. 8
    
9.
Yilmaz S, Demirkilinc Biler E, Ece Solmaz A, Serdaroglu G, Gazeteci Tekin H, Gokben S. Optic disc drusen mimicking papilledema in an infant with Joubert syndrome. Genet Couns 2015;26:35-39.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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